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The V angle compliments radiographic assessment of acute acromioclavicular joint dislocations by differentiating between Rockwood types III versus V and by considering dynamic horizontal translation in coronal radiographs

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Acromioclavicular joint (ACJ) dislocations are usually graded radiographically according to Rockwood, but differentiation between Rockwood types III and V may be ambiguous. The potentially clinically relevant horizontal instability is barely addressed in coronal radiographs. It was hypothesized that a new radiologic parameter (V angle) would complement ACJ diagnostics on anteroposterior radiographs by differentiating between cases of Rockwood III and V while also considering the aspect of dynamic horizontal translation (DHT).

Methods

Ninety-five patients with acute ACJ dislocations (Rockwood types III and V) were included retrospectively between 2017 and 2020. On anteroposterior views (weightbearing: n = 62, non-weight-bearing: n = 33), the coracoclavicular (CC) distance and the newly introduced V angle for assessing scapular orientation were measured bilaterally. This angle is referenced between the spinal column and a line crossing the superior scapular angle and the crossing point between the supraspinatus fossa and the medial base of the coracoid process, reported as the side-comparative difference (non-injured side *minus* injured side). DHT on Alexander views was divided into stable, partially unstable or completely unstable.

Results

The V angle on the injured side alone (mean 50.0°; 95% confidence interval (CI), 48.6°–51.3°) showed no correlation with the side-comparative CC distance [%] (r = − 0.040; n.s.). Thus, the V angle on the non-injured side was considered, displaying a normal distribution (n.s.) with a mean of 58.0° (95% CI, 56.6°–59.4°). The side-comparative V angle showed a correlation with the side-comparative CC distance (r = 0.83; p < 0.001) and was able to differentiate between Rockwood types III (4.7°; 95% CI, 3.9°–5.5°; n = 39) and V (10.3°; 95% CI, 9.7°–11.0°; n = 56) (p < 0.001). A cut-off value of 7° had a 94.6% sensitivity and an 82.1% specificity (area under curve, AUC: 0.954; 95% CI, 0.915–0.994). The side-comparative V angle was greater for cases with complete DHT (8.7°; 95% CI, 7.9°–9.5°; n = 78) than for cases with partial DHT (4.8°; 95% CI, 3.3°–6.3°; n = 16) (p < 0.001). A cut-off value of 5° showed a sensitivity of 84.6% and a specificity of 66.7% (AUC 0.824; 95% CI, 0.725–0.924).

Conclusion

The scapular-based V angle on anteroposterior radiographs distinguishes between Rockwood types III and V as well as cases with partial or complete DHT.

Study design

Diagnostic study.

Level of evidence

Level II.

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Abbreviations

ACJ:

Acromioclavicular joint

AUC:

Area under curve

CC:

Coracoclavicular

CI:

Confidence interval

DHT:

Dynamic horizontal translation

DTF:

Deltotrapezial fascia

ICC:

Intraclass correlation coefficient

RW:

Rockwood

References

  1. Alexander OM (1954) Radiography of the acromioclavicular articulation. Med Radiogr Photogr 30(2):34–39

    CAS  PubMed  Google Scholar 

  2. Azar F, Pfeifer C, Alt V, Pregler B, Weiss I, Mayr A et al (2019) Clavicle elevation or shoulder girdle depression in acromioclavicular joint dislocation: a radiological investigation. Orthop J Sports Med 7(11):2325967119879927

    Article  PubMed  PubMed Central  Google Scholar 

  3. Boström Windhamre H, von Heideken J, Une-Larsson V, Ekström W, Ekelund A (2022) No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial. J Shoulder Elbow Surg 31(6):1122–1136

    Article  PubMed  Google Scholar 

  4. De Rooij PP, Van Lieshout EMM, Schurink IJ, Verhofstad MHJ, ACJ Injury Study Group (2021) Current practice in the management of acromioclavicular joint dislocations; a national survey in the Netherlands. Eur J Trauma Emerg Surg 47(5):1417–1427

    Article  PubMed  Google Scholar 

  5. Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39(2):175–191

    Article  PubMed  Google Scholar 

  6. Feichtinger X, Dahm F, Schallmayer D, Boesmueller S, Fialka C, Mittermayr R (2021) Surgery improves the clinical and radiological outcome in Rockwood type IV dislocations, whereas Rockwood type III dislocations benefit from conservative treatment. Knee Surg Sports Traumatol Arthrosc 29(7):2143–2151

    Article  PubMed  Google Scholar 

  7. Karargyris O, Murphy RJ, Arenas A, Bolliger L, Zumstein MA (2020) Improved identification of unstable acromioclavicular joint injuries in a clinical population using the acromial center line to dorsal clavicle radiographic measurement. J Shoulder Elbow Surg 29(8):1599–1605

    Article  PubMed  Google Scholar 

  8. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15(2):155–163

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kozono N, Takeuchi N, Okada T, Hamai S, Higaki H, Shimoto T et al (2020) Dynamic scapulohumeral rhythm: comparison between healthy shoulders and those with large or massive rotator cuff tear. J Orthop Surg (Hong Kong) 28(3):2309499020981779

    Article  PubMed  Google Scholar 

  10. Kraus N, Hann C, Gerhardt C, Scheibel M (2018) Dynamic instability of the acromioclavicular joint: a new classification for acute AC joint separation. Obere Extrem 13(4):279–285

    Article  PubMed  PubMed Central  Google Scholar 

  11. Kurata S, Inoue K, Shimizu T, Nagashima M, Murayama H, Kawamura K et al (2022) Acromioclavicular joint instability on cross-body adduction view: the biomechanical effect of acromioclavicular and coracoclavicular ligaments sectioning. BMC Musculoskelet Disord 23(1):279

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS (2014) Management of acromioclavicular joint injuries. J Bone Joint Surg Am 96(1):73–84

    Article  CAS  PubMed  Google Scholar 

  13. Mardani-Kivi M, Asadi K, Leili EK, Hashemi-Motlagh K, Izadi A, Pishgahpour M et al (2022) Horizontal instability after acromioclavicular joint reduction using the two-hole technique is preferred over the loop technique: a single-blind randomized clinical trial. Clin Shoulder Elb 25(3):224–229

    Article  PubMed  PubMed Central  Google Scholar 

  14. Martetschläger F, Kraus N, Scheibel M, Streich J, Venjakob A, Maier D (2019) The diagnosis and treatment of acute dislocation of the acromioclavicular joint. Dtsch Arztebl Int 116(6):89–95

    PubMed  PubMed Central  Google Scholar 

  15. Moroder P, Akgün D, Plachel F, Baur ADJ, Siegert P (2020) The influence of posture and scapulothoracic orientation on the choice of humeral component retrotorsion in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 29(10):1992–2001

    Article  PubMed  Google Scholar 

  16. Murphy RJ, Moor BK, Lesniewski PJ, Hayoz A, Alcantara W, Zumstein MA (2021) Evaluation of the circles measurement and the ABC classification of acromioclavicular joint injuries. Am J Sports Med 49(6):1619–1625

    Article  PubMed  Google Scholar 

  17. Nordqvist A, Petersson CJ (1995) Incidence and causes of shoulder girdle injuries in an urban population. J Shoulder Elbow Surg 4(2):107–112

    Article  CAS  PubMed  Google Scholar 

  18. Okereke I, Abdelfatah E (2022) Surgical management of acute rockwood grade III acromioclavicular joint dislocations: a systematic review. Cureus 14(9):e28657

    PubMed  PubMed Central  Google Scholar 

  19. Papageorgiou SN (2022) On correlation coefficients and their interpretation. J Orthod 49(3):359–361

    Article  PubMed  PubMed Central  Google Scholar 

  20. Peeters I, Braeckevelt T, Herregodts S, Palmans T, De Wilde L, Van Tongel A (2021) Kinematic alterations in the shoulder complex in rockwood v acromioclavicular injuries during humerothoracic and scapulothoracic movements: a whole-cadaver study. Am J Sports Med 49(14):3988–4000

    Article  PubMed  Google Scholar 

  21. Peeters I, Braeckevelt T, Palmans T, De Wilde L, Van Tongel A (2022) Differences between coracoclavicular, acromioclavicular, or combined reconstruction techniques on the kinematics of the shoulder girdle. Am J Sports Med 50(7):1971–1982

    Article  PubMed  Google Scholar 

  22. Pogorzelski J, Beitzel K, Ranuccio F, Wörtler K, Imhoff AB, Millett PJ et al (2017) The acutely injured acromioclavicular joint - which imaging modalities should be used for accurate diagnosis? A systematic review. BMC Musculoskelet Disord 18(1):515

    Article  PubMed  PubMed Central  Google Scholar 

  23. Rockwood CA Jr (1984) Fractures and dislocations of the shoulder. In: Rockwood CA, Green DP (eds) Fractures in adults. Lippincott, Philadelphia, pp 860–910

    Google Scholar 

  24. Rosso C, Martetschläger F, Saccomanno MF, Voss A, Lacheta L, ESA DELPHI Consensus Panel et al (2021) High degree of consensus achieved regarding diagnosis and treatment of acromioclavicular joint instability among ESA-ESSKA members. Knee Surg Sports Traumatol Arthrosc 29(7):2325–2332

  25. Shaw KA, Synovec J, Eichinger J, Tucker CJ, Grassbaugh JA, Parada SA (2018) Stress radiographs for evaluating acromioclavicular joint separations in an active-duty patient population: What have we learned? J Orthop 15(1):159–163

    Article  PubMed  PubMed Central  Google Scholar 

  26. Vetter P, Eckl L, Bellmann F, Allemann F, Scheibel M (2023) Minimalinvasive Techniken zur Therapie der Schultereckgelenksprengung [Minimally Invasive Techniques for the Treatment of Acute and Chronic Acromioclavicular Joint Instabilities]. Z Orthop Unfall 161(2):219–238

    PubMed  Google Scholar 

  27. Vetter P, Eckl L, Bellmann F, Audigé L, Scheibel M (2023) In vivo analysis of the circles measurement supports its use in evaluating acromioclavicular joint dislocations. J Shoulder Elbow Surg 32(6):1295–1302

    Article  PubMed  Google Scholar 

  28. Voss A, Löffler T, Reuter S, Imhoff AB, Kellner R, Csapo R et al (2021) Additional acromioclavicular cerclage limits lateral tilt of the scapula in patients with arthroscopically assisted coracoclavicular ligament reconstruction. Arch Orthop Trauma Surg 141(8):1331–1338

    Article  PubMed  Google Scholar 

  29. Zanca P (1971) Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J Roentgenol Radium Ther Nucl Med 112(3):493–550

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Traumatology, University Hospital Zurich, Zurich, Switzerland

    Philipp Vetter

  2. Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zurich, Switzerland

    Larissa Eckl, Frederik Bellmann, Philipp Moroder, Laurent Audigé & Markus Scheibel

  3. Center for Musculoskeletal Surgery, Charite-Universitaetsmedizin Berlin, Berlin, Germany

    Markus Scheibel

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  1. Philipp Vetter
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  2. Larissa Eckl
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  3. Frederik Bellmann
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  4. Philipp Moroder
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  5. Laurent Audigé
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  6. Markus Scheibel
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Contributions

PV: data curation, formal analysis, investigation, software, visualization, writing—original draft. LE: data curation, formal analysis, investigation, methodology, project administration, software, validation, writing—review & editing. FB: data curation, formal analysis, investigation, methodology, project administration, software, validation, writing—review & editing. PM: data curation, formal analysis, investigation, methodology, project administration, software, supervision, validation, writing—review & editing. LA: data curation, formal analysis, investigation, methodology, project administration, software, supervision, validation, writing—review & editing. MS: conceptualization, data curation, investigation, methodology, project administration, resources, supervision, validation, writing—review & editing.

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Correspondence to Philipp Vetter.

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Ethical approval was granted by the cantonal ethics commission of Zurich (BASEC-Nr. 2021-00675).

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Vetter, P., Eckl, L., Bellmann, F. et al. The V angle compliments radiographic assessment of acute acromioclavicular joint dislocations by differentiating between Rockwood types III versus V and by considering dynamic horizontal translation in coronal radiographs. Knee Surg Sports Traumatol Arthrosc 31, 5962–5969 (2023). https://doi.org/10.1007/s00167-023-07570-1

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