Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults: Cochrane systematic review
Assessed as up to date: 2009/04/30
Dislocation of the acromioclavicular joint is one of the most common shoulder problems in general orthopaedic practice. The question of whether surgery should be used remains controversial.Objectives
To assess the relative effects of surgical versus conservative (non-surgical) interventions for treating acromioclavicular dislocations in adults.Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to February 2009), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to February 2009), EMBASE (1988 to February 2009), and LILACS (1982 to February 2009), trial registries and reference lists of articles. There were no restrictions based on language or publication status.Selection criteria
All randomised and quasi-randomised trials that compared surgical with conservative treatment of acromioclavicular dislocation in adults were included.Data collection and analysis
All review authors independently performed study selection. Two authors independently assessed the included trials and performed data extraction.Main results
Three trials were included in this review. These involved a total of 174 mainly male participants. Two trials were randomised and one was quasi-randomised. None used validated measures for assessing functional outcome.
Fixation of the acromioclavicular joint using coracoclavicular screws, acromioclavicular pins or, usually threaded, wires was compared with supporting the arm in a sling or similar device. There were no significant differences between the two groups in unsatisfactory longer-term (one year) shoulder function based on a composite measure including pain, movement and strength or function (risk ratio 1.49, 95% confidence interval 0.75 to 2.95), nor in treatment failure that generally required an operation (risk ratio 1.72, 95% confidence interval 0.72 to 4.12). However, there were fixation failures in all three trials. Particularly, the trial using wires reported a high incidence of wire breakage (16/39 (41%)). Two trials reported that surgery significantly delayed the return to work. The methods used in the three trials also meant a routine second operation for implant removal was necessary.Authors' conclusions
There is insufficient evidence from randomised controlled trials to determine when surgical treatment is indicated for acromioclavicular dislocation in adults in current practice. Sufficiently powered, good quality, well-reported randomised trials of currently-used surgical interventions versus conservative treatment for well-defined injuries are required.
Tamaoki Marcel Jun S, Belloti João Carlos, Lenza Mário, Matsumoto Marcelo Hide, Gomes dos Santos Joao Baptista, Faloppa Flávio
Surgical versus conservative for treatment for acromioclavicular dislocations of shoulder in adults
The acromioclavicular joint is located at the top of the shoulder. It is the joint between the lateral (outer) end of the clavicle (collar bone) and the acromion (a projection from the scapula, or shoulder blade, which is located at the point of the shoulder). Acromioclavicular dislocation is one of the most common shoulder problems treated in general orthopaedic practice.
This review identified three trials, involving 174 mainly male participants. The surgical interventions involved fixation using screws, pins or wires; and conservative treatment involved resting the arm with an arm sling or similar. None of the trials found significant differences between the two groups in shoulder function at one year. However, having surgery delayed the return to work and activities and also required a routine second operation to remove wires and pins. Pooled results on treatment failure, generally requiring an operation, showed no difference between the two groups. However, there were some fixation failures particularly involving the movement and breakage of wires in one trial. There was not enough reliable evidence to draw conclusions about whether or when surgery is more appropriate for acromioclavicular dislocations.
Implications for practice
There is insufficient evidence from three small and flawed trials to establish the relative effects of surgical versus conservative treatment on final functional outcome of people with acromioclavicular dislocation. All three trials, however, reported complications from the breakage and migration of implants used for primary fixation across the acromioclavicular joint that sometimes required a further operation additional to the routine surgery needed for implant removal. Surgery was also associated with a longer time off from work and other activities. While these results favour a non-operative approach, possible benefits of surgery cannot be ruled out including for more complex, high grade injuries. Additionally, the lack of evidence to inform on the use of other and newer surgical approaches should be noted.
Implications for research
Further research exploring the comparison between surgical versus conservative for treating acromioclavicular dislocation is justified. We suggest that:
- Consensus on indications for surgical and conservative treatment of acromioclavicular dislocation should be developed to determine the priorities for criteria inclusion for future comparative studies. Then a multi-centre randomised controlled trial of high quality could be developed to compare the current surgical methods and conservative treatment;
- Future trials should be developed using standard and validated outcome measures, including patient assessed functional outcomes, and also assess resource implications;
- Comparisons of surgical techniques commonly used nowadays, such as anatomic reconstructions, hook plate, arthroscopic reconstruction, among others, should be tested in randomised controlled clinical trials.
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