Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials.

BACKGROUND: 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.

METHODS: 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.

RESULTS: 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).

CONCLUSIONS: 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.