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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 44-48

Surgical fixation of Rookwood Type III–V acromioclavicular joint dislocation with acromioclavicular: Hook plate


Department of Orthopaedics, Mysore Medical College and Research Institute, Mysore, Karnataka, India

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Idris Kamran
Room No. 115, Mysore Medical College and Research Institute, PG Hostel for Men, Irwin Road, Mysore - 570 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_5_18

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  Abstract 

Context: Acromioclavicular (AC) joint dislocation is one of the common shoulder problems accounting for 9% of all shoulder injuries and occurs five times more frequently in men than in women. Aims: In the present study, we aim to assess the functional outcome of hook plate fixation for the treatment of acute Rockwood Type III–V AC joint dislocation and to know the complications associated with the implant. Settings and Design: This was a prospective study. Subjects and Methods: Twenty patients, both male and female, with a mean age of 42 years who had acute dislocation of the AC joint were included for the study. Nine patients had Type III, four patients had Type IV, and 7 patients had Type V dislocation according to Rockwood classification. Patients were followed up till 6 months and were evaluated using Constant–Murley score. Statistical Analysis used: For the statistical analysis, descriptive statistics were calculated with the objective of summarizing the set of data analyzed. Results: The mean Constant–Murley score was 82.5 at 6-month follow-up. Four patients had complications of which one had superficial infection, two had subacromial erosion, and one had osteoarthritis of AC joint. Conclusions: Radiographic outcome based on the maintenance of reduction indicates that hook plate fixation is a better treatment option and is an effective method for the treatment of AC joint dislocation. Osteoarthritis and osteolysis are two common complications, which are associated with impairment of shoulder function. Shoulder function will be improved after the removal of hook plate.

Keywords: Acromioclavicular hook plate, acromioclavicular joint dislocation, Constant–Murley score, Rockwood Type III–V


How to cite this article:
Lingaraju K, Kamran I, Shobha H P, Wahaj S. Surgical fixation of Rookwood Type III–V acromioclavicular joint dislocation with acromioclavicular: Hook plate. J Orthop Traumatol Rehabil 2018;10:44-8

How to cite this URL:
Lingaraju K, Kamran I, Shobha H P, Wahaj S. Surgical fixation of Rookwood Type III–V acromioclavicular joint dislocation with acromioclavicular: Hook plate. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2021 Sep 20];10:44-8. Available from: https://www.jotr.in/text.asp?2018/10/1/44/239261


  Introduction Top


Acromioclavicular (AC) joint dislocation is one of the common shoulder problems accounting for 9% of all shoulder injuries.[1] It can result from both direct and indirect trauma. Direct trauma is caused by superiorly directed impact on the lateral part of the shoulder with arm in adducted position forcing the arm in an inferior direction.[2],[3] Indirect trauma generally results from fall on an adducted and outstretched arm causing the humeral head to be driven into the inferior aspect of the acromion and the joint itself.[4]

On the basis of magnitude and direction of dislocation, Rockwood et al.[5] introduced a classification system to classify AC joint dislocations from Grade I to VI. It is generally accepted that Types I and II can be managed conservatively, conservative or operative is still controversial for Type III injuries, and Types IV–VI injuries are treated operatively.[6] Various surgical options have been developed including fixation across the AC joint by tension band wiring or fixing using K-wires and extra-articular Bosworth screws to maintain reduction. However, both of these techniques lead to a nondynamic fixation, which can lead to loosening or breakage of the implant,[7],[8] and then came other surgical modalities such as coracoacromial ligament transfer (Weaver–Dunn procedure), coracoclavicular (CC) fixation, and AC or CC reconstruction. However, the clinical superiority of these procedures remains debatable, and various complications have been reported.[9],[10]

Later, AC hook plates were developed as an alternative method of fixation for dislocations of AC joint in which the hook of the plate is inserted under the acromion process and plate fixed to the lateral clavicle. The plate by maintaining reduction of the joint promoted natural healing of the ligaments.[11] However, concerns were raised about subacromial impingement, subacromial erosion, osteoarthritis of AC joint, and even rotator cuff injuries for which early removal of plate was advocated.[12]

In the present study, we aim to assess functional outcome of hook plate fixation for the treatment of acute Rockwood Type III–V AC joint dislocation without CC ligament reconstruction and to know the complications associated with the implant.


  Subjects and Methods Top


Twenty patients, both male and female, who had acute dislocation of the AC joint and with AC hook plate fixation were included in the study. All patients had closed fractures. Patients with open injuries and severe soft-tissue compromise were excluded from the study. Sixteen were male patients and four were female patients. The mean age of patients was 42 years (age range from 20 to 50 years). Right AC joint was injured in 12 patients and left in eight patients.

Road traffic accidents (n = 13) were major form of injury where patients had direct trauma to their shoulder. Five patients had self-fall on their shoulder. Two had sports injuries [Figure 1]. Patients were evaluated using anteroposterior radiograph for both shoulders and classified according to Rockwood classification [Figure 2]. Nine patients had Rockwood Type III [Figure 3], four patients had Type IV, and seven patients had Type V dislocation [Figure 4].
Figure 1: Bar diagram showing distribution of Mech of injury in males and females in the study

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Figure 2: Graphical representation of Rockwood AC joint dislocation types in the study

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Figure 3: Preoperative X-ray of case 1

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Figure 4: Preoperative X-ray of case 2

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Surgical technique-Patient put in beach-chair position. Tranverse incision made over lateral end of clavicle and acromion. After cutting the deltotrapezial fascia, the joint was reduced by direct visualization and appropriately sized hook plate was applied with the hook positioned posteroinferior to the acromion. Finally, the plate was then fixed to the clavicle using screws. No supplemental repair or reconstruction of CC/AC ligaments was done. Wound closed and arm sling were used for 14 days postoperatively.

Passive-assisted range of motion started from postoperative day 3 as per pain tolerance. Progressive rehabilitation was initiated after 2 weeks. All patients were allowed to use their arm for daily activities, and nonrestricted movement was allowed at 6 weeks postoperatively [Figure 5]. Lifting weights were allowed from 3 months postoperatively. Patients were followed up till 6 months [Figure 6] and [Figure 7] and at final follow-up were evaluated using Constant–Murley score [Figure 8], [Figure 9], [Figure 10].
Figure 5: Postoperative X-ray at 3 months of case 2

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Figure 6: Postoperative X-ray at 6 months in case 1

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Figure 7: Range of motion at 6 months case 2

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Figure 8: Clinical picture of range of motion at 6 months in case 1

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Figure 9: Clinical picture of abduction in case 1 at 6 months

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Figure 10: Clinical picture of internal rotation case 1 at 6 months

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After evaluating the score, hook plate removal was considered at 6 months postoperatively. Constant murley score has 4 compoents: Pain, activity level, range of motion, strength. Pain (maximum score: 15 points); activity level (maximum score: 20 points); range of motion (maximum score: 40 points); strength (maximum score: 25 points), total score of 100 points. The better the function, the higher the score (Source for Constant–Murley score table: http://www.eoj.eg.net).


  Results Top


Patients were followed up at 1, 3, and 6 months postoperatively. Radiological assessment was done at each follow-up by taking anteroposterior X-ray for both shoulders to check for subacromial erosion, osteolysis of lateral clavicle, osteoarthritis of the AC joint, and loss of reduction, which were assessed by measuring the distance between coracoid process and the clavicle and compared these with the contralateral side. At final follow-up at 6 months, two patients had subacromial erosion [Figure 11] and one had osteoarthritis of AC joint.
Figure 11: Postoperative X-ray 6-month case 2 with subacromial erosion

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Patients were analyzed for functional outcome at 6-month follow-up. The mean Constant–Murley score was 82.5 at final follow-up which has a maximum score of 100 points. Four patients had complications of which one had superficial infection which was treated by intravenous antibiotics and regular dressing for 3 days followed by oral antibiotics for 1 week. No deep infection or neurovascular deficits were seen. Two patients had subacromial erosion and one had osteoarthritis of AC joint where patients complained of pain on shoulder abduction beyond 90° [Figure 12]. This subsided once hook plate was removed at 6 months after the surgery. None of the patients had loss of reduction, fracture of acromion or lateral clavicle, or implant failure.
Figure 12: Clinical picture of painful abduction in case 2 at 6 months

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  Discussion Top


Conventionally, K-wires or tension band wiring and extra-articular Bosworth screw were used to maintain reduction. However, these techniques lead to loosening and breakage of the implant. Other surgical modalities such as coracoacromial ligament transfer (Weaver–Dunn procedure), CC fixation, and AC or CC reconstruction are also used. However, the clinical superiority of these procedures remains debatable, and various complications have been reported with these techniques.[13] On the other hand, AC hook plate has become widely used as it enables secure fixation against horizontal, rotational, and vertical forces as well as allows early joint motion. The plate by maintaining reduction of the joint promotes natural healing of the ligaments and avoids direct injury to the joint because it is not fixed by pins or screws into the AC joint.[3],[14] Previous studies have reported satisfactory clinical results of hook plate fixation for AC joint dislocation.[15]

In our study, mean Constant–Murley score was 82.5 at 6-month follow-up and was comparable with similar study by Yoon et al.[16] which had Constant–Murley score of 90.2. Patients returned to their activities as early as 2 weeks and were comparable with results of similar earlier studies. Lin et al. demonstrated that AC hook plate could cause subacromial shoulder impingement and rotator cuff lesion, and they advocated the removal of the implant as soon as ligamentous healing is achieved that is by 6 months.[17]

In our study, two patients had subacromial erosion and one had osteoarthritis of AC joint causing pain on overhead abduction which subsided with removal of implant. There were no loss of reduction and therefore no need for any secondary surgery for reduction apart from surgery for removal of implant.[18] The CC distance was maintained after the removal of hook plate. Based on radiographic maintenance of reduction, hook plate fixation is considered superior, despite the higher incidence of acromial erosion, osteoarthritis associated with this technique which can be avoided by timely removal of the implant.[19],[20] The limitation of our study is a relatively small sample size (20 patients) and absence of control group.


  Conclusions Top


Radiographic outcome based on the maintenance of reduction indicates that hook plate fixation is a better treatment option and is an effective method for the treatment of AC joint dislocations. Osteoarthritis, subacromial osteolysis, and subacromial shoulder impingement are the common complications which are associated with hook plate, resulting in pain and impairment of shoulder function. Shoulder function will be improved after removal of the hook plate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mazzocca AD, Arciero RA, Bicos J. Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 2007;35:316-29.  Back to cited text no. 1
    
2.
Willimon SC, Gaskill TR, Millett PJ. Acromioclavicular joint injuries: Anatomy, diagnosis, and treatment. Phys Sportsmed 2011;39:116-22.  Back to cited text no. 2
    
3.
Flinkkilä T, Ristiniemi J, Lakovaara M, Hyvönen P, Leppilahti J. Hook-plate fixation of unstable lateral clavicle fractures: A report on 63 patients. Acta Orthop 2006;77:644-9.  Back to cited text no. 3
    
4.
Calvo E, López-Franco M, Arribas IM. Clinical and radiologic outcomes of surgical and conservative treatment of type III acromioclavicular joint injury. J Shoulder Elbow Surg 2006;15:300-5.  Back to cited text no. 4
    
5.
Rockwood CA Jr., Williams GR, Young DC. Injuries to the acromioclavicular joint. In: Rockwood CA Jr., Green DP, Buchholz RW, Heckman JD, editors. Fractures in Adults. Philadelphia: Lippincott Raven; 1996. p. 1341-413.  Back to cited text no. 5
    
6.
Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study. J Bone Joint Surg Am 1986;68:552-5.  Back to cited text no. 6
    
7.
Schindler A, Schmid JP, Heyse C. Temporary fixation with the Balser hook plate in the treatment of a fresh and complete acromioclavicular joint dislocation. Results of the follow-up of 41 patients. Unfallchirurg 1985;88:533-40.  Back to cited text no. 7
    
8.
Graupe F, Dauer U, Eyssel M. Late results of surgical treatment of tossy III acromioclavicular joint separation with the balser plate. Unfallchirurg 1995;98:422-6.  Back to cited text no. 8
    
9.
Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br 1989;71:848-50.  Back to cited text no. 9
    
10.
Hoffler CE, Karas SG. Transacromial erosion of a locked subacromial hook plate: Case report and review of literature. J Shoulder Elbow Surg 2010;19:e12-5.  Back to cited text no. 10
    
11.
Di Francesco A, Zoccali C, Colafarina O, Pizzoferrato R, Flamini S. The use of hook plate in type III and V acromio-clavicular Rockwood dislocations: Clinical and radiological midterm results and MRI evaluation in 42 patients. Injury 2012;43:147-52.  Back to cited text no. 11
    
12.
von Heideken J, Boström Windhamre H, Une-Larsson V, Ekelund A. Acute surgical treatment of acromioclavicular dislocation type V with a hook plate: Superiority to late reconstruction. J Shoulder Elbow Surg 2013;22:9-17.  Back to cited text no. 12
    
13.
Ejam S, Lind T, Falkenberg B. Surgical treatment of acute and chronic acromioclavicular dislocation tossy type III and V using the hook plate. Acta Orthop Belg 2008;74:441-5.  Back to cited text no. 13
    
14.
Hackenbruch W, Regazzoni P, Schwyzer K. Surgical treatment of lateral clavicular fracture with the “clavicular hooked plate”. Z Unfallchir Versicherungsmed 1994;87:145-52.  Back to cited text no. 14
    
15.
Meda PV, Machani B, Sinopidis C, Braithwaite I, Brownson P, Frostick SP, et al. Clavicular hook plate for lateral end fractures: A prospective study. Injury 2006;37:277-83.  Back to cited text no. 15
    
16.
Yoon JP, Lee BJ, Nam SJ, Chung SW, Jeong WJ, Min WK, et al. Comparison of results between hook plate fixation and ligament reconstruction for acute unstable acromioclavicular joint dislocation. Clin Orthop Surg 2015;7:97-103.  Back to cited text no. 16
    
17.
Lin HY, Wong PK, Ho WP, Chuang TY, Liao YS, Wong CC, et al. Clavicular hook plate may induce subacromial shoulder impingement and rotator cuff lesion – Dynamic sonographic evaluation. J Orthop Surg Res 2014;9:6.  Back to cited text no. 17
    
18.
De Baets T, Truijen J, Driesen R, Pittevils T. The treatment of acromioclavicular joint dislocation tossy grade III with a clavicle hook plate. Acta Orthop Belg 2004;70:515-9.  Back to cited text no. 18
    
19.
ElMaraghy AW, Devereaux MW, Ravichandiran K, Agur AM. Subacromial morphometric assessment of the clavicle hook plate. Injury 2010;41:613-9.  Back to cited text no. 19
    
20.
Chiang CL, Yang SW, Tsai MY, Kuen-Huang Chen C. Acromion osteolysis and fracture after hook plate fixation for acromioclavicular joint dislocation: A case report. J Shoulder Elbow Surg 2010;19:e13-5.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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