Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury

Abstract

Background: Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking.

Hypothesis: It was hypothesized that surgical treatment will outperform nonsurgical treatment.

Study design: Randomized controlled trial; Level of evidence, 1.

Methods: A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years.

Results: At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment.

Conclusion: Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates.

Registration: ISRCTN registry (study ID: ISRCTN92265154).

Keywords: Rockwood type 3; acromioclavicular dislocation; functional outcome; skillful neglect; surgery.

Figure 1.

CONSORT flow diagram of assignment to the surgical and nonsurgical treatment groups. ACJ, acromioclavicular joint; CONSORT, Consolidated Standards of Reporting Trials.

Figure 2.

Longitudinal comparison of Constant score (primary outcome measure) between the surgical and nonsurgical treatment groups at different time points. Error bars represent standard deviation. Preop, preoperatively.

Figure 3.

At 6-week follow-up, significantly superior ROM was seen in the nonsurgical treatment group on all ROM planes. Error bars represent standard deviation. *Statistically significant difference between groups (P < .05). ABD, abduction; ERO, external rotation; FLEX, flexion; IRO, internal rotation; ROM, range of motion.

Figure 4.

Longitudinal comparison of secondary outcome measurements between surgical and nonsurgical treatment groups at different time points: (A) ASES score, (B) Taft score, (C) ACJI score, and (D) NRS pain score. Error bars represent standard deviation. *Statistically significant difference between groups (P < .05). ACJI, Acromioclavicular Joint Instability; ASES, American Shoulder and Elbow Surgeons; NRS, numeric rating scale; Preop, preoperative.

Figure 5.

Longitudinal comparison of the coracoclavicular distance at different time points between surgical and nonsurgical treatment groups. Error bars represent standard deviation. *Statistically significant difference between groups (P < .05). Preop, preoperatively; CC, coracoclavicular.