Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean Six-Year Follow-up

Joseph Lamplot; Sarav Shah; Justin Chan; Kyle Hancock; Joseph Gentile; Scott Rodeo; Answorth Allen; Riley Williams; David Altchek; David Dines; Russell Warren; Frank Cordasco; Lawrence Gulotta; Joshua Dines

摘要

Objectives: Over the past decade, there have been advances in arthroscopic-assisted approaches for coracoclavicular (CC) reconstruction with less surgical morbidity and enhanced visualization while also allowing for the treatment of concomitant glenohumeral pathology. Previous studies reporting outcomes using both open and arthroscopic-assisted techniques are limited by short-term follow-up and small patient populations. It also remains unclear how maintenance of reduction and clinical outcomes correlate with one another. The purpose of our study was to report clinical and functional outcomes including return to pre-injury activity level following arthroscopic-assisted CC ligament reconstruction (AA-CCR) and to determine associations between return to pre-injury activity level, radiographic outcomes and patient-reported outcomes scores following AA-CCR. We hypothesized that patients undergoing AA-CCR would have a high rate of return to pre-injury activity level, clinical outcomes would not be associated with RLOR, and that the treatment of concomitant glenohumeral pathology would not adversely affect outcomes. Methods: A retrospective review of prospectively collected data from an institutional registry of all AA-CCR performed from January 2007-January 2016 was performed. Exclusion criteria included revision CCR, open CCR, and patients with less than two-year follow-up. Demographics and patient characteristics including sex, age at index surgery, grade of AC joint injury, duration between injury and index surgery, concomitant glenohumeral pathologies and procedures performed, complications, and subsequent surgeries were recorded. Grade of AC joint injury was determined using the Rockwood classification, and patients indicated for surgery had at least a Type III injury. Time elapsed between injury and index surgery was recorded and classified as acute (0–30 days) or chronic (& 30 days). The arthroscopic-assisted portion of the CC reconstruction has been prevously described and is as follows: The base of the coracoid then exposed either through a subacromial or intraarticular approach. Passing sutures were then placed around the coracoid for later shuttling of the soft tissue graft (allograft semitendinosus/posterior tibialis/anterior tibialis or autograft semitendinosus, according to surgeon preference) and heavy suture, which was used for ancillary fixation. Postoperative radiographs were obtained at approximately two weeks and six months following surgery. The CC distance was measured at final radiographic follow-up and compared to the unaffected contralateral side on an anteroposterior (AP) radiograph. Radiographic loss of reduction (RLOR), was defined as at least a 25% increase in CC distance as measured from the superior cortex of the coracoid process and the undersurface of the clavicle using a radiographic ruler compared to the contralateral side. Clinical assessment at final follow-up included SANE score, and additionally, patients were asked which sports(s) and/or recreational activity(s) they participated in prior to injury. For each sport or recreational activity, they were then specifically asked: “Were you able to return to the same or higher level of (specific sport or activity) as prior to your injury?” Failure of AA-CCR was defined as any one of the following: 1.) Patient underwent revision AC joint stabilization surgery, 2.) Patient was unable to return to the same or higher level of sport(s) and/or recreational activity(s) as prior to injury, 3.) Patient had RLOR as defined above. For comparative analysis, patients were characterized as having one primary mode of treatment failure. Post-hoc analysis was performed considering that patients may have more than one mode of treatment failure. Results: There were 88 patients (89.8% male) with a mean age of 39.6 years (range 18-65) and minimum 2-year follow-up (mean 6.1 years, range 2.1-10.3). Follow-up rate was 67.7%. Mean time from injury to surgery was 7.2±2.4 months, with 70% chronic injuries and 63.6% grade V. Concomitant arthroscopic procedures were performed in 48.9% of cases. Overall, mean SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%, with 8.0% unable to return to activity, 5.7% with RLOR, and 3.4% undergoing revision surgery for failed AA-CCR. Each patient undergoing revision surgery had an identifable traumatic event. All patients with RLOR were able to return to pre-injury activity level. SANE score was lower among patients who were unable to return to activity compared to those with RLOR and compared to non-failures (p=0.0002) ( Table 1 ). Post-hoc analysis considering multiple modes of treatment failure for individual patients demonstrated that SANE score was still significantly lower among those unable to return to pre-injury activity level compared to patients with RLOR and compared to patients considered non-failures (p=0.00003). Ninety three percent of patients who participated in weightlifting, 97% who

机译：目的：在过去十年中，关节镜辅助（CC）重建的关节镜辅助方法已经提高，手术发病率较少，增强的可视化，同时还允许治疗伴随的胶质形状病理学。以前的研究通过短期随访和小患者群体的限制，使用开放和关节镜辅助技术报告结果。它还仍然尚不清楚如何维持减少和临床结果彼此相关。我们的研究目的是报告关节性疗法辅助CC韧带重建（AA-CCR）后恢复损伤前活性水平的临床和功能结果，并确定恢复前损伤活动水平，放射线结果和患者之间的关联 - 据报道，AA-CCR后的成果分数。我们假设接受AA-CCR的患者将具有高损伤急性活性水平的速率，临床结果不会与劳动力相关，并且伴随的胶质形状病理学的治疗不会对结果产生不利影响。方法：对来自2007年1月至2016年1月至2016年1月至2016年1月至2016年1月的所有AA-CCR的预期收集数据的回顾性审查。排除标准包括修订CCR，开放性CCR，以及少于两年后的患者。人口统计和患者特征，包括性别，年龄在指数手术，AC关节损伤等级，损伤和指数手术之间的持续时间，伴随着表现，并发症和随后的手术。使用Rockwood分类确定AC关节损伤的等级，并且手术表明的患者至少具有III型损伤。记录伤害和指数手术之间经过的时间，并归类为急性（0-30天）或慢性（＆amp; 30天）。已术自术语中CC重建的关节镜辅助部分，如下：然后通过亚群或外部方法暴露胶链的碱。然后将通过缝合线围绕螺旋置于甲烷醇，以便于软组织移植物（同种异体移植的半核素/后胫骨粒/前胫骨/前胫骨菌或自体性移植术，根据外科医生偏好）和重型缝合线，其用于辅助固定。术后射线照片在手术后约两周和六个月获得。在最终的射线照相随后测量CC距离，并与非受影响的对侧侧进行比较，在前胸内（AP）X光片上。减少射线照相丧失（劳动率），被定义为CC距离增加的至少25％，从胶链过程的高级皮层测量和使用射线照相尺与对侧侧的锁骨尺的下表面测量。最终随访的临床评估包括Sane评分，另外，患者被问及他们在受伤前参加哪些运动和/或娱乐活动。对于每项运动或娱乐活动，他们被专门询问：“你是否能够在受伤之前返回与（具体的运动或活动）相同或更高水平？” AA-CCR的失败被定义为以下任一项：1）患者接受了修订的AC关节稳定手术，2.）患者无法恢复到相同或更高水平的运动和/或娱乐活动（ s）如在损伤之前，3.）患者具有如上所定义的劳动。对于对比分析，患者的特征是具有一种主要的治疗方法。考虑到患者可能具有多种治疗衰竭模式进行后HOC分析。结果：有88名患者（男性89.8％），平均年龄为39.6岁（范围18-65）和最低2年的随访（平均6.1岁，2.1-10.3范围）。后续率为67.7％。从伤害到手术的平均时间为7.2±2.4个月，慢性损伤70％，V 63.6％V.伴随的关节镜手术在48.9％的病例中进行。总体而言，平均Sane评分为86.3±17.5。治疗失败发生在17.1％以上，8.0％不能恢复活性，5.7％，劳动力为5.7％，接受了AA-CCR的失败手术。经历修订手术的每位患者具有可识别的创伤事件。所有含有劳动的患者都能够恢复损伤前活动水平。与劳动力的人无法恢复活性的患者中，患者的Sane评分较低，与非故障相比（P = 0.0002）（表1）。考虑到多种治疗失败的后HOC分析表明，与劳动力患者相比，在无法恢复到损伤前活动水平的情况下，仍然显着降低，与患者视为非故障的患者（P = 0.00003）。百分之九十三名患者参与举重，97％谁

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean Six-Year Follow-up

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