- Open Access
Mid-term results after operative treatment of rockwood grade III-V Acromioclavicular joint dislocations with an AC-hook-plate
© I. Holzapfel Publishers 2011
Received: 16 July 2010
Accepted: 4 August 2010
Published: 24 February 2011
Acromioclavicular joint dislocations often occur in athletic, young patients after blunt force to the shoulder. Several static and dynamic operative procedures with or without primary ligament replacement have been described. Between February 2003 and March 2009 we treated 313 patients suffering from Rockwood III-V lesions of the AC joint with an AC-hook plate. 225 (72%) of these patients could be followed up. Mean operation time was 42 minutes in the conventional group and 47 minutes in the minimal invasive group. The postoperative pain on a scale from 1 to 10 (VAS-scale) was rated 2.7 in the conventional group and 2.2 in the minimal invasive group. Taft score showed very good and good results in 189 patients (84%). Constant score showed an average of 92.4 of 100 possible points with 89% excellent and good results and 11% satisfying results. All patients had some degree of pain or discomfort with the hookplate in place. These symptoms were relieved after removal of the plate. The overall complication rate was 10.6%. There were 6 superficial soft tissue infections, 1 fracture of the acromion, 7 redislocations after removal of the hook-plate. We observed 4 broken hooks which could be removed at the time of plate removal, 4 seromas and 2 cases of lateral clavicle bone infection, which required early removal of the plate. We can conclude that clavicle hook plate is a convenient device for the surgical treatment of Rockwood Grade III-V dislocations, giving good mid-term results with a low overall complication rate compared to the literature. Early functional therapy is possible and can avoid limitations in postoperative shoulder function.
Acromioclavicular joint dislocations and fractures of the lateral end of the clavicle are common injuries in orthopaedic surgery and sports medicine. These injuries often occur in athletic, young patients after blunt force to the shoulder . While conservative treatment is the option of choice for Rockwood Type I and II acromioclavicular injuries and most fractures of the shaft and the medial part of the clavicle, operative treatment is still discussed controversially for Rockwood type III injuries and is the option of choice for type IV - VI injuries and Jaeger and Breitner type IIa fractures of the lateral clavicle [1–5]. Reason for the instability that lead to a relative dislocation of the lateral clavicle is the involvement of the coracoclavicular ligaments. The mechanism of injury is usually a direct trauma to the superior aspect of the acromion in relation to the distal end of the clavicle [6, 7]. For the reconstruction of acromioclavicular joint separation several static and dynamic operative procedures with or without primary ligament replacement have been described. Techniques, that focus on the primary healing of the coracoclavicular ligaments, by holding the clavicle in a reduced position, which is usually sufficient in cases of primary reconstruction, include tension bands and K-wires applied through the acromioclavicular joint and extraarticular Bosworth screws to maintain reduction . Both techniques lead to a non-dynamic fixation, which can lead to loosening or breakage of the metalwork [1, 9, 10]. Other more dynamic fixation techniques use plate fixation to keep reduction of the lateral clavicle [11, 12]. One disadvantage of the Balser plate is that it can only maintain coracoclavicular distance, but not anterior-posterior dislocation and width of the acromiclavicular joint. Early limited physiotherapy is possible after this procedure . Wolter introduced an AC-hook plate with an additional vertical hook as an alternative to the Balser plate in 1882 . This plate complementary maintains reduction of anterior-posterior dislocation and acromioclavicular joint width and can be used for the treatment of acromioclavicular luxation and fractures of the lateral clavicle . In some cases this device also has been used for sternoclavicular joint dislocations . After modification of the plate in 2005 it is also available with locked screws, which gives extra stability for the treatment of fractures of the lateral clavicle and makes minimal invasive application of the plate with the use of only two screws possible. Previous studies proved, that acromioclavicluar fixation techniques are more successful than coracoclavicular fixation techniques . Lately, arthroscopically-assisted repair techniques with focus on restoration of the coracoclavicular ligaments have been described and successfully applied for acromioclavicular joint reconstruction using Tight-rope devices [1, 18]. Today more than 150 different surgical and conservative treatment options are described for the treatment of AC-joint dislocations and they are still discussed controversially . Complication rates vary depending on the different operative technique but can be as high as 60% [4, 20].
Materials and methods
The treatment protocol included inpatient surgery, single shot antibiotics with the use of Cefazolin (Fresenius KaBi Dtl, Bad Homburg, Germany), postoperative immobilisation with Gilchrist-Bandage for four to six days and limitation of ROM to 90° of abduction and anteversion for six weeks under the instruction of a physiotherapist. Removal of metalwork was scheduled after 12 weeks. After that we treated with physiotherapy for 4 weeks. Minimal invasive approach was used in 134 cases. We included 262 male and 51 female patients. Mean age was 38.4 years (range, 23 - 68 years). Coherent data of ordinal scaled variables were tested using the Student's t-test. Statistical significance was tested with the Wilcoxon test for related and nonrelated samples. Differences were considered significant at p > 0.05.
225 patients (72%) could be followed up within a mean follow-up-period of 36 months (range, 10 - 71 months). At follow up we performed clinical examination with determination of the Constant-Murley and Taft score [23, 24]. Native X-ray was used to determine AC-joint width (AC-joint) and coracoclavicular distance (CCDistance) in correlation to the preoperative data. We also determined postoperative pain (VAS-scale) and limitation of range of motion (ROM) at follow-up. Mean procedure time was 42 minutes (range, 26 - 56 minutes) in the conventional group and 47 minutes (range, 23 - 77 minutes) in the minimal invasive group without statistical significance (p > 0.05). The postoperative pain on a scale from 1 to 10 (VAS-scale) was rated 2.7 (range, 1 - 5) in the conventional group and 2.2 (range, 1 - 4) in the minimal invasive group without statistical significance (p > 0.05). Incision length was 34 mm (range, 31 - 53 mm) in the minimal invasive group (Figure 2) and 62 mm (range, 50 - 72 mm) for the conventional group. These differences were significant (p < 0.05).
Distance in mm
Range in mm
5.6 - 10.3
12.3 - 18.6
2.2 - 4.3
10.1 - 13.2
Results Taft Score.
Results Constant and Murley Score.
Constant and Murley Score
Superficial Soft tissue infection
Fracture of the Acromion
Redislocation after hook-plate removal
Lateral clavicle Osteitis
The AC joint is involved in 4-8% of joint injuries . In most of the cases sports injuries, especially hiking and road traffic injuries are the reason for AC joint dislocations. Many different types of operative procedures have been described to treat acromioclavicular dislocations and operative versus conservative treatment of Rockwood III lesions is still discussed controversially [2–6]. Results and complication rates of the countless procedures vary . There are other minimal invasive methods available using tight rope devices, without the need for a second operation to remove metalwork, but long term results for these techniques are not yet available . Our satisfying midterm results with a large number of treated patients (313 patients - 225 of these included in this study could been followed up) can be compared to the literature [27–30]. The procedure permits exact positioning and rather rigid retention of the reduction in the transverse and axial plane. The operation can be performed in a minimal invasive technique and with an operation time of less than 50 minutes the procedure is fast and relatively simple. Using the minimal invasive technique with only two fixed-angle screws the procedure time was not extended significantly (5 min.), but the length of the scar could be significantly reduced (28 mm). Taft and constant-Score of our group showed good results at follow-up concerning AC-joint- and shoulder function.
- Walz L, et al.: The anatomic reconstruction of acromioclavicular joint dislocations using 2 TightRope devices: a biomechanical study. Am J Sports Med 2008,36(12):2398–406. 10.1177/0363546508322524PubMedView ArticleGoogle Scholar
- Nuber GW, Bowen MK: Acromioclavicular Joint Injuries and Distal Clavicle Fractures. J Am Acad Orthop Surg 1997,5(1):11–18.PubMedGoogle Scholar
- Gstettner C, et al.: Rockwood type III acromioclavicular dislocation: surgical versus conservative treatment. J Shoulder Elbow Surg 2008,17(2):220–5. 10.1016/j.jse.2007.07.017PubMedView ArticleGoogle Scholar
- Broos P, et al.: [Surgical management of complete Tossy III acromioclavicular joint dislocation with the Bosworth screw or the Wolter plate. A critical evaluation]. Unfallchirurgie 1997,23(4):153–9. discussion 160PubMedView ArticleGoogle Scholar
- 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(4):552–5.PubMedGoogle Scholar
- Galpin RD, Hawkins RJ, Grainger RW: A comparative analysis of operative versus nonoperative treatment of grade III acromioclavicular separations. Clin Orthop Relat Res 1985, 193: 150–5.PubMedGoogle Scholar
- Luis GE, et al.: Acromioclavicular joint dislocation: a comparative biomechanical study of the palmaris-longus tendon graft reconstruction with other augmentative methods in cadaveric models. J Orthop Surg Res 2007, 2: 22. 10.1186/1749-799X-2-22PubMed CentralPubMedView ArticleGoogle Scholar
- Kuchenreuter G: [Experiences in the nailing of dislocations of the acromioclavicular joint according to Bosworth]. Chirurg 1956,27(6):250–2.PubMedGoogle Scholar
- 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(12):533–40.PubMedGoogle Scholar
- Graupe F, Dauer U, Eyssel M: [Late results of surgical treatment of Tossy III acromioclavicular joint separation with the Balser plate]. Unfallchirurg 1995,98(8):422–6.PubMedGoogle Scholar
- Albrecht J, Wroblewska B, Mossakowski MJ: The binding of insulin to cerebral capillaries and astrocytes of the rat. Neurochem Res 1982,7(4):489–94. 10.1007/BF00965500PubMedView ArticleGoogle Scholar
- Faraj AA, Ketzer B: The use of a hook-plate in the management of acromioclavicular injuries. Report of ten cases. Acta Orthop Belg 2001,67(5):448–51.PubMedGoogle Scholar
- Schmittinger K, Sikorski A: [Experiences with the Balser plate in dislocations of the acromioclavicular joint and lateral fractures of the clavicle]. Aktuelle Traumatol 1983,13(5):190–3.PubMedGoogle Scholar
- Wolter D, Eggers C, Koch W: Die operative Behandlung der akromioklavikulären Luxation und der distalen Klavikulafraktur oder - pseudarthrose mit der AC Hakenplatte". Operat Orthop Traumatol 1989,1(3):145–152. 10.1007/BF02513098View ArticleGoogle Scholar
- Queitsch C, et al.: Osteosynthesis of Lateral clavicle Fractures with Hook Plate. Akt Traumatol 2005, 35: 203–207. 10.1055/s-2005-865949View ArticleGoogle Scholar
- Gille J, et al.: Hook plate for medial clavicle fracture. Indian J Orthop 44(2):221–3.Google Scholar
- Lancaster S, Horowitz M, Alonso J: Complete acromioclavicular separations. A comparison of operative methods. Clin Orthop Relat Res 1987, 216: 80–8.PubMedGoogle Scholar
- Salzmann GM, et al.: Arthroscopic anatomical reconstruction of the acromioclavicular joint. Acta Orthop Belg 2008,74(3):397–400.PubMedGoogle Scholar
- Prokop A, et al.: [Tossy III injuries of the acromioclavicular joint. In what circumstances is surgery still justified? Personal results and literature review]. Orthopade 2003,32(5):432–6. 10.1007/s00132-002-0419-5PubMedView ArticleGoogle Scholar
- Blatter G, Meier G: [Augmentation of the coracoclavicular ligament suture. Comparison between wire cerclage, vicryl tape and PDS cord]. Unfallchirurg 1990,93(12):578–83.PubMedGoogle Scholar
- Tossy JD, Mead NC, Sigmond HM: Acromioclavicular separations: useful and practical classification for treatment. Clin Orthop Relat Res 1963, 28: 111–9.PubMedGoogle Scholar
- Wolter D, Schümann U, Seide K: Universal Titanium Internal Fixator. Trauma Berufskrankh 1999, 1: 12.Google Scholar
- Taft TN, Wilson FC, Oglesby JW: Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 1987,69(7):1045–51.PubMedGoogle Scholar
- Haaker R, et al.: [Comparative study of surgically treated shoulder injuries with or without metal implants]. Z Orthop Ihre Grenzgeb 1994,132(4):306–11. 10.1055/s-2008-1039979PubMedView ArticleGoogle Scholar
- Constant CR, Murley AH: A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987, 214: 160–4.PubMedGoogle Scholar
- Rehn J, Thelen E: [Injuries of the acromioclavicular joint]. Hefte Unfallheilkd 1975, 126: 131–6.PubMedGoogle Scholar
- 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(4):441–5.PubMedGoogle Scholar
- De Baets T, et al.: The treatment of acromioclavicular joint dislocation Tossy grade III with a clavicle hook plate. Acta Orthop Belg 2004,70(6):515–9.PubMedGoogle Scholar
- Habernek H, Schmid L, Walch G: [Management of acromioclavicular joint dislocation with the Wolter hookplate. One year follow-up of 35 cases]. Unfallchirurgie 1993,19(1):33–9. 10.1007/BF02588225PubMedView ArticleGoogle Scholar
- Sim E, et al.: Repair of complete acromioclavicular separations using the acromioclavicular-hook plate. Clin Orthop Relat Res 1995, 314: 134–42.PubMedGoogle Scholar
- ElMaraghy AW, et al.: Subacromial morphometric assessment of the clavicle hook plate. Injury 2010,41(6):613–9. 10.1016/j.injury.2009.12.012PubMedView ArticleGoogle Scholar
- Weitzman G: Treatment of acute acromioclavicular joint dislocation by a modified Bosworth method. Report on twenty-four cases. J Bone Joint Surg Am 1967,49(6):1167–78.PubMedGoogle Scholar
- Sundaram N, Patel DV, Porter DS: Stabilization of acute acromioclavicular dislocation by a modified Bosworth technique: a long-term follow-up study. Injury 1992,23(3):189–93. 10.1016/S0020-1383(05)80043-9PubMedView ArticleGoogle Scholar