Non-operative management of grade III-V acromioclavicular joint dislocations may improve early function and allow for earlier return to work compared to operative plate fixation
Resident Focus - Volume 12, Issue 6
Acromioclavicular (AC) joint dislocations comprise approximately 9% of all injuries to the shoulder. They can occur with either direct trauma or indirect force associated with overhead movements and lifting. Though AC dislocations are more prevalent in males aged 20-29, these injuries affect patients of all ages, sexes, and activity levels (Am J Sports Med. 2007 Feb;35(2):316-29). Current management of AC joint injuries is based on the grade of injury using the Rockwood classification system (grades I-VI). Grades I-II are typically managed non-surgically, but there are variations in recommended and clinical approaches to grade III-V AC dislocations (Essentials of Musculoskeletal Care. 4th ed. Rosemount, Ill.: American Academy of Orthopaedic Surgeons, 2010). There is no high-quality evidence demonstrating a difference in outcomes with operative versus non-operative management of grade III and higher dislocations. As the healthcare system works diligently to concomitantly reduce healthcare costs while improving patient care, is it possible to manage grade III-V AC joint dislocations non-operatively while preserving patient satisfaction with their post-injury functional improvements?
A recent multi-center trial aimed to investigate this question by randomizing 83 patients aged 16-60 years with isolated, complete, grade III-V AC joint dislocations to operative (updated hook plate fixation) versus non-operative management < 28 days from injury. Mechanisms of injury were similar in both groups. Non-operative management included a shoulder sling for support and comfort for 4 weeks followed by active/passive exercises and eventually resistance and strengthening exercises starting at 6 weeks. Surgical management included anatomic reduction of the AC joint, fixation with hook plate and screws, and no intraoperative ligament reconstruction or intraoperative ligamentous repair. The primary outcome of functional disability was measured using the Disabilities of the Arm, Shoulder, & Hand (DASH) score (lower scores indicating better function, minimum clinically important difference reported as 10 points) assessed at 6 weeks and 3, 6, 12 and 24 months after injury. At follow-up appointments, patients underwent clinical assessment, DASH scoring, Constant shoulder score (surgeon-based scoring system where higher scores are better) and x-ray surveillance. There was high loss to follow-up in both non-operative (33% of patients at 1 year, 37% at 2 years) and operative groups (25% of patients at 1 year, 30% at 2 years).
Functional disability measured by DASH scores were lower (better) in the non-operative group compared to the operative group at 6 weeks (31 vs. 45 points, p = 0.014) and 3 months (16 vs. 29 points, p = 0.005). There was no significant difference in DASH scores between groups at 6 months, 1 year, or 2 years, but both groups continued to improve from the 6-week assessment. 76% of the non-operative group returned to work by 3 months compared to 43% of patients in the operative group, p = 0.004). At 1 year, almost all patients in both groups had returned to work and all had range of motion within 5 degrees of the uninjured arm. There was no difference in patient satisfaction regarding the cosmetics of their shoulder appearance.
The data from this trial demonstrate that non-operative management of grade III-V AC joint dislocations may allow for earlier return of function and return to work compared to operative management. While this study did not investigate healthcare costs associated with these interventions, it would seem likely that avoiding surgery would result in significant savings. These conclusions are limited by the high loss to follow-up at 2 years. More data is needed to better compare long-term outcomes of operative vs non-operative management of these injuries. Future research should evaluate prognostic factors to discern which patients may have negative outcomes.
Ashley Austin, MD graduated from the Medical College of Georgia in Athens and is currently a second year resident at the University of Virginia Family Medicine Program. Her interests include medical Spanish, sports medicine, nutrition, and travel medicine. Faculty contributions by Katharine DeGeorge, MD, MS.