Division of Sports Medicine, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA.
Sports Surgery Clinic (SSC), Royal College of Surgeons in Ireland, Dublin, Ireland.
J Shoulder Elbow Surg. 2023 Jun;32(6):1146-1158. doi: 10.1016/j.jse.2023.01.039. Epub 2023 Mar 5.
Acute Rockwood type III-V acromioclavicular (AC) dislocations have been treated with numerous surgical techniques over the years. The purpose of this study was to perform a network meta-analysis (NMA) of randomized controlled trials to quantitatively define the optimal treatment for AC dislocations requiring operative treatment.
A literature search of 3 databases was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Randomized controlled trials comparing 1 of 10 treatments for acute Rockwood type III-V AC dislocations-nonoperative treatment, Kirschner wire fixation (KW), coracoclavicular screw fixation (Scr), hook plate (HP), open coracoclavicular cortical button (CBO), arthroscopic coracoclavicular cortical button (CBA), ≥2 coracoclavicular cortical buttons (CB2), isolated graft reconstruction (GR), cortical button with graft augmentation (CB-GR), and coracoclavicular and acromioclavicular fixation (AC)-were included. Clinical outcomes were compared using a frequentist approach to NMA, with statistical analysis performed using the R program. Treatment options were ranked using the P-score, which estimates the likelihood that the investigated treatment is the ideal method for an optimal result in each outcome measure on a scale from 0 to 1.
Of 5362 reviewed studies, 26 met the inclusion criteria, with a total of 1581 patients included in the NMA. AC, CB-GR, GR, CB2, CBA, and CBO demonstrated superiority over HP, Scr, KW, and nonoperative treatment at final follow-up for the Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score, with AC and CB-GR showing the highest P-scores for the Constant-Murley score (0.957 and 0.781, respectively) and GR and CBO showing the highest P-scores for the Disabilities of the Arm, Shoulder and Hand score (0.896 and 0.750, respectively). GR had the highest P-score for the visual analog scale score (0.986). HP, CB2, CB-GR, AC, CBA, and CBO demonstrated superiority in the coracoclavicular distance (CCD) and recurrence at final follow-up, with HP and CB2 having the highest P-scores for the CCD (0.798 and 0.757, respectively) and with GR and CB-GR having the highest P-scores for recurrence (0.880 and 0.855, respectively). KW and Scr showed the shortest operative times (P-scores of 0.917 and 0.810, respectively), whereas GR and CBA showed the longest operative times (P-scores of 0.120 and 0.097, respectively).
Although there are multiple fixation options for acute Rockwood type III-V AC dislocations, adding AC fixation or graft augmentation likely improves functional outcomes and decreases the CCD and recurrence rate at final follow-up-at the expense of longer operative times.
急性 Rockwood Ⅲ-Ⅴ型肩锁关节（AC）脱位多年来一直采用多种手术技术治疗。本研究的目的是进行网状荟萃分析（NMA），以定量确定需要手术治疗的 AC 脱位的最佳治疗方法。
根据系统评价和荟萃分析的首选报告项目指南，对 3 个数据库进行文献检索。比较 10 种治疗急性 Rockwood Ⅲ-Ⅴ 型 AC 脱位的治疗方法的随机对照试验 - 非手术治疗、克氏针固定（KW）、喙锁螺钉固定（Scr）、钩板（HP）、开放式喙锁皮质纽扣（CBO）、关节镜下喙锁皮质纽扣（CBA）、≥2 个喙锁皮质纽扣（CB2）、单纯移植物重建（GR）、皮质纽扣加移植物增强（CB-GR）和喙锁和肩锁固定（AC）。使用频率主义方法对 NMA 进行临床结果比较，使用 R 程序进行统计分析。使用 P 分数对治疗选择进行排名，P 分数估计在所研究的治疗方法在每个结果测量中的理想方法的可能性，每个结果测量的理想方法的可能性在 0 到 1 的范围内。
在 5362 篇综述研究中，26 项符合纳入标准，共有 1581 名患者纳入 NMA。AC、CB-GR、GR、CB2、CBA 和 CBO 在最终随访时的 Constant-Murley 评分和上肢残疾评分（DASH）方面优于 HP、Scr、KW 和非手术治疗，AC 和 CB-GR 对 Constant-Murley 评分的 P 分数最高（分别为 0.957 和 0.781），GR 和 CBO 对 DASH 的 P 分数最高（分别为 0.896 和 0.750）。GR 在视觉模拟量表评分方面的 P 分数最高（0.986）。HP、CB2、CB-GR、AC、CBA 和 CBO 在最终随访时的喙锁距离（CCD）和复发方面表现出优势，HP 和 CB2 的 CCD 的 P 分数最高（分别为 0.798 和 0.757），GR 和 CB-GR 的复发 P 分数最高（分别为 0.880 和 0.855）。KW 和 Scr 的手术时间最短（P 分数分别为 0.917 和 0.810），而 GR 和 CBA 的手术时间最长（P 分数分别为 0.120 和 0.097）。
尽管急性 Rockwood Ⅲ-Ⅴ 型肩锁关节脱位有多种固定选择，但增加 AC 固定或移植物增强可能会改善功能结果，并降低最终随访时的 CCD 和复发率 - 但手术时间更长。
