Treatment 5 articles were obtained through snowball search.

Treatment in patients with
Rockwood III acromioclavicular joint luxation: surgery or conservative. A
systematic review

Bachelorthesis
Lorenzo Texel
2569946

    

    
    

 

Abstract 

Background:
Methods: The medical
research database PubMed was used to conduct this systematic review. Five
search terms with their synonyms and variants were used: (1) Rockwood III;
(2) luxation; (3) acromioclavicular joint; (4) operative; (5) conservative.
This resulted in a total of 178 hits. 5 articles were obtained through
snowball search. Initially, 181 articles were screened on title and
abstract. After exclusion, 12 articles were critically assessed on
eligibility. 10 articles remained and were included and clinical and
radiographic results were extracted
Results:
Discussion:

Introduction

To do

Methods

Search strategy

To conduct this research, the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. The
electronic research database PubMed was used to find articles. I used the terms
‘Rockwood III’ or ‘grade III’ in combination with ‘luxation’ ‘acromioclavicular
joint’, ‘conservative’ and ‘operative’. In addition, synonyms and variants of
the mentioned search terms were added to come to the following search:
(“Rockwood III”tiab OR “Rockwood 3″tiab OR
“Rockwood type 3″tiab OR “Rockwood type III”tiab OR
“Tossy III”tiab OR “Tossy type 3″tiab OR “Tossy
3″tiab OR “Rockwood grade 3″tiab OR “Rockwood grade III”tiab) OR
“grade 3″tiab OR “grade III”tiab) AND
(luxat*tiab OR dislocat*tiab OR disrupt*tiab OR injurytiab OR
separate*tiab) AND (“AC joint”tiab
OR acromioclaviculartiab OR ACJtiab OR acromiontiab OR clavicular tiab
OR acromio*tiab OR clavicul*tiab OR clavicletiab) AND ((surgerytiab OR treatmenttiab OR operativetiab OR
resectiontiab OR sectiontiab OR fixat*tiab) OR (conservativetiab OR “wait and see” tiab OR nothingtiab OR
“non-operative”tiab OR “non operative”tiab OR physiotiab OR “physio
therapy”tiab OR physiotherapytiab)). All search terms were searched for in
title and abstract. This search resulted in 178 hits. Initially, all articles
that matched the search terms were included for further analysis. Endnote X8
was used to manage the articles.

 

Study selection

First, 2 duplicates were removed from the Endnote X8
library. Hereafter, all 176 remaining articles were screened on title and
abstract. Exclusion criteria were: (1) animal study; (2) abstract not in
English or German; (3) study is a systematic review; (4) absence of
conservative or operative treatment arm. 12 articles remained and the full text
was assessed for eligibility. From one article, it was not possible to retrieve
the full text and was therefore removed. Other exclusion criteria were: (1) no
Rockwood III results mentioned; (2) no clinical or radiologic results
mentioned. (3) articles from before 2000. 10 articles met all search criteria
and were included in this systematic review. Figure 1 shows the study flow.

 

Outcomes of interest

To make a clear overview, a table was conducted
containing all results of the included studies. Outcomes of interest were
clinical and radiographic outcomes which were measured by: (1) Imatani scale;
(2) DASH score; (3) Constant score; (4) UCLA scale; (5) ostheoarthritis; (6)
ossification of the coracoclavicular (CC) ligaments; (7) ASES scale; (8) ACJI;
(9) pain; (10) strength; (11); ACJ width; (12) Poigenfurst criteria; (13) range
of motion; (14) SST; (15) OSS; (16) quality of life (QoL).

 

Figure 1: study flow

Results

A table of all important study characteristics was
conducted (Table 1). In this table
the study’s aim, methods and a differentiation between the conservative group
and the operative group on the basis of: number of patients mean age, mean
follow-up time and technique used, are visible.

 
Author (y)

 
Aim

 
Methods

                  Operative

Conservative

 
Main results

N

MA

MFUT

Tech

N

MA

MFUT

Tech

Calvo E. et al (2006)

Compare incidence of posttraumatic anatomic
alterations after surgical or conservative treatment in Rockwood III ACJ
luxation

Retrospective study. Follow-up for at least 12
months with a questionnaire and physical and radiographic examination

32

39.6y

122.8m

Modified Phemister

11

34.5y

40.5m

Sling and physio-therapy

No statistically significant clinical differences by
using the Imatani scale. Surgically treated group showed significant higher
incidence of both osteoarthritis and ossification of the CC ligament.         

The Canadian Orthopaedic Trauma Society (2015)

Determine which treatment (surgical or conservative)
is superior on both patient-based and surgeon-based outcome measures in the
treatment of ACJ dislocations

Multicentre randomized prospective clinical trial.
Measurements: (1) DASH score at 1 year after surgery; (2) complete clinical
assessment; (3) evaluation of Constant score; (4) radiographic evaluation at
6 weeks and at 3, 6, 12 and 24 months

40

UK

24m

Hook plate

43

UK

24m

Sling and physio-therapy

Significantly better (lower) DASH scores in
conservative group at 6 weeks and 3 months. No significant differences
between the groups after 3 months. Significantly better (higher) Constant scores
in conservatives group at 6 weeks and at 3 and 6 months. No significant
differences between the groups after 6 months. Superior radiographic outcomes
in operative group at all measure times. Patients in conservative groups
returned to work earlier.

De Carli A. et al (2015)

Compare surgical and conservative therapy in
athletes between 18 and 36 years old with type III ACJ luxation by analysing
clinical and radiological results

Retrospective study. Measurements: (1) Constant
score; (2) UCLA scale; (3) ASES; (4) ACJI; (5) subjective evaluation of
patient satisfaction, aesthetic results and shoulder function; (6)
radiographic evaluation. MFUT of 3.5 years

30

29.2y

UK

TightRope™

25

28.5y

UK

Kenny-Howard Splint

The UCLA scale, Constant score and ASES scale show
no significant differences. ACJI is significantly (better) higher in the
surgical group. Radiologic evaluation showed significant differences in
favour of surgical treatment. Conservative treatment shows earlier return to
sports. In both groups, an equal number of patients returns to same level of
sports as before the injury

Esen E. et al (2011)

Compare the effectiveness and results of surgical
and conservative treatment in patients with a Rockwood III ACJ luxation

Retrospective study. Evaluation with Poigenfurst
criteria

17

46.8y

36.1m

Modified Weaver-Dunn

17

40.4y

29.6m

AC bandage

No significant difference according to the
Poigenfurst criteria between the two groups

Fremerey R. et al (2005)

Compare conservative and operative treatment in
patients with an ACJ luxation based on a long follow-up period, by using
objective, subjective and radiologic measurements

Retrospective study. Clinical examination by using
(1) ULCA scale; and (2) Constant score. Subjective outcomes: (1) pain; (2)
throwing ability; (3) satisfaction by using a VAS score. Objective outcomes:
(1) range of motion; (2) strength

32

35.9y

6.1y

Suturing ligaments plus PDS banding

31

33.7y

6.5y

Sling and physio-therapy

No significant differences in clinical outcome, pain
and strength between the two groups. Significantly earlier return to work and
earlier full range of motion in the conservative group

Gstettner C. et al (2008)

Compare surgical treatment using a hook plate with
conservative therapy in the treatment of Rockwood III ACJ dislocations

Retrospective study. Evaluation of clinical and
radiologic examination (CE/RE). CE consisted of (1) Constant score; (2)
subjective SST score and OSS; (3) patient’s evaluation of shoulder function
on a VAS. RE consisted of (1) CC distance; (2) ACJ width; (3) AC arthrosis
and calcification

24

37.2y

32.1m

Hook plate

17

36.2y

36.8m

Sling and physio-therapy

Significant superiority of the surgical group
regarding the Constant score, mainly caused by the subgroups pain and power.
Significant wider ACJ in conservative group. No significant difference in
SST, OSS, patient’s evaluation on shoulder function or CC distance

Joukainen A. et al (2014)

Determine the difference in long-term outcomes
between surgical treatment and conservative treatment in patients with a
Rockwood type III or V ACJ luxation

Randomized controlled trial. Evaluation of Constant
score, UCLA, Larsen score, and SST score. Clinical examination on: (1) range
of motion; (2) pain; (3) cross-arm test. Radiologic examination on: (1) ACJ
width; (2) osteolysis lateral clavicle; (3) calcification CC ligaments

7

53y

18.7y

Kirschner wires

4

54y

19.1y

Kenny-Howard splint

ACJs were significantly more prominent or unstable
in conservative group. No significant differences in Constant score, UCLA,
Larson, or SST scores between the two groups. Mean width was significantly
greater in conservative group

Mah M. and the Canadian Orthopaedic Trauma Society, (2017)

Assess general health status after surgical or
conservative treatment in patients with ACJ luxation

Prospective multicentre Randomized Clinical Trial.
Evaluation of mental and physical health using the SF-36 version 2 survey.
Assessment at 6 weeks, 3 months, 6 months, 1 year and 2 years

37

UK

UK

Hook plate

33

UK

UK

Sling and physio-therapy

Significant better physical health scores in
conservative group at three months. No significant difference in mental
health scores between both groups

Natera-Cisneros N. and Reiriz J. (2017

Compare the QoL of patients treated surgically
versus patients treated conservatively, 24 months or more after ACJ injury

Retrospective cohort study. QoL evaluation with (1)
physical and mental SF-36 score; (2) VAS for pain; (3) DASH score; (4)
Constant score; (5) Global satisfaction; (6) scapular dyskinesis

5

41y

32.5m

Hook plate

4

39y

34.8m

Sling and physio-therapy

No significant differences in QoL, scapular
dyskinesis, calcification of CC ligaments or osteolysis of clavicle between
the two groups were found. ACJ dislocation in 36.36% of patients surgically
treated and in 100% of patients conservatively treated

Prokop A. et al (2003)

Compare surgical and conservative treatment in
patients with a Tossy III ACJ luxation

Prospective study. Clinical and radiologic
evaluation using the Taft score

3

37y

16m

PDS banding

3

30.3y

19.3m

Gilchrist bandage

No differences in pain or Taft score

Table 1: Study characteristics

AC = acromioclavicular; ACJ = acromioclavicular joint;
ACJI = Acromioclavicular Joint Instability; ASES = American Shoulder and Elbow
Surgeon Scale; CC = coracoclavicular; DASH = Disability of Arm, Shoulder and
Hand; m = months; MA = mean age; MFUT = mean follow-up time; N = number of
patients; OSS = Oxford Shoulder Score; QoL = quality of life; SF-36 = Short
Form-36; SST = Simple Shoulder Test; Tech = technique; UCLA = University of California
Los Angeles; UK = unknown; VAS = Visual Analog Scale;

Study characteristics

In total, 10 studies were included in this systematic
review. Three studies were randomized controlled trials (Joukainen, A. et al., 2014; Mah, J. M. & The
Canadian Orthopaedic Trauma Society, 2017; The Canadian Orthopaedic Trauma
Society, 2015). Mah, J.M
& The Canadian Orthopaedic Trauma Society (2017) and The Canadian
Orthopaedic Trauma Society (2015) were both multicentre RCTs. Six studies were
retrospective (Calvo, E. et al., 2006; De Carli, A. et al., 2015;
Esen, E. et al., 2011; Fremerey, R. W. et al., 2005; Natera Cisneros, L. G.
& J. Sarasquete Reiriz, 2017). Prokop, A.
et al (2003) performed a prospective study. Combined, 227 patients with a
Rockwood III ACJ luxation were treated operatively, and 188 patients were
treated conservatively. All studies had a mean follow-up time of at least 12
months. Two studies had a longer follow-up time with a mean of 6.3 years (Fremerey, R. W. et al., 2005) and 18.9
years (Joukainen, A. et al., 2014). Two studies
did not report mean age (Mah, J. M. & The Canadian Orthopaedic Trauma
Society, 2017; The Canadian Orthopaedic Trauma Society, 2015). Amalgamated,
the mean age of the other studies was 40 years in the operative group and 37
years in the conservative group. A wide range of surgical techniques were used.
Four studies used the hook plate (Gstettner, C. et al., 2008; Mah, J. M. & The
Canadian Orthopaedic Trauma Society, 2017; Natera Cisneros, L. G. & J. Sarasquete
Reiriz, 2017; The Canadian Orthopaedic Trauma Society, 2015). Two studies
used PDS banding (Fremerey, R. W. et al., 2005; Prokop, A. et al.,
2003). The four
remaining articles used the modified Phemister technique (Calvo, E. et al., 2006), the
modified Weaver-Dunn technique (Esen, E. et al., 2011), a TightRope™
(De Carli, A. et al., 2015), or Kirschen
wires (Joukainen, A. et al., 2014). Conservative
therapy was provided by a sling in seven studies (Calvo, E. et al., 2006; Fremerey, R. W. et al., 2005;
Gstettner, C. et al., 2008; Mah, J. M. & The Canadian Orthopaedic Trauma
Society, 2017; Natera Cisneros, L. G. & J. Sarasquete Reiriz, 2017; The
Canadian Orthopaedic Trauma Society, 2015), by a
Kenny-Howard splint in two studies (De Carli, A. et al., 2015; Joukainen, A. et al.,
2014), and by a
bandage in two studies (Esen, E. et al., 2011; Prokop, A. et al., 2003). In all
studies, initial conservative therapy was followed by physiotherapy. All these
study characteristics can be found in Table
1.

 

Subgroup analysis

Shoulder function

Objective shoulder function was assessed through
multiple objective scoring systems (Constant score, Imatani scale, Poigenfurst
criteria, Taft score, DASH score, UCLA score, ASES, ACJI, SST score or OSS) in
eight studies (De Carli, A. et al., 2015; Esen, E. et al., 2011;
Gstettner, C. et al., 2008; Joukainen, A. et al., 2014; Prokop, A. et al.,
2003; The Canadian Orthopaedic Trauma Society, 2015)

(Calvo, E. et al., 2006; Fremerey, R. W. et al., 2005). The
Canadian Orthopaedic Society (2015), found a significant difference in DASH
score in the favour of conservative therapy.

 

Pain

Hsbvj

 

Radiologic examination

Jhh

 

Rehabilitation time

gvh

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Esen, E., Ozturk,
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