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Combined Intra-articular K-wire and Coracoclavicular Screw Fixation for Type III Acromioclavicular Joint Dislocations- A Randomized Controlled Study with Minimum of 3 Years Follow-up

Sourabh Chachan, Biswajit Sahu

Sourabh Chachan, MBBS, MS (ortho), MRCS (Edin.), Orthopaedic surgeon, Department of Orthopaedics, Changi General Hospital, Singapore
Biswajit Sahu, MBBS, MS (ortho), Associate Professor, Department of Orthopaedics, VSS Medical College, Sambalpur, Odisha, India

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http: //creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Sourabh Chachan, #13-15, Tower B2, 732 bedok reservoir road, Singapore-479262.
Email: drsourabhchachan@gmail.com
Telephone: +6596906470

Received: November 28, 2016
Revised: April 18, 2017
Accepted: April 21 2017
Published online: August 28, 2017

ABSTRACT

BACKGROUND: Treatment of Rockwood type III acromioclavicular dislocations is still controversial with evidence present in favour of both operative and non-operative interventions.

MATERIAL AND METHODS: A prospective randomized controlled clinical trial was conducted at the Department of Orthopaedics of a Level I trauma centre including 54 (male = 34, female = 20) cases of type III acromioclavicular dislocations, randomized into two groups A (operative) and B (non-operative). Group A cases underwent surgery using combined intra-articular K-wire and coracoclavicular screw fixation. Group B cases were treated non-operatively using arm sling and rest.

RESULTS: Mean follow-up period was 40.8 months (range = 36-49). Mean Constant Shoulder scores for group A and B were 93 and 83.5 after 12 months (p value ≤ 0.0001); 93.3 and 86.5 after 36 months (p value ≤ 0.0001), respectively. Complications reported from group A were hardware failure, heterotopic ossification, distal clavicle osteolysis and superficial stich infection and from group B were cosmetic deformity and intermittent pain around shoulder.

CONCLUSIONS: In this study, operatively managed cases did significantly better than the non-operatively treated ones with faster and improved functional outcomes.

Key words: Acromioclavicular dislocations; Coracoclavicular screw; Constant shoulder score

© 2017 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Chachan S, Sahu B. Combined Intra-articular K-wire and Coracoclavicular Screw Fixation for Type III Acromioclavicular Joint Dislocations- A Randomized Controlled Study with Minimum of 3 Years Follow-up. International Journal of Orthopaedics 2017; 4(4): 796-801 Available from: URL: http: //www.ghrnet.org/index.php/ijo/article/view/1936

INTRODUCTION

Acromioclavicular dislocation is quiet common with most common mode being direct trauma due to fall on shoulder[1]. Treatment of Rockwood type III acromioclavicular dislocations is still controversial with evidence present in favour of both operative and non-operative interventions[1,2,3,4,5]. Various operative modalities available for fixation of acromioclavicular dislocations are intra-articular fixation with K-wires or Steinmann pins, ligament reconstruction procedures and extra-articular coracoclavicular repairs[1]. Each modality has its own advantages and limitations. This study was conducted to compare the outcomes of combined intra-articular K-wire fixation and coracoclavicular screw repair against non-operative management for type III acromioclavicular dislocations.

Materials and Methods

Between January 201 and April 2013, a prospective randomized controlled clinical trial was conducted at the department of orthopaedics of a tertiary care centre. 54 (males = 34, females = 20) cases of Rockwood type III (OTA type 10B3.3 and 10B3.4) acromioclavicular dislocations were included in this study[1,2]. Two groups were created, group A (operative) received surgery with combined intra-articular k-wire and coracoclavicular screw fixation, whereas group B (control) received conservative management. All the cases were evaluated clinically and radiography was performed with anterior-posterior, lateral and Zanca views. Inclusion and exclusion criteria for patients were set (Table 1). All the surgeries were done by single surgeon. Evaluation was done using Constant Shoulder score at follow-up visits. Statistical analysis was done using unpaired student’s t-test.

Table 1 Inclusion and Exclusion Criteria for study
 Inclusion CriteriaExclusion Criteria
1)Isolated AC joint dislocationAssociated injuries
2)Acute, <7 days old>7 days old
3)Closed dislocationOpen dislocation, soft tissue injury
4)Rockwood type III injury (OTA type 10B3.3, 10b3.4)Rockwood Type I, II, IV, V, VI
5)Age= 20-50 yearsAge= <20 or > 50 years
6)Normal neuro-vascular status of the limbAbnormal neuro-vascular status of the limb due to current or pre-existing conditions
AC: acromioclavicular; OTA: Orthopaedic Trauma Association

Surgical technique

(1) General anaesthesia was used. (2) Patient was placed supine on operation table. (3) Whole limb along with neck and chest prepared with antiseptic solutions. (4) A curvilinear incision of appropriate size was taken over shoulder. (5) Soft tissue dissection was done to reach joint surface. (6) Joint was debrided free of any interposing soft tissue and haematoma was evacuated. (7) Open reduction of acromioclavicular joint dislocation was achieved. (8) Joint was fixed with two 2.0 mm K- wires, driven from acromion to clavicle traversing acromioclavicular joint. (9) Then coracoclavicular repair was performed with 6.5 mm cannulated cancellous lag screw. (10) Acromioclavicular joint capsule was repaired. (11) Wound closed in layers.

Post-operative protocol

Antibiotics and analgesics were given as required. Shoulder immobiliser was given for two weeks. Active and passive range of motion exercises were begun on 15th postoperative day and were increased as tolerable. Overhead abduction, weight lifting more than 4lbs, and sports participation was restricted for 12 weeks. K wire removal was performed at 4 weeks and coracoclavicular screw was removed at 12 weeks.

Conservative treatment protocol

Patients were given oral analgesics and arm sling for 7-10 days. Range of motion exercises were instituted as soon as tolerable. Heavy weight lifting, overhead abduction and active sports participation were restricted for at least 12 weeks or till there was no pain on palpation.

RESULTS

Mean age of all cases was 32.8 years (range = 22-45 years). Group A had 25 (males = 16, females = 9) cases while group B had 29 (males = 18, females = 11) cases (Table 2). Mean age of group A cases was 33.6 years while for group B was 32.1 years (p value = 0.22). Mean time between injury and surgery was 2.8 days (range 1-6 days). Mean follow-up period was 40.8 months (range = 36-49 months).

Table 2 Age and Gender distribution of Patients
Age & Gender groupGroup A (operative)Group B (non-operative)
1 21-30 years Male710
2 21-30 years Female33
3 31-40 years Male48
4 31-40 years Female56
5 41-50 years Male50
6 41-50 years Female12
7 TotalMales=16, Females=9Males=17, Females=11

Post-operatively, the average Constant shoulder score for group A at 2 weeks, 3, 6, 12 and 36 months was 22, 54.5, 76.5, 93 and 93.3, respectively (Table 3). For group B, the Constant shoulder score at 2 weeks, 3, 6, 12 and 36 months was 21.1, 42.4, 63.9, 83.5 and 86.6, respectively (Table 4). The Constant shoulder score improved progressively in both the operative and non-operative groups. At 2 weeks post-surgery, there was no statistically significant difference between the Constant shoulder scores for operative and non-operative group (Table 5). However, from 3 months onwards till 36 months follow-up, the average Constant shoulder scores for operative group remained significantly better than the non-operative group (Table 5).

Table 3 Group A (Operative).
Sr. No. Age & SexInj-Sx time (days)Follow-up period (months)Constant Shoulder ScoresComplications
2 weeks 3 months 6 months 12 months 36 months
123M6372458799493nil
229M2452255829293nil
333M3462658809090Coracoclavicular screw pull-out & Distal clavicle osteolysis
445M5482051789293nil
539M3362456769089nil
633M3382051739495nil
725M2372658829897nil
839M3391851769092Superficial stitch infection
945M3382053829895nil
1023M2451855809698nil
1141M2472051799092nil
1227M4372256829495nil
1343M4461851809495nil
1429M2362053799290Heterotopic ossification
1543M2482856829695nil
1623M2452055829496nil
1733F3422058799089nil
1837F3372251799291nil
1943F2402253769492K-wire failure
2023F1392256789296nil
2129F3362658829698nil
2231F4402453799294nil
2337F3422455829492nil
2439F1402058809293nil
2529F2402453789089Heterotopic ossification

Table 4 Group B (Non-operative).
Sr. No.Age & SexFollow-up period (months)Constant Shoulder ScoresComplications
2 weeks 3 months 6 months 12 months 36 months
124M382043628990poor cosmesis
226M402241668185nil
334M362041648388poor cosmesis & intermittent pain
422M451841628384intermittent pain
540M382246647986poor cosmesis
636M362447688186intermittent pain
734M382041668385intermittent pain
826M452241648788poor cosmesis & intermittent pain
938M462443628590poor cosmesis
1030M462446627984poor cosmesis & intermittent pain
1136M452646648184intermittent pain
1230M391841648388intermittent pain
1338M452039628588intermittent pain
1428M451637648389intermittent pain
1524M422041668789intermittent pain
1630M362443628185nil
1740M361841648587poor cosmesis
1822M392243627978poor cosmesis & intermittent pain
1938F491846648992nil
2026F402047668389poor cosmesis & intermittent pain
2134F382046648590poor cosmesis
2232F412443628185intermittent pain
2338F482446648585intermittent pain
2422F382241668990nil
2542F381839648790poor cosmesis & intermittent pain
2628F372237627980poor cosmesis & intermittent pain
2732F402241688185poor cosmesis
2838F372243648382poor cosmesis & intermittent pain
2944F382039628589poor cosmesis

Table 5 Mean Constant Shoulder Scores of both groups
TimeGroup A (operative) CS scoresGroup B (non-operative) CS scoresT-valuep-value (student t-test)
2 weeks2221.11.269p=0.2102
3months54.542.415.978p=<0.0001
6months76.563.926.959p=<0.0001
12months9383.512.53p=<0.0001
36 months93.386.68.158P=<0.0001
CS score: Constant Shoulder Score

2 cases from group A (incidence = 8%) were complicated by hardware failure, one case had K-wire back-out (Figure 3) and other had coracoclavicular screw pull-out (Figure 4). 1 case from operative group (incidence = 4%) had superficial stitch infection which subsided with antibiotics. Heterotopic ossification was seen in 2 cases in group A (incidence = 8%) (Figure 5). Osteolysis of distal clavicle was observed in 1 case who also had coracoclavicular screw pull-out(incidence = 4%) (Figure 6). In group B, 15 (incidence = 51.7%) cases were unsatisfied with the cosmetic appearance of shoulder and 18 patients (incidence = 62.1%) reported intermittent pain around the shoulder which was mild to moderate in intensity. All other cases had a completely uneventful recovery with constant improvement in shoulder range of motion, strength, functional ability and Constant Shoulder scores.

Figure 1 A: Case 1 pre-op X-ray; B: Case 1 post-op X-ray.

Figure 2 A: Case 2 pre-op X-ray; B: Case 2 post-op X-ray.

Figure 3 K-wire back-out.

Figure 4 Coracoclavicular screw pull-out.

Figure 5 Heterotopic Ossification.

Figure 6 Distal clavicle osteolysis.

DISCUSSION

Historically most of these cases have been treated conservatively with various bandages, slings and rest[1]. But as the technology improved and functional demands of the patients increased, the importance of having a perfect acromioclavicular joint with normal shoulder biomechanics became more obvious. The stability of acromioclavicular joint depends upon the ligamentous structures around it[1]. Most important is the coracoclavicular ligament[1]. This ligament is majorly involved in weight transmission across the pectoral girdle[1]. Currently, conservative treatment is indicated in Rockwood type I and II injuries only and types IV, V, VI are universally accepted as indications for operative management[1,2,4].The treatment of type III acromioclavicular joint injuries is still controversial[1,2,3,4,5]. Although, various studies have compared operative and non-operative treatment methods, but there is lack of consistency in the treatment methods employed in these studies[1,2,3].The use of numerous non-operative methods like strapping, slings, bandages, braces, etc. have been reported[1,3,6-9]. Many authors have reported good results with non-operative treatments and outcomes as good as operative treatments with relatively less complications[3,6-13]. Operative modalities have been broadly divided into intra-articular fixations, coracoclavicular repairs and ligament reconstruction procedures[1]. Intra-articular fixation includes use of Steinmann pins, K-wires, tension band wiring etc. for maintaining joint reduction and many authors have reported technical difficulties with placing of pins across the joint and also the fixation is less rigid with early loss of reduction and hardware pull-out[1]. Ligament reconstruction procedures like anatomical reconstructions and Weaver-Dunn procedures have gained widespread popularity recently[1,14]. Coracoclavicular repairs can be achieved with coracoclavicular screw, Dacron cerclage technique, mersilene tapes, biological screws etc[1,15,16-21]. The treatment of acromioclavicular joint injuries with coracoclavicular repair is based upon the fact that coracoclavicular ligament is ruptured in all cases of complete acromioclavicular dislocations[1]. Consequently the gap between coracoid process and clavicle increases and also weight transmission across pectoral girdle is hampered[1]. Coracoclavicular repairs helps in normalising the clavicle-coracoid process gap and apposes torn edges of coracoclavicular ligament for good healing[1]. The use of open and percutaneous techniques for coracoclavicular screw placements has also been reported[24]. But fixation with only coracoclavicular screw was reported to produce results only comparable to non-operative management and was associated with high complication rates of hardware failure[15,22-24]. To provide a stable joint, generally two or three surgical modalities like K-wire with ligament reconstruction or ligament repair with tension band wiring are combined. In 2006 Lin et al compared coracoclavicular fixation and acromioclavicular joint tension band wiring against coracoclavicular fixation and coracoacromial ligament reconstruction and found comparable outcomes in both the groups[5]. In this study, we combined the two surgical modalities of intra-articular K-wires and coracoclavicular repair with screw to provide a more rigid construct and at the same time to decrease the common complications like hardware pull-out. On final analysis, we found that Constant Shoulder Score improvement was significantly (p value ≤ 0.0001) better in operatively treated group as compared to the non-operatively managed cases. In group A, only 20% cases reported complications as compared to about 69% cases reporting complications from the non-operatively treated group. This study shows that type III acromioclavicular dislocations can benefit from timely operative intervention in the form of combined intra-articular K-wire fixation and coracoclavicular repair with screw. Although non-operatively managed cases also showed constant improvement in Constant Shoulder Scores in this study but operatively managed cases performed significantly better both in terms of functional outcomes and complication rates.

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Peer reviews: Abdel-Rahman Aly; Rubén Arellano; Ashish Babhulkar

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