Clinical Question

Is surgical intervention for acromioclavicular (AC) joint dislocation superior to conservative interventions in adults?

Evidence-Based Answer

Surgical treatment for AC joint dislocation of the shoulder does not appear to be superior to conservative management in adults. Both strategies resulted in similar quality of life, function, and return to previous activities after one year. Surgical therapy increases the risk of hardware complications, infection, and continued discomfort.¹ (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Dislocation of the AC joint accounts for about 9% of shoulder injuries in the general population and increases to 40% among elite athletes participating in highly competitive impact sports.² Dislocation of the AC joint involves injury to the AC ligament with or without coracoclavicular ligament disruption. It most commonly occurs in sports such as football, boxing, martial arts, and cycling and results from a direct impact or fall onto the superior aspect of the shoulder. The most widely accepted classification of AC joint injuries is the Rockwood classification, which grades the injury from I to VI. Types I and II are generally considered nonsurgical, and grades IV through VI are surgical. Treatment of type III injuries is controversial and is outside the scope of this review. The authors of this Cochrane review sought to determine if surgical management of AC joint dislocation was superior to conservative management.

The review included six randomized or quasi-randomized controlled trials and 357 participants.¹ Most participants were male with a mean age of 32 years. All studies were determined to be at high risk of bias; blinding was impossible, and sham surgeries are unethical. Although not all studies specified the severity of injury, by description they all seemed to include type III, and some also included types IV through VI. Primary outcomes were shoulder function, pain level, and treatment failure leading to unplanned surgical intervention, with most studies assessing the need for additional surgical intervention over the subsequent one to four years. A number of secondary outcomes were examined, including return to activity and adverse effects.

The Disabilities of the Arm, Shoulder and Hand questionnaire (https://www.myoptumhealthphysicalhealth.com/Documents/Forms/DASH.pdf) is a validated self-reporting tool that assesses the ability to perform upper limb movements. For the primary outcome of shoulder function, low-quality evidence in studies that used this tool favored conservative (i.e., nonsurgical) treatment within the first three months (mean difference = 8.38 points; 95% CI, 2.62 to 14.14). However, there were no significant differences in shoulder function by one year in studies that included any validated shoulder function assessment tool. No significant differences occurred between treatment groups in level of pain or episodes of treatment failure, although these outcomes had only very low-quality evidence.

Return to previous activities tended to occur earlier or was more successful in those who were managed conservatively, although this secondary outcome was assessed with very low-quality evidence and was measured in a variety of ways that could not be consolidated for meta-analysis. Most adverse effects were reported in the surgical group and included infection, problems with hardware, and restricted range of motion.

It should be noted that this Cochrane review encompassed at least 35 conservative treatments and 150 distinct surgical methods for treating AC joint dislocation; further study on specific techniques is warranted because newer methods may have more success. Surgical management may also be warranted for cases in which the shoulder injury is more extensive, such as a co-occurring coracoclavicular ligament strain. However, at least one other systematic review of 14 studies that included 646 patients found no significant difference in outcomes for patients with more severe AC joint dislocations, further suggesting that conservative therapy may be warranted initially for most patients.³

The practice recommendations in this activity are available at http://www.cochrane.org/CD007429.

The views expressed in this publication are those of the authors and do not necessarily reflect the official policy of the Department of Defense, the Department of the Army, the U.S. Army Medical Department, or the U.S. government.