Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques

Abstract

Background: Acromioclavicular (AC) instability is a frequent injury affecting young and athletic populations. Symptomatic, high-grade dislocations may be managed by a myriad of operative techniques that utilize different grafts to achieve reduction. Comparative data are lacking on the ability of these techniques to achieve excellent patient outcomes and stable AC reduction and to minimize complications. Purpose: To systematically review the outcomes and complications of different techniques of AC joint reconstruction. Study Design: Systematic review and meta-analysis. Methods: The MEDLINE, Scopus, Embase, and Cochrane Library databases were accessed to perform a systematic review of the scientific literature from 2000 to 2018 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following keywords: “acromioclavicular” and “reconstruction.” Included articles were evaluated for loss of reduction, complication rate, revision rate, and change in coracoclavicular distance. Articles were stratified by graft and surgical material used: suture only, Endobutton with suture, TightRope, GraftRope, synthetic artificial ligament, tendon graft, and Weaver-Dunn coracoacromial ligament transfer. These outcomes were pooled using a random-effects model and stratified by surgical technique and arthroscopic versus open reconstruction. Results: Fifty-eight articles were included in the analysis, with 63 homogeneous populations composed of 1704 patients. The mean age was 37.1 years (range, 15-80 years) with a mean follow-up of 34.3 months (range, 1.5-186 months). The overall failure rate was 20.8% (95% CI, 16.9%-25.2%). The overall pooled complication rate was 14.2% (95% CI, 10.5%-18.8%). The most common complications were infection (6.3% [95% CI, 4.7%-8.2%]), fracture to the coracoid or distal clavicle (5.7% [95% CI, 4.3%-7.6%]), and hardware/button failure (4.2% [95% CI, 3.1%-5.8%]). There were no differences between arthroscopic and open techniques in regard to loss of reduction ( P = .858), overall complication rate ( P = .774), and revision rate ( P = .390). Open surgery had a greater rate of clavicular/coracoid fractures than arthroscopic surgery ( P = .048). Heterogeneity, best assessed from the pooled loss of reduction, was measured as I2 = 64.0%. Conclusion: Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. Complications are significant, and profiles vary between surgical techniques, which should be evaluated in the decision making of selecting the technique.