EFFECTIVENESS OF SIMPLE SOLUTIONS IN SURGICAL TREATMENT OF DISLOCATIONS OF ACROMIAL EXTREMITY OF CLAVICLE Parshikov M.V., Yarygin N.V., Lysov V.G., Gnetetskiy S.F., Chemyanov I.G., Govorov M.V., Chemyanov G.I., Uzhakhov I.M.
Department of traumatology, orthopedics and disaster medicine, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia,
Trubchevsk Central Regional Hospital, Trubchevsk, Russia
Injuries to the acromioclavicular joint (ACJ), and, primarily, clavicle dislocations exceed 10-12 % of cases with various injuries to the shoulder joint. Various researchers indicate that dislocations of acromial extremity of the clavicle (AEC) are identified in 6.7-26.1 % of cases with acute dislocations of bones of locomotor system [1, 2]. Social importance of ACJ is determined by the fact that most patients are young people, some of them are professional sportsmen, and active population at the age of 25-45 which also deals with hard physical work [3].
The approaches to selection of treatment for such pathology are divided into conservative and surgical [4]. According to some authors, conservative management can provide positive results in most cases [5, 6, 7]. It is almost impossible to achieve complete immobilization of the joint with use of dressing owing to its anatomic and functional features [8].
Development of new and modern approaches and surgical techniques is often based on analysis and estimation of causes of negative results. Moreover, each technique has followers and opponents [9, 10]. The main disadvantages are traumatic potential of some operations (Sterling, Weaver-Dunn) [11], failure of allografts [12], bone tissue resorption around metal constructs, and necessity of recurrent surgery for their removal [13]. Some cases of osteolysis and acromial fracture of the clavicle have been described as result of use of plates [14, 15]. Moreover, D. Chaudhary, V. Jain, D. Joshi et al. [16] conducted a multi-center randomized study of treatment of acute dislocation of the clavicle in ACJ. They did not find any statistically significant differences in functional possibilities of an injured hand in patients after surgical management with use of the hook plate, treated with only immobilization. According to A.K. Kilybaev et al. [17], some types of interventions with transarticular and extraarticular fixation with screws, nails, complex constructs and apparatus can cause severe purulence with formation of sequester, failure of constructs and recurrence. Moreover, the use of external fixing devices for recovery of the acromioclavicular joint causes daily home problems. A hard controlled condition of pins can manifest itself in view of excessive correction of the clavicle and formation of conditions for its recurrent dislocation. Technical difficulties, which sometimes appear after application of apparatus, narrow the possibilities of use [3]. Also such treatment techniques do not provide the simplicity of the use. Theoretically, they give the possibility for early rehabilitation, but the construct limits the movement mode [18]. Currently, dynamic arthroscopic systems are being implemented into clinical practice for restoration of ACJ [19]. At the same time, a fixing technique of Tight Rope type allows wide implementation of debridement of the coracoid process from the side of the inferior surface, but it does not exclude nervous and vascular injuries in this region and damages of residual coracoclavicular ligament [10]. The above-mentioned complications and disadvantages of existing and new surgical techniques for AEC dislocation explain high rate of poor outcomes (25-35 %) [19]. K.A. Dyachkov et al. [2] concluded the absence of quite simple and efficient confirmed treatment programs for patients with AEC dislocations in various time intervals after an injury, considering a degree and specific features of trauma.
The current situation in Russia is characterized by the fact that maximal possibilities of modern novel techniques can be used by trauma surgeon only in big capital, regional or republican special facilities with inpatient and outpatient units equipped according to modern high standards, where a physician can use various constructs for each individual patients and achieve maximally positive results of treatment. Technical coverage in rural hospitals is still low. Despite of this, specialists of these hospitals (Central Regional Hospital) increase their qualification in universities of Moscow, Saint Petersburg and other big cities, but they cannot use acquired knowledge and skills. They are forced to use common techniques, which are currently rarely used for treatment of locomotor system injuries and diseases in big medical facilities. Sometimes they improve them. The common approach for such strategy is treatment of dislocations of AEC in conditions of a rural hospital.
Objective − to study and analyze the results of operations in patients with dislocations of acromial extremity of clavicle without use of expensive complex fixing devices in the Central Regional Hospital.
MATERIALS AND METHODS
The study included 106 patients treated for dislocation of acromial extremity of the clavicle in Trubchevsk Regional Hospital in 1990-2019. The age of the patients was 18-62. There were 102 men and 4 women. The highest amount of patients was at the active age of 29-38 (n = 78, 73.6 %).
The study was conducted in compliance with requirements of the ethical committee of A.I. Yevdokimov Moscow State University of Medicine and Dentistry according to Helsinki Declare − Ethical Principles for Medical Research with Human Subjects 2000, and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Health Ministry of RF on June 19, 2003, No. 266. All participating persons gave their informed consent. Realization of the study was based on the federal law − About Foundations of Health of Citizens of the Russian Federation (2011), WMA Lisbon Declaration on the Rights of the Patients (1995), European Code of Medical Ethics (1987), and WHO Declaration of Politics in Patients' Rights in Europe (1994).
The statistical analysis of results was conducted with use of non-parametrical techniques. Analysis of variance was used. Coefficient f was 0.35436. P-value was 0.078751. P < 0.05 was considered as statistically significant.
For objective estimation of results and exclusion of influence of rough changes, during estimation of mean values, the extreme values were not considered according to random values distribution law.
The patients were commonly injured at home, outside (61 cases − 57, 55 %) and during sports activities (24 patients − 22, 64 %). It corresponds to the data of other studies [3]. The classification by J.D. Tossy was used in the clinical work [21]. Having only 3 categories in its base, it gives special attention to condition of ligaments of AEC. After admission, condition of 18 patients corresponded to Tossy I, of 88 − Tossy II-III.
Patients with degree 1 of AEC dislocation were treated with conservative techniques with two stages: the first stage − reduction; the second stage − stabilization of the clavicle in reduced condition with use of dressings of Babich, Sunilo or Simbaretskiy. Recently, polymer material dressings were used: Mac-Kannel dressing with use of adhesive elastic plaster Lenkotape or other modern orthoses.
Watkins-Kaplan surgery was selected during estimation of management strategy and selection of surgical techniques for patients with Tossy II-III.
Why this surgical technique was used? There were several reasons which were important for rendering medical care in a regional hospital: technical simplicity, low traumatic potential, minimal use of materials and fixing constructs. The important and fundamental moment was adherence to the concept of the surgical technique. The traditional stages have been modified slightly: the intraarticular disk of the acromioclavicular joint was removed; 4 lavsan fibers No. 6 were crossed in the site of fixation of an injured ligament to the clavicle and were conducted behind the coracoid process of the scapula in intraperiosteal manner; the clavicle was reduced, and ACJ congruity was restored; transarticular synthesis with single or several K-wire was conducted (through the acromial process transcutaneously); dosed and careful tightening of lavsan fibers above the clavicle; acromioclavicular ligament was sutured with interrupted U-shaped sutures. Finally, the acromial extremity of the clavicle was in ACJ in the achieved position. We would like to note that restoration of integrity and continuity of ligaments is the important and obligatory element of the technique. Duration of surgical intervention varied from 25 to 60 minutes (40-45 minutes on average), depending on body weight. 4 weeks later, the pins were removed through punctures (minimal traumatic potential). After this, the course of rehabilitation was carried out: remedial gymnastics, physiotherapy, massage. Before 2006, postsurgical immobilization was conducted with various plaster dressings. From 2006, a wide range of posting-orthoses (bandages with various rigidity) appeared which can be used without additional preparation, with various technical features, but with standard sizes. We started to use such posting-orthoses for additional immobilization. Their advantages are possibility of regulation of the shape, volume and configuration of a bandage without arresting of fixation; simplicity of use for both doctor and patient; they can be used in various situations (at hospital, at home, outside); no special tools or other technical devices are needed; a possibility for temporary removal of dressing to perform remedial gymnastics; the design; relatively low price.
Constant Score was used for estimation of treatment efficiency [22]. This system considers the patient's personal opinion and objective parameters of achieved results, which characterize functional condition of the shoulder joint [23]. The following values were assessed: pain (maximal rate [MR] − 15 points); daily activity (MR − 20); range of movements in the shoulder joint (MR − 40); strength load (MR − 25); total estimate (MR − 100). The values were examined on the 14th day (after removal of sutures), after 6 weeks (by the moment of completion of main rehabilitation procedures) and within 2 years (depending on possibility of examination of a patient).
The period of postsurgical working incapability was 1.5-2 months. The results of treatment of 88 operated patients were exposed to proper investigation and analysis from 14 days to 2 years after surgery.
RESULTS AND DISCUSSION
The table shows the results of the use of Watkins-Kaplan technique according to Constant Score. Pain was estimated for all operated patients by the moment of removal of sutures. As one can see in the table, this value was 12.4 ± 0.6 by the moment of suture removal, 14.4 ± 0.6 days after 6 weeks (79 patients were examined −89.8 %), and 14.6 ± 0.4 days within time intervals up to 2 years (56 patients − 63, 6 %).
Table
Results of use of Watkins-Kaplan technique according to Constant Score
|
Points |
||||
|
Studied parameters |
Day 14 |
6 weeks |
Before 2 years |
Analysis of variance (ANOVA) f = 0.35436 P = 0.078751* |
|
Pain syndrome |
12.4 ± 0.6 |
14.4 ± 0.6 |
14.6 ± 0.4 |
Std.dev. 1.2166 Std.err. 0.7024 |
|
Life quality |
9.8 ± 1. 2 |
17.7 ± 1.4 |
19.2 ± 0.8 |
Std.dev. 5.0501 Std.err. 2.9157 |
|
Volume of motions in shoulder joint |
0 |
29.4 ± 2.7 |
38.1 ± 1.9 |
Std.dev. 19.96 Std.err. 11.5 |
|
Strength |
0 |
18.2 ± 1.7 |
23.4 ± 1.6 |
Std.dev. 12.287 Std.err. 7.094 |
The daily activity level (life quality) was 9.8 ± 1.2 points on the day 14. The low level was determined by discomfort with dressing wearing. However, after switch to posting-orthoses, the life quality improved. Also the value depended on location of an injury (lower values for dislocation of the right clavicle). After completion of rehabilitation, remedial gymnastics and physiotherapy, the value sharply increased to 17.7 ± 1.4. Within 2 years, the value was quite stable and high (despite of hard work or sports) − 19.2 ± 0.8.
The range of movements in the shoulder joint before completion of immobilization was not estimated according to objective reasons and was equal to 0. But after 6 weeks, the total value was 29.4 ± 2.7 points. For its calculation, the values of anterior flexion, abduction, external and internal rotation were estimated and summed.
A trend to increasing volume of movements was associated with the volume and characteristics of rehabilitation, and with volitional powers. Within 2 years, this criterion was stable and corresponded to 38.1 ± 1.9. Strength capability restored simultaneously with the range of movements in the shoulder joint: 18.2 ± 1.7 after 6 weeks, 23.4 ± 1.6 within 2 years.
Estimation of treatment quality with Constant Score (totally 79 points, 7 ± 2.8 and 95.3 ± 2.1) showed good and excellent values. Poor outcomes were absent. A partial suture disruption was noted in two cases and did not influence on the final result. There were not any infectious complications. Considering the specific features of working specialties, most patients resumed their professional activity.
A clinical case. A patient, female, year of birth − 1980, was admitted to the surgery unit of Trubchevsk Central Regional Hospital on October 15, 2006. She suffered from a civilian accident − falling onto her right upper extremity outside home. The examination identified a dislocation of acromial extremity of the right clavicle − Tossy III (Fig. 1). The surgery was conducted with Watkins-Kaplan technique (Fig. 2).
Figure 1
The patient, year of birth − 1980. X-ray image before surgery (2006).
Figure 2
The patient, year of birth − 1980. X-ray image of the right shoulder joint after an operation according to the Watkins-Kaplan method (2006).
The postsurgical period was without complications. Immobilization with the posting-orthosis lasted for 4 weeks. After its completion, the pins were removed, the rehabilitation course of remedial gymnastics, physiotherapy and massage was carried out. After 6 weeks, the total Constant Score was [22] 81, after one year − 96, after 13 years − 97. The function of the right lower extremity restored to the full degree. Pain was absent (Fig. 3, 4, 5).
Figure 3
The patient, year of birth − 1980. Functional result 13 years after surgery (2019).
Figure 4
The patient, year of birth − 1980. X-ray control 13 years after surgery (2019).
Figure 5
The patient, year of birth − 1980. Cosmetic result 13 years after surgery (2019).
The analysis of treatment of AEC dislocations showed some anatomical features of ligaments fixing the acromial clavicular extremity to the scapula. These are two potent ligaments: acromioclavicular and coracoclavicular. The coracoclavicular ligament consists of two parts. Also deltoid and trapezius muscles and, to lesser degree, the coracoacromial ligament participate in fixation of ACJ. For complete dislocation (Tossy III), the first two ligaments tear, and their ends disperse or they can be partially necrotized, resulting in shortening of ends of injured ligaments. Therefore, before opened reduction, it is necessary to remove ruptured tissues, frayed parts of ligaments and residuals of the articular disk, i.e. removing the interposition [24]. If ligaments are not sutured with the primary suture (such possibility is absent), then Watkins-Kaplan technique with K-wires is justified.
Despite of occurrence of new constructs and technologies, modern trauma surgeons, including foreign ones, prefer this simple way of fixation [25]. It is explained by attempt to maximally store the blood circulation and vitality of paraosseal tissues. It is accentuated that biology presents one of the main factors of injury healing. From this point of view, K-wire is the most optimal and less traumatic fixator. Moreover, in case of limited financing, the relevance of pin osteosynthesis increases due its low costs. Primarily, it is important for hospital with low budget. Pins of various diameter are usually available in any medical facility of this level as compared to more complex constructs.
Pin osteosynthesis is characterized with the following moments: low traumatic potential (maximal preservation of local blood perfusion); stability in combination with external mobilization; simple realization (installment and removal of the fixator); minimal duration of surgery (about 45 minutes).
CONCLUSION
1. The use of Watkins-Kaplan technique for dislocations of acromial extremity of the clavicle allows correction of pain syndrome in an injured joint by the 6th week after surgery (Constant Score = 14.4 ± 0.6), significant increase in the range of movements (29.4 ± 2.7) and improvement in life quality (17.7 ± 1.4).
2. Within 2 years, the values stabilized at high level (Constant Score = 14.6 ± 0.4; 38.1 ± 1.9; 19.2 ± 0.8 correspondingly). It characterized full recovery of the shoulder joint function.
3. Watkins-Kaplan technique, which was developed quite long time ago for surgical management of AEC dislocation, leads to good and fine results even at the present time, allowing use of simple and non-expensive fixing constructs.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.