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A F G Groom – One of the best experts on this subject based on the ideXlab platform.
Acromioclavicular Dislocation conservative or surgical therapyClinical Orthopaedics and Related Research, 1998Co-Authors: A M Phillips, C Smart, A F G GroomAbstract:
A literature review was performed to clarify available information which influences decisions whether to advise a young adult patient to undergo surgery for a severely displaced Acromioclavicular Dislocation. Twenty-four papers were retrieved yielding 1172 patients of whom the mean followup for the 833 surgically treated patients was 43.7 months and not surgically treated was 60.4 months. Of the 24 papers, only five reported surgical and conservative outcomes; two of these papers used prospective randomized methodology and three used nonrandomized methodology. Fourteen papers reported surgical outcome only and five papers reported conservative outcome only. Overall, 88% of surgically treated patients and 87% of nonsurgically treated patients had a satisfactory outcome. Complications most commonly listed were (surgically treated versus nonsurgically treated): need for further surgery (59% versus 6%), infection (6% versus 1%), and deformity (3% versus 37%). Return to activity was no quicker with surgery. Pain was not any more common without surgery. Range of movement was more frequently normal or near normal without surgery (95% versus 86% if surgically treated) and so was strength (92% versus 87%). Meta-analysis of the four studies including data from surgical and conservative therapy showed on significant benefit from surgery. Power studies suggest that to show a statistically significant benefit from surgery, large studies would be required, which, given the relative incidence of these injuries, would probably be multicenter and therefore vulnerable to methodologic difficulties. There does not seem to be any reason to recommend an operative procedure to a patient with a Rockwood et al Type III injury based on the evidence currently available.
Jennifer M Hootman – One of the best experts on this subject based on the ideXlab platform.
Acromioclavicular Dislocation conservative or surgical therapyJournal of Athletic Training, 2004Co-Authors: Jennifer M HootmanAbstract:
Abstract REFERENCE: Phillips AM, Smart C, Groom AFG. Acromioclavicular Dislocation: conservative or surgical therapy. Clin Orthop. 1998;353:10-17. CLINICAL QUESTION: Among patients with Acromioclavicular (AC) Dislocation, does surgical intervention produce better outcomes than conservative therapy? DATA SOURCES: Studies were identified by a MEDLINE search (1966-1997) and a manual search of the reference lists of each relevant study identified. The medical subject heading of Acromioclavicular Dislocation was used as the primary search term. STUDY SELECTION: The search was limited to English-language journals listed in Index Medicus. Studies were included if they described severely displaced Dislocations of the AC joint, mostly characterized as grade III injuries (Allman or Rockwood classification) or if there was at least 1-cm displacement of the clavicle. If more than 1 study included the same group or subgroups of patients, the study with the best assessed methods was used. Studies were divided into 4 classifications: group 1, randomized trials of surgery versus conservative therapy; group 2, nonrandomized trials of surgery versus conservative therapy; group 3, surgical trials only; and group 4, conservative trials only. DATA EXTRACTION: Data-extraction and study quality-assessment procedures were not explained in detail. The primary outcome measures were overall outcome, return to work, return to premorbid activities, complications, and radiographic features. Secondary measures were pain, range of motion, and strength. RevMan software (version 1.05; Cochrane Centre, Oxford, UK) was used for statistical analysis. MAIN RESULTS: Specific search criteria identified 600 articles for review, of which 24 met inclusion and exclusion criteria: 2 in group 2, 3 in group 3, 14 in group 4, and 5 in group 4. A total of 1172 patients were represented (surgical treatment = 833, mean = 43.7 months’ follow-up; conservative treatment = 339, mean = 60.4 months’ follow-up). Both surgically and conservatively treated patients reported similar overall satisfactory outcome (88% surgical versus 87% conservative). Patients with surgical treatment reported longer time to return to work and premorbid activities. Among patients treated surgically, 59% had additional surgery, 6% had wound breakdown, 20% had fixation failure, and 3% reported residual deformity. Only 1% of conservatively treated patients reported wound problems, 6% had additional surgery, and 37% reported residual deformity. In only 1 study did the authors report the incidence of posttraumatic arthritis: 25% among surgically treated and 43% among conservatively treated patients. Analysis of secondary outcomes suggests that both groups had little or no pain (93% surgical, 96% conservative) but more conservatively treated patients had normal to near-normal range of motion (95% versus 86%) and normal strength (92% versus 87%). Conservative treatment of AC Dislocations is 21% more likely to result in a satisfactory outcome than surgical treatment (odds ratio = 0.79, 95% confidence interval = 0.36, 1.71). The need for additional surgery is 7.4 times more likely and infection is 3.2 times more likely with surgical management. CONCLUSIONS: These data suggest that the current evidence does not support surgical treatment of grade III AC Dislocations with respect to overall patient satisfaction as well as clinical outcomes such as pain, range of motion, and strength.
Flavio Faloppa – One of the best experts on this subject based on the ideXlab platform.
surgical versus conservative interventions for treating Acromioclavicular Dislocation of the shoulder in adultsCochrane Database of Systematic Reviews, 2010Co-Authors: Marcel Jun Sugawara Tamaoki, Joao Carlos Belloti, Mario Lenza, Marcelo Hide Matsumoto, Joao Baptista Gomes Dos Santos, Flavio FaloppaAbstract:
BACKGROUND Dislocation of the Acromioclavicular joint is one of the most common shoulder injuries in a sport-active population. The question of whether surgery should be used remains controversial. This is an update of a Cochrane Review first published in 2010. OBJECTIVES To assess the effects (benefits and harms) 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 June 2019), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 6), MEDLINE (1946 to June 2019), Embase (1980 to June 2019), and LILACS (1982 to June 2019), trial registries, and reference lists of articles. There were no restrictions based on language or publication status. SELECTION CRITERIA We included all randomised and quasi-randomised trials that compared surgical with conservative treatment of Acromioclavicular Dislocation in adults. DATA COLLECTION AND ANALYSIS At least two review authors independently performed study screening and selection, ‘Risk of bias’ assessment, and data extraction. We pooled data where appropriate and used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included five randomised trials and one quasi-randomised trial. The included trials involved 357 mainly young adults, the majority of whom were male, with acute Acromioclavicular Dislocation. The strength of the findings in all studies was limited due to design features, invariably lack of blinding, that carry a high risk of bias. Fixation of the Acromioclavicular joint using hook plates, tunnelled suspension devices, coracoclavicular screws, Acromioclavicular pins, or (usually threaded) wires was compared with supporting the arm in a sling or similar device. After surgery, the arm was also supported in a sling or similar device in all trials. Where described in the trials, both groups had exercise-based rehabilitation. We downgraded the evidence for all outcomes at least two levels, invariably for serious risk of bias and serious imprecision.Low-quality evidence from two studies showed no evidence of a difference between groups in shoulder function at one year, assessed using the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) (0 (best function) to 100 (worst function)): mean difference (MD) 0.73 points, 95% confidence interval (CI) -2.70 to 4.16; 112 participants. These results were consistent with other measures of function at one-year or longer follow-up, including non-validated outcome scores reported by three studies. There is low-quality evidence that function at six weeks may be better after conservative treatment, indicating an earlier recovery. Very low-quality evidence from one trial found no difference between groups in participants reporting pain at one year: risk ratio (RR) 1.32, 95% CI 0.54 to 3.19; 79 participants. There is very low-quality evidence that surgery may not reduce the risk of treatment failure, usually resulting in non-routine secondary surgery: 14/168 versus 15/174; RR 0.99, 95% CI 0.51 to 1.94; 342 participants, 6 studies. The main source of treatment failure was complications related to surgical implants in the surgery group and persistent symptoms, mainly discomfort, due to the Acromioclavicular Dislocation in the conservatively treated group.There is low-quality evidence from two studies that there may be little or no difference between groups in the return to former activities (sports or work) at one year: 57/67 versus 62/70; RR 0.96, 95% CI 0.85 to 1.10; 137 participants, 2 studies. Low-quality but consistent evidence from four studies indicated an earlier recovery in conservatively treated participants compared with those treated with surgery. There is low-quality evidence of no clinically important difference between groups at one year in quality of life scores, measured using the 36-item or 12-item Short Form Health Survey (SF-36 or SF-12) (0-to-100 scale, where 100 is best score), in either the physical component (MD -0.63, 95% CI -2.63 to 1.37; 122 participants, 2 studies) or mental component (MD 0.47 points, 95% CI -1.51 to 2.44; 122 participants). There is very low-quality and clinically heterogenous evidence of a greater risk of an adverse event after surgery: 45/168 versus 16/174; RR 2.82, 95% CI 1.65 to 4.82; 342 participants, 6 studies; I2 = 48%. Common adverse outcomes were hardware complications or discomfort (18.5%) and infection (8.7%) in the surgery group and persistent symptoms (7.1%), mainly discomfort, in the conservatively treated group. The majority of surgical complications occurred in older studies testing now-outdated devices known for their high risk of complications. The very low-quality evidence from one study (70 participants) means that we are uncertain whether there is a between-group difference in patient dissatisfaction with cosmetic results.It is notable that the evidence for function, return to former activities, and quality of life came from the two most recently conducted studies, which tested currently used devices and interventions in clearly defined participant populations that represented the commonly perceived population for which there is uncertainty over the use of surgery. There were insufficient data to conduct subgroup analysis relating to type of injury and whether surgery involved ligament reconstruction or not. AUTHORS’ CONCLUSIONS There is low-quality evidence that surgical treatment has no additional benefits in terms of function, return to former activities, and quality of life at one year compared with conservative treatment. There is, however, low-quality evidence that people treated conservatively had improved function at six weeks compared with surgical management. There is very low-quality evidence of little difference between the two treatments in pain at one year, treatment failure usually resulting in secondary surgery, or patient satisfaction with cosmetic result. Although surgery may result in more people sustaining adverse events, this varied between the trials, being more common in techniques such as K-wire fixation that are rarely used today. There remains a need to consider the balance of risks between the individual outcomes: for example, surgical adverse events, including wound infection or dehiscence and hardware complication, against risk of adverse events that may be more commonly associated with conservative treatment such as persistent symptoms or discomfort, or both.There is a need for sufficiently powered, good-quality, well-reported randomised trials of currently used surgical interventions versus conservative treatment for well-defined injuries.