The surgical treatment of acromioclavicular dislocations.

The treatment of acromioclavicular dislocation in the United Kingdom is usually conservative, using a splint, a bandage and analgesics (Copeland and Kessel 1980). Watson-Jones thought that in young sportsmen with severe injuries this approach might not be justified (Wilson 1976). Severe injuries are classified as Grade III (Allman 1967) and are usually the result of a strong force which has ruptured the acromioclavicular and the coracoclavicular ligaments, with dislocation of the joint. This is in contradistinction to Grade II injuries which are the consequence of a more moderate force with rupture of the capsule and the acromioclavicular ligament ; the coracoclavicular ligament is intact but the joint is subluxated. Grade I injuries are the result ofmild force with involvement of but few fibres of the acromioclavicular ligament and capsule. Several studies have shown that Grade III injuries treated conservatively fare badly in terms of pain and decreased function, especially in sportsmen. A study of the literature in 1954 (Kennedy and Cameron 1954) showed that 20 per cent of Grade III acromioclavicular . dislocations treated conservatively had unsatisfactory results, with pain, instability and residual loss of shoulder movement. Dawe (1980), reviewing 17 Grade III acromioclavicular dislocations between 9 and 30 months, noted that in 13 there was residual pain during vigorous activity which was sufficiently severe to cause three to change jobs and five to give up contact sports. The case against conservative treatment is not clear. For instance, Urist (1946) claimed an 80 per cent success rate with conservative treatment. Jacobs and Wade (1966), reviewing 17 acromioclavicular dislocations treated conservatively, noted that 53 per cent were asymptomatic but 23 per cent had a decreased range of movement. Several recent papers have reviewed the results of open reduction and internal fixation. Alldredge (1965) reviewed the results in 24 patients, of which 20 were excellent, two good and two fair. Weaver and Dunn (1972) commented upon the difficulty of maintaining conservative treatment due to the need for frequent attendances for changes of plaster, problems with the skin, residual deformity and a stiff shoulder, especially in older patients. Of the 15 patients they treated surgically, 12 were operated upon primarily and in three the operation was delayed : all but one of these obtained either a good or a fair result. Powers and Bach (1974) reviewing 14 cases of Grade III acromioclavicular dislocations treated surgically, noted nine good results and two fair but there had been three poor results. Imatani, Hanlon and Cady (1975) reviewed 23 acromioclavicular dislocations in a prospective study : of 1 1 treated surgically, four had an excellent result, one was satisfactory, one fair but five were poor. It is to be noted, however, that in the surgical technique they used, the ruptured ligaments were not repaired, the joint was fixed with pins and the meniscus excised. On considering these results, we felt that the place of surgery was still unclear. One of us (BAR) was of the opinion that a Grade III injury in a young person treated conservatively resulted in disabling residual symptoms sufficient to prevent contact sport. Accordingly, all such injuries in these patients have been treated surgically in this hospital and the results are reviewed.