Surgical versus conservative interventions for treating acromioclavicular dislocation of the shoulder in adults

Abstract

Background: 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 strategy: 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.

Figure 1

Algorithm of search strategy results

Figure 2

Participant flow for Bannister 1989

Figure 3

Participant flow for Imatani 1975

Figure 4

Participant flow for Larsen 1986

Analysis 1.1

Comparison 1 Surgical intervention versus conservative intervention, Outcome 1 Pain: presence of pain (slight or moderate).

Analysis 1.2

Comparison 1 Surgical intervention versus conservative intervention, Outcome 2 Unsatisfactory function (only 'poor' or 'fair' category ) at one year.

Analysis 1.3

Comparison 1 Surgical intervention versus conservative intervention, Outcome 3 Treatment failure (usually requiring a subsequent operation).

Analysis 1.4

Comparison 1 Surgical intervention versus conservative intervention, Outcome 4 Clinical outcomes.

Analysis 1.5

Comparison 1 Surgical intervention versus conservative intervention, Outcome 5 Treatment‐related complications.