Conservative vs surgical approach for ACJ rockwood type 3 injury

1. JOURNAL CLUB
Presenter : Dr. Renjith R John
Moderators: Dr. Prajwal mane
Dr. Deepak Pinto

3. Aim of the review
• The most appropriate approach for acute Rockwood type III
ACJ dislocation
– surgical / conservative ??
• Analyze operative and conservative outcomes to guide
orthopedics in daily practice.

4. ACJ injuries
• Represents about 10% of all injuries to the scapular girdle.
• Usually in males <30 yrs
• Fol by direct high energy trauma to the shoulder

5. Mechanisms of injury
1) Medially directed force at lateral shoulder
drives the acromion underneath the distal clavicle
2) Fall on outstretched arm, locked elbow extension
drives humeral head superiorly into the acromion

8. Materials and methods
Study by PRISMA
• Preferred Reporting Items for Systematic Reviews and Meta-Analyses
• Evidence-based minimum set of items for reporting in systematic reviews and
meta-analyses.
• Primarily focuses on reporting of reviews evaluating the effects of interventions.
• AIM - help authors improve the reporting of systematic reviews and meta-
analyses.

9. Inclusion criteria
• Review articles
• RCTs
• Prospective and retrospective studies with Levels of Evidence
1 to 4
• conservative or surgical treatment in acute type III ACJ
dislocation between 2000 and 2022 with a mean follow-up
of 24 months .

10. Exclusion criteria
• Biochemical and in-vitro studies
• Case reports
• Editorials
• Technical reports
• Preclinical studies
• Studies with LOE 5
For a better quality of study

11. Search Strategy
• 4 databases- Pubmed, Scopus, Embase and Medline
• 2000 to march 2022
• 1360 studies found

13. Data extraction
• Study design
• LOE
• Sample size
• Mean age
• Studies followed up
• No. patients lost at follow up
• Surgical technique and conservative approach used
• Constant score
• Radiological ACD
• CCD
• complications

14. Data Analysis
Meta-analysis on clinical and
radiographic outcomes
– surgical vs conservative
CS, ACD and CCD
were considered for the
comparative studies

15. Constant murley score
CMS - outcome measuring tool.
Multi-item functional scale assessing pain, ADL,
ROM and strength of the affected shoulder.
0 to 100 – represents worst and best shoulder
function, respectively.

16. Conservative – 73
Surgical – 110

18. Surgical techniques
1) Hook plate
2) Modified phemister technique
3) Modified weaver dunn procedure
4) Tight Rope
VS
Conservative Approach
- Immobilization with shoulder sling

19. Complications : acromial fracture ,
hardware prominence
Superior clavicular plates with
lateral hooks / AC hook plates
Modified Weaver Dunn
Procedure

20. Intra-thoracic migration of k-wire

21. Tight-Rope technique
Device consists of 2 buttons
- one round clavicle button and
- one oblong coracoid button.
The buttons are joined by a
continuous loop of 5 fibre wires

24. CM score

25. ACD

26. CCD

27. Conclusion
• The systematic review and meta-analysis showed statistically
significant superiority of the mean ACD in the surgical groups on
radiological follow up over the conservative group
• Also better radiological and clinical results (CCD and CS scores)

28. References
• Tornetta P, Edgar C. Acromioclavicular injuries. In: Rockwood and Green’s
fractures in adults. 8th ed. Philadelphia: Wolters Kluwer; 2015.
• Via RG, Bosco F, Giustra F, Lavia AD, Artiaco S, Risitano S, et al. Acute Rockwood
type III ACJ dislocation: Conservative vs surgical approach. A systematic review and
meta-analysis of current concepts in literature. Injury-international Journal of the Care
of the Injured . 2022 Oct 1;53(10):3094–101.
• Beaty JH, Daugherty K, Jones L, Campbell WC, Masciolli A. Acute dislocations. In:
Campbell’s Operative Orthopaedics. 14th ed. Philadelphia, PA: Elsevier; 2021.
• Vrotsou K, Ávila M, Machón M, Mateo-Abad M, Pardo Y, Garin O, et al. Constant–
Murley Score: systematic review and standardized evaluation in different shoulder
pathologies. Quality of Life Research. 2018 May 10;27(9):2217–26.

29. Critical Appraisal
• Was the purpose of the study stated clearly ?
YES
Was the relevant background literature reviewed ?
YES
Was the study design appropriate ?
YES

30. • Was sampling appropriate ?
YES
Was the outcome measures reliable ?
YES
Can the results be applicable to local population ?
YES

31. THANK YOU