Radiographic features and complications following coracoclavicular ligament reconstruction

Abstract

Objective

To report radiographic features and complications of coracoclavicular ligament reconstruction and the association of radiographic features with symptomatology.

Materials and methods

Retrospective picture archiving and communication system query (1/2012–8/2018) identified subjects with prior coracoclavicular ligament reconstruction. Post-operative radiographs were reviewed with attention to the following: (1) acromioclavicular alignment, (2) coracoclavicular width, (3) distal clavicular osteolysis, (4) osseous tunnel widening, and (5) hardware complication or fracture. Medical records were reviewed to determine purpose of imaging follow-up (symptomatic versus routine). Statistical analysis determined associations between binary features and outcomes, and inter-reader agreement.

Result

Review of 55 charts identified 32 subjects (23 male, 9 females; age range 24–64; imaged 1–34 months following surgery) meeting inclusion criteria. Loss of acromioclavicular reduction was the most common imaging finding (n = 25, 78%), with 76% progressing to coracoclavicular interval widening. Distal clavicular osteolysis was seen in 21 cases (66%) and was significantly associated with loss of acromioclavicular joint reduction (p = 0.032). Tunnel widening occurred in 23 patients (82%) with more than one follow-up radiograph. Six (19%) had hardware complication or fracture. No radiographic feature or complication had significant correlation with symptomatology (p values 0.071–0.721). Inter-reader agreement was moderate to substantial for coracoclavicular interval widening and hardware complication, fair to substantial for tunnel widening, and fair to moderate for loss of acromioclavicular reduction and distal clavicular osteolysis.

Conclusion

Loss of acromioclavicular joint reduction, coracoclavicular interval widening, distal clavicular osteolysis, and tunnel widening are common radiographic features after coracoclavicular ligament reconstruction; however, they do not necessarily correlate with symptomatology.

Introduction

Acromioclavicular joint injuries are common injuries of the shoulder girdle, typically occurring secondary to direct trauma to the shoulder such as a fall with the arm in an adducted position [1]. Injury severity is classified according to the Tossy-Rockwood classification system [2]. Type I and II injuries are limited to the capsuloligamentous structures of the acromioclavicular joint and are treated conservatively, while types IV–VI involve the coracoclavicular ligaments, resulting in varying degrees of anteroposterior and craniocaudal instability and necessitating surgical intervention. The management for type III injuries is more controversial and beyond the scope of this article [1]. A large number of surgical techniques, which focus on restoring the stability of the coracoclavicular interval with reconstruction of the coracoclavicular ligaments, have been described [3,4,5,6,7,8]. Increasingly, this is being accomplished with the use of either synthetic graft material (Fig. 1) or an allograft (Fig. 2).

Fig. 1
figure1

33-year-old male with normal post-operative appearance of coracoclavicular reconstruction with synthetic graft material. a Normal post-operative radiograph of the left shoulder demonstrates normal alignment of the acromioclavicular joint in a 33-year-old male, 10 days status post coracoclavicular ligament reconstruction utilizing synthetic graft material. The clavicular and coracoid cortical fixation buttons (arrows) are visualized, as is the radiolucent clavicular tunnel (arrowhead). The coracoid tunnel is not typically visualized on radiographs. b Schematic representation of the patient in a. The clavicular and coracoid cortical fixation buttons (arrows) are visualized, as are the clavicular and coracoid tunnels (arrowheads)

Fig. 2
figure2

31-year-old male with normal post-operative appearance of coracoclavicular reconstruction with allograft. a Immediate post-operative radiograph demonstrates two radiolucent clavicular tunnels (black arrows) in a 31-year-old male, status post coracoclavicular ligament reconstruction utilizing allograft, and a double tunnel technique. Post-operative air is present (white arrowhead). b Schematic representation of the patient in a. The allograft (arrowheads) is looped in a figure-of-eight fashion through the clavicular tunnels (arrows) and passed under the coracoid process

In the surgical literature, several case series have examined the post-operative findings of coracoclavicular ligament reconstruction, with most studies focusing on the status of the reduction, perioperative complications, hardware complications, and patient outcomes [5, 6, 9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25]. A small subset of studies in the orthopedic literature have evaluated other potential radiographic outcomes, such as tunnel widening or distal clavicular osteolysis, although this is less commonly reported [10, 16, 18, 19, 23, 25, 26]. To the best of our knowledge, there have been no prior studies within the radiology literature detailing the post-operative imaging findings and complications following coracoclavicular ligament reconstruction, and the association of each radiographic feature with symptomology.

The purpose of our study, therefore, was to report radiographic features and complications following coracoclavicular ligament reconstruction, and to assess correlation of radiographic features with post-operative symptomatology. Based on our clinical experiences, we believe that positive radiographic findings would be frequent and associated with patient symptoms. Assessing the correlation of each radiographic feature with symptomology would allow the radiologist to prioritize and more effectively communicate imaging findings which may potentially require surgical intervention.

Methods

Institutional review board approval was obtained, and informed consent was waived for this retrospective, Health Insurance Portability and Accountability Act (HIPAA) compliant study.

Study population

Patients who underwent coracoclavicular ligament reconstruction were identified via a retrospective query of our department imaging database from January 1, 2012 to August 15, 2018, utilizing the report search phrase “coracoclavicular reconstruction.” Patients with imaging follow-up greater than 1 month after the date of surgery were included for further review. Patients with clavicular fractures at the time of injury requiring internal fixation of the clavicle, unavailable operative reports, or an unknown date of surgery were excluded from the cohort.

Age at the time of surgery, sex, time elapsed since the initial injury, Tossy-Rockwood acromioclavicular injury grade indicated by the operative report [2], type of reconstruction (synthetic graft versus allograft) indicated by the operative report, and the total time of imaging follow-up were recorded. In instances where patients specified only the month of injury, the injury dates were assumed to have occurred on the first of the specified month of injury. Chart review for each patient was performed to determine if the orthopedic visit associated with the final post-operative radiograph was performed for the purpose of routine follow up or for symptomatology.

Imaging interpretation

Radiographs of the acromioclavicular joint (including dedicated acromioclavicular joint or shoulder series, and intraoperative fluoroscopic images, when available) were reviewed in consensus by a musculoskeletal radiology attending (3 years of musculoskeletal radiology experience) and a musculoskeletal radiology fellow. If available, accompanying CT or MRI exams of the shoulder were also reviewed.

All available post-operative radiographic images were assessed for the presence of 5 findings: (1) loss of acromioclavicular joint reduction (defined as any offset at the inferior margins of the distal clavicle and acromion), (2) widening of the coracoclavicular interval (defined as a coracoclavicular distance greater than 13 mm), (3) distal clavicular osteolysis, qualified according to previously published criteria, including irregularity of the clavicular subchondral bone plate and frank osseous erosion [27], (4) interval widening of the operative tunnels from the baseline exam when measured at the widest transverse dimension (not assessed in patients with only one post-operative radiograph), and (5) evidence of hardware complication or fracture. If a finding was deemed to be present, then the time interval following surgery was recorded according to the following subclassifications: immediate post-operative period (up to 1 month following surgery), 1–3 months following surgery, 3–6 months following surgery, 6–9 months following surgery, 9–12 months following surgery, and 12 or more months following surgery.

Two additional musculoskeletal radiologists (3 and 33 years of experience) received a brief, image-based tutorial on the spectrum of post-operative findings seen after coracoclavicular ligament reconstruction, including representative examples and specific measurement criteria, as previously described. Two weeks following this training, the two readers independently reviewed the same cohort initially reviewed by the consensus readers for loss of acromioclavicular joint reduction, widening of the coracoclavicular interval, distal clavicular osteolysis, tunnel widening, and hardware complication or fracture. Responses of both reviewers (readers 2 and 3) were compared with each other and with the primary consensus review (reader 1) to determine reader agreement.

Statistical analysis

The post-surgical outcomes, as evaluated by the primary consensus review, were represented in the analysis as binary indicators of whether the patients manifested specific imaging findings after surgery. Fisher exact tests were used to assess the association of the binary features (injury grade (type III or type V), type of reconstruction device (synthetic graft or allograft), and whether surgery occurred within or at some time after the first 180 days after injury) with each binary outcome, and to assess the association of each binary outcome with symptomatology. All statistical tests were conducted at the two-sided 5% significance level using SAS 9.3 software (SAS Institute, Cary, NC).

Reader agreement was assessed in terms of the percentage of times readers provided concordant opinions for the same subject and using the simple kappa coefficient. The level of agreement was interpreted as poor when kappa (K) was less than zero, slight when 0 ≤ K ≤ 0.2, fair when 0.2 < K ≤ 0.4, moderate when 0.4 < K ≤ 0.6, substantial when 0.6 < K ≤ 0.8, and almost perfect when K > 0.8.

Results

The imaging database search yielded 55 patients with prior coracoclavicular ligament reconstruction and at least 1 month of imaging follow-up. Of these 55 patients, 23 were excluded due to either a fracture requiring internal fixation, lack of available operative reports, or an unknown date of surgery, yielding a cohort of 32 patients (23 male, 9 female, average age 43.1 years, age range 24–64 years). Type III injuries were present in 9 patients (28%), type IV injuries were seen in 1 patient (3%), and type V injuries were present in 22 patients (69%). Twenty patients (63%) underwent reconstruction with a synthetic ligament while 12 patients (37%) underwent reconstruction with an allograft. The average time interval between the injury and surgery was 664 days (range 0–10,072), and the average imaging follow-up time after surgery was 281 days (range 31–1048). Review of the electronic medical record for the most recent orthopedic note associated with the last x-ray available for review demonstrated that 21 patients (66%) were imaged for the purpose of any symptomology, and 11 patients (34%) were imaged for the purpose of asymptomatic routine follow-up.

Post-operative findings demonstrated at imaging follow-up are detailed in Table 1. In 4 patients, only one post-operative radiograph was available, and tunnel widening could not be assessed. Twenty-five patients (78%) demonstrated loss of acromioclavicular joint reduction (Fig. 3), with 22 of the 25 cases (88%) occurring within 6 months of surgery. Nineteen of the 25 patients with loss of acromioclavicular joint reduction (76% of the patients with loss of acromioclavicular joint reduction, 59% of the overall cohort) also demonstrated widening of the coracoclavicular interval, with 15 of the 19 cases (79%) occurring within 6 months of surgery. Twenty-one patients (66%) demonstrated distal clavicular osteolysis (Fig. 4), with 19 of the 21 cases (90%) occurring within 6 months of surgery. Tunnel widening (Fig. 5) occurred in 23 of the 28 patients with more than one post-operative radiograph (82%), with an average tunnel widening of 2 mm (range 1–4 mm). Lastly, hardware complication or fracture occurred in 6 patients (19%), with 3 cases of hardware failure (2 operatively diagnosed disrupted allografts and 1 displaced cortical button, Fig. 6), and 3 cases of fractures, one at the base of the coracoid and two at the clavicular tunnels (Fig. 7).

Table 1 Post-operative imaging findings and temporal relationship to surgery
Fig. 3
figure3

48-year-old female with loss of reduction after coracoclavicular reconstruction. a Immediate post-operative radiograph in a 48-year-old female status post coracoclavicular ligament reconstruction demonstrating the two radiolucent clavicular tunnels (black arrows) following allograft reconstruction of the coracoclavicular ligament. b Follow-up radiograph taken 1 month post-operatively after experiencing a popping sensation, sudden onset of pain, and a new shoulder deformity while lifting boxes, showing loss of acromioclavicular joint reduction (black bracket) and widening of the coracoclavicular interval (white bracket). Revision surgery was required in this patient, and the allograft was found to be ruptured intra-operatively

Fig. 4
figure4

35-year-old male with distal clavicular osteolysis after coracoclavicular ligament reconstruction. a Immediate post-operative radiograph in a 35-year-old male demonstrates two radiolucent clavicular tunnels (black arrows), and appropriate acromioclavicular joint alignment. Note the sharp margins of the subchondral bone at the distal clavicular articular surface (black arrowheads) b Three months following the initial radiograph, there has been resorption of the distal clavicle with distal clavicular irregularity (black arrowheads) and new widening of the acromioclavicular joint (black bracket)

Fig. 5
figure5

30-year-old female with tunnel widening after coracoclavicular ligament reconstruction. a Immediate post-operative radiograph in a 30-year-old female following coracoclavicular ligament reconstruction demonstrates the clavicular and coracoid cortical fixation buttons (arrows) and a thin, regular appearance of the radiolucent clavicular tunnel (black line). b Sixth-month post-operative radiograph obtained for persistent pain following surgery, which reveals significant interval widening and irregularity of the clavicular tunnel (black line). There is also slight loss of acromioclavicular joint reduction (bracket) and irregularity of the subchondral bone at the distal clavicular articular surface (arrowhead)

Fig. 6
figure6

55-year-old male with hardware complication after coracoclavicular ligament reconstruction. Radiographs obtained 1.5 months status post-coracoclavicular ligament reconstruction with acromioclavicular separation, widening of the coracoclavicular interval, and distal clavicular osteolysis. The clavicular button (white arrow) is in normal position while the coracoid button (black arrow) is superiorly displaced. There is resultant widening of the coracoclavicular interval (bracket). Distal clavicular osteolysis is also noted (arrowheads). This patient was subsequently revised with a clavicular hook plate

Fig. 7
figure7

32-year-old male with fracture after coracoclavicular ligament reconstruction. a Eighteenth-month post-operative radiograph in a 32-year-old male status post-coracoclavicular ligament reconstruction, demonstrating a subtle nondisplaced fracture through the medial clavicular tunnel (arrow). b Twenty-fifth-month post-operative radiograph demonstrates evidence of clavicular fracture non-union (white arrow) with interval development of hypertrophic, nonbridging marginal callus formation (black arrows). c Open reduction and internal fixation of the distal clavicular fracture using a clavicular plate and screw construct 28 months following the initial surgery

Table 2 shows the results of the Fisher exact test of the association of certain binary outcomes with individual binary features and each other. Loss of acromioclavicular joint reduction was found to have a statistically significant association with widening of the coracoclavicular interval (p = 0.001) and distal clavicular osteolysis (p = 0.032). Widening of the coracoclavicular interval was also found to have a statistically significant association with patients who underwent reconstruction more than 180 days following the initial date of injury (p = 0.036). There was no statistically significant association between hardware type (synthetic graft or allograft), or injury type (type III or type V) and the radiographic outcomes.

Table 2 Fisher exact test (association of binary outcomes/feature, p values)

Table 3 shows the results of the inter-reader agreeability as assessed with the Cohen’s kappa value. Between the 3 readers, there was fair to moderate agreeability with interpretation of loss of acromioclavicular joint reduction and distal clavicular osteolysis, fair to substantial agreeability with interpretation of tunnel widening, and moderate to substantial agreeability with interpretation of coracoclavicular interval widening and hardware complication or fracture.

Table 3 Interobserver agreement in review of radiographs

Table 4 shows the results of the Fisher exact test for association of presence of post-operative radiographic features and complications with symptomatology. Reported post-operative symptoms included the following: pain after new injury (n = 5), new cosmetic deformity over the acromioclavicular joint (n = 4), decreased range of motion and/or activity related pain (n = 5), nonspecific post-operative pain (n = 5), hand numbness (n = 1), and draining wound over the acromioclavicular incision site (n = 1). No radiographic feature or complication demonstrated a significant association with symptomatology (p values 0.071–0.721).

Table 4 Fisher exact test for association of patients with pain and binary outcomes

Discussion

Our study retrospectively reviewed radiographic features and complications following coracoclavicular ligament reconstruction, and the association of each radiographic feature and complications with symptomatology, which, to the best of our knowledge, has not been previously reported in the radiology literature. Our patient cohort of 32 patients also represents one of the larger cohorts based on our review of the literature (1–116 patients, median 18 patients [5,6,7,8,9,10,11,12, 15, 17,18,19,20,21,22,23,24,25,26, 32]. As hypothesized, loss of acromioclavicular joint reduction, widening of the coracoclavicular interval, distal clavicular osteolysis, and tunnel widening were seen frequently in our cohort (59–82%), while hardware complication or fracture was observed in 19%. Despite the frequency of each observed radiographic feature and contrary to our hypothesis, there was no demonstrable association of imaging findings with symptomatology (p values 0.071–0.721).

Reader agreement was highest in the assessment for hardware complication or fracture and widening of the coracoclavicular interval (each demonstrating moderate to substantial agreement). Although nondisplaced fracture along the clavicular or coracoid tunnel may occasionally be subtle (particularly a nondisplaced coracoid fracture), hardware complication, often demonstrating marked displacement of the cortical fixation buttons, is often readily apparent. Similarly, coracoclavicular interval widening may often be dramatic and readily identified. In contrast, lower reader agreement for loss of acromioclavicular joint reduction (fair to moderate) may be attributed to variability in angulation of the acromioclavicular joint, causing difficulty in the identification of the inferior joint margin and detection of subtle loss of reduction to be variable among readers.

Surgical intervention is typically preformed for patients with type IV–type VI acromioclavicular separation injuries, while patients with type I and type II injuries are typically managed conservatively. The main differentiating factor is the involvement of the coracoclavicular ligaments and resultant craniocaudal and anteroposterior instability that occurs with type IV–VI injuries. Conversely, type I and type II injuries are limited only to disruption of the capsuloligamentous structures of the acromioclavicular joint, and thus lack the same degree of instability. While type III injuries do involve tears of the coracoclavicular ligament, there is no consensus in the surgical literature regarding optimal management [1]. Many patients with type III injuries can be successfully treated non-operatively, with conversion to reconstruction if the patient has persistent symptoms despite an appropriate attempt at non-surgical management.

Reconstruction techniques can be divided into two broad groups: one using synthetic materials and the other using allografts as the primary means of reconstructing the coracoclavicular ligaments. There is a large degree of variability in techniques within each of these groups which are beyond the scope of this article [3,4,5,6,7,8]. Ultimately, the goal of surgical intervention is to restore the acromioclavicular and coracoclavicular alignment and maintain the stability of the acromioclavicular joint and coracoclavicular interval. The radiographic appearance of synthetic ligament reconstruction and allograft reconstruction differ. Synthetic grafts typically utilize a single clavicular tunnel and require cortical fixation buttons to secure the graft along the clavicle and coracoid (Fig. 1), while allografts may utilize either a single- or double-clavicular tunnel technique and may be fixated by radiolucent polyetheretherketone (PEEK) screw or a bioabsorbable screw (Fig. 2). At our institution, both synthetic grafts and tendon allografts are used, and the double tunnel method is more often preferred when utilizing allograft reconstruction.

Loss of acromioclavicular joint reduction following coracoclavicular ligament reconstruction has been previously described in the orthopedic literature [10, 11, 13, 15, 17,18,19,20,21,22,23,24, 26] and was seen in 78% of our cohort. Several studies have previously suggested this post-operative imaging finding to be within the realm of expected post-operative change, particularly for subjects presenting with higher grade injury, and is not necessarily clinically symptomatic or significant [20,21,22]. Loss of acromioclavicular joint reduction in our cohort was significantly associated with distal clavicular osteolysis (p = 0.032). Given that one of the more accepted models of distal clavicular osteolysis proposes that osteolysis occurs as a result of repetitive microtrauma causing subchondral stress fractures and remodeling, we postulated that the increased rate of osteolysis in patients with loss of acromioclavicular joint reduction may be related to instability at the acromioclavicular joint resulting in increased stress at the distal clavicle, leading to osteolysis, and potentially generating pain [28, 29]. Despite this potential association, our study did not find a statistically significant association between patients presenting with symptomatology on their final post-operative visit and distal clavicular osteolysis, or any other radiographic feature.

Fractures were observed in 9% of our cohort and occurred at the clavicular reconstruction tunnel, which we believe acts as a stress riser, or at the base of the coracoid. These findings are similar to those previously reported in the orthopedic literature [22, 24]. Prior biomechanical studies have indicated that the surgical tunnels can act as points of failure but found no significant difference in the load to failure or the linear stiffness in clavicles that have been treated with single or double tunnel reconstructions [30]. This is concordant with the findings of our study where we noted fractures at the clavicular tunnels both in patients with single tunnel reconstruction utilizing synthetic graft material and in patients with double tunnel reconstruction utilizing allograft. Additionally, we had one case of fracture at the base of the coracoid process which has been demonstrated both in biomechanical studies and in the surgical literature [2, 19, 22, 24, 31, 32]. It is important for the radiologist, therefore, to scrutinize all tunnels and the surrounding bone on follow-up exams for the presence of the occasionally subtle fracture.

Non-fracture-related hardware complications in our patient population included complete rupture of the graft in two patients who underwent allograft reconstruction (Fig. 3) and displacement of a coracoid fixation button in a patient who underwent synthetic graft reconstruction (Fig. 6). In a prior biomechanical study, Thomas K et al. evaluated various coracoclavicular reconstruction techniques, each of which were stressed to evaluate the mode of failure and required load to failure. Allograft rupture, which was diagnosed intra-operatively in two of our cases requiring revision surgery, was one of the reported modes of failure for allograft reconstruction, while the only cases of failure for synthetic reconstruction involved displacement of the coracoid button through the coracoid tunnel, as occurred in one of our cases [31].

Tunnel widening occurred in 82% of our patients with more than one post-operative radiograph available for review and was not significantly associated with symptomatology. A limited number of previous studies assessing tunnel width have shown a near universal presence of widening [10, 23, 25]. Different mechanisms for tunnel widening have been proposed, including osteolysis in the setting of polyethylene plugs or bioabsorbable screws used for allograft fixation versus osteolysis due to chronic motion of the graft.

Our study has several limitations. Primarily, our cohort is limited by heterogeneity in both the frequency and duration of available follow-up imaging, with some referring physicians preferring routine post-operative imaging, and others only imaging subjects with persistent or new symptoms, potentially skewing our patient population to include a disproportionate number of patients with positive imaging findings. Additionally, since no standard post-operative imaging protocol exists, there was heterogeneity in the types of post-operative radiographs obtained, with some patients receiving shoulder radiographs only, some patients receiving dedicated acromioclavicular radiographs only, and some patients receiving a mixture of the two. This heterogeneity may affect the results of our study and limits our ability to perform a more robust quantitative analysis on findings such as the degree of coracoclavicular interval widening. Although we were able to assess the purpose of post-operative imaging (symptomatic versus routine), it is possible that symptoms were attributed to shoulder pathology unrelated to the acromioclavicular joint. In addition, because we included patients with less than 12 months of post-operative follow-up, some patients in our cohort may have been captured prior to the development of radiographic findings seen in our study, although most imaging features were observed within 6 months of surgery. Finally, intraoperative imaging or immediate post-operative imaging was not available in all patients, and therefore, we were unable to assess immediate post-operative alignment or determine if complete reduction was achieved intra-operatively.

In conclusion, we found loss of acromioclavicular joint reduction, widening of the coracoclavicular interval, distal clavicular osteolysis, and tunnel widening to be common radiographic findings in patients who have undergone coracoclavicular ligament reconstruction. Fractures were observed along the clavicular tunnels, which may act as stress risers, and at the coracoid base, and thus, it behooves the interpreting radiologist to carefully scrutinize each location for the presence of fracture. Although we were unable to correlate imaging findings with symptomatology, radiologists should be aware of and develop a search pattern for frequently observed post-operative imaging features and complications. Future prospective studies seeking to more directly correlate patient symptoms with radiographic findings would be useful.

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Acknowledgments

We would like to thank Dr. James Babb for providing statistical analysis for our study.

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Correspondence to Brian P. Kennedy.

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Kennedy, B.P., Rosenberg, Z.S., Alaia, M.J. et al. Radiographic features and complications following coracoclavicular ligament reconstruction. Skeletal Radiol 49, 955–965 (2020). https://doi.org/10.1007/s00256-020-03375-2

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Keywords

  • Shoulder
  • Coracoclavicular reconstruction
  • Post-operative