Noninvasive bracing of acromioclavicular joint dislocations is not superior to early functional rehabilitation and not inferior to surgical stabilization in Rockwood type III and V injuries

Tazio Maleitzke; Nicolas Barthod-Tonnot; Nina Maziak; Natascha Kraus; Mark Tauber; Alexander Hildebrandt; Jonas Pawelke; Larissa Eckl; Lukas Mödl; Kathi Thiele; Doruk Akgün; Philipp Moroder

doi:10.1016/j.jse.2024.08.040

Noninvasive bracing of acromioclavicular joint dislocations is not superior to early functional rehabilitation and not inferior to surgical stabilization in Rockwood type III and V injuries

J Shoulder Elbow Surg. 2024 Oct 21:S1058-2746(24)00771-7. doi: 10.1016/j.jse.2024.08.040. Online ahead of print.

Authors

Affiliations

¹ Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Berlin, Germany; Trauma Orthopaedic Research Copenhagen Hvidovre (TORCH), Department of Orthopaedic Surgery, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. Electronic address: tazio.maleitzke@charite.de.
² Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany.
³ Department of Orthopaedics, University Clinic, Greifswald, Germany.
⁴ Department for Shoulder and Elbow Surgery, ATOS Clinic Munich, Munich, Germany; Department for Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Salzburg, Austria.
⁵ Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Julius Wolff Institute, Berlin, Germany.
⁶ Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany.
⁷ Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany; Department of Shoulder and Elbow Surgery, Auguste Viktoria Hospital, Berlin, Germany.
⁸ Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Center for Musculoskeletal Surgery, Berlin, Germany; Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland.

PMID: 39442863
DOI: 10.1016/j.jse.2024.08.040

Abstract

Background: Treatment of acromioclavicular joint (ACJ) separations remains controversial. Yet, conservative treatment has become more common even for high-grade injuries. Available conservative treatment does currently however not address the loss of anatomical joint integrity in Rockwood (RW) III and V injuries. In a recent case report, we outlined the concept of restoring ACJ integrity by noninvasively bracing a RW V injury.

Aim: The purpose of this study was to prospectively evaluate the clinical and radiological efficacy of a modern Kenny-Howard splint like brace and compare it to early functional rehabilitation or surgery in RW III and V injuries after a minimum of 12 months.

Methods: Patients with acute RW III injuries (n = 18) and patients with RW V injuries who refused surgery (n = 7) were prospectively enrolled and treated with an ACJ brace and followed up clinically and radiologicalally for 12 months. Endpoint results were compared to injury grade-, sex-, age-, and follow-up-period-matched patients treated with early functional rehabilitation (n = 23) or surgical TightRope stabilization (n = 23). Clinical outcomes included Constant Score (CS), Subjective Shoulder Value (SSV), Taft Score (TS), and modified Acromioclavicular Joint Instability Score (mAJIS) and radiological outcome included coracoclavicular index.

Results: CS, SSV, TS, and mAJIS improved in RW III and CS and SSV in RW V patients over time, when treated with the ACJ brace. Significance was only reached in RW III patients (P < .001). Radiological indices did not improve over time in RW III and V patients. No differences were found when comparing functional and cosmetic outcomes (CS, SSV, TS, mAJIS) after a minimum of 12 months between bracing, surgery, and early functional rehabilitation in RW III and V patients. The coracoclavicular index was most improved in patients treated with surgery compared to bracing after a minimum of 12 months (P = .0011 for RW III).

Conclusion: Brace treatment led to comparable clinical and cosmetic outcomes as early functional rehabilitation or surgery in patients with high grade ACJ injuries after a minimum of 12 months. However, no sustainably improved reduction of the ACJ resulted from bracing, when compared to early functional rehabilitation, thus questioning its utility. While surgery ensured radiological improvement compared to bracing, no benefit was seen over early functional rehabilitation.

Keywords: Shoulder; brace; conservative; dislocation; physiotherapy; separation.