Arthroscopy-assisted loop titanium plate versus clavicular hook plate for acute acromioclavicular joint dislocation: clinical efficacy and cost-effectiveness

Abstract

BACKGROUND: Surgical management of acute Rockwood type III-V acromioclavicular joint dislocations remains controversial. While clavicular hook plate fixation is widely adopted, it carries risks of postoperative complications. The emerging arthroscopy-assisted loop titanium plate technique, despite its minimally invasive advantages, requires further validation regarding long-term efficacy and cost-effectiveness. OBJECTIVE: To compare the clinical efficacy and cost-effectiveness of modified arthroscopic loop titanium plate fixation versus clavicular hook plate fixation for the treatment of acute Rockwood type III-V acromioclavicular joint dislocations. METHODS: Eighty eligible patients with acute Rockwood type III-V acromioclavicular joint dislocations admitted at Zhongshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine between January 2021 and July 2024 were enrolled and randomly assigned to either the loop titanium plate group (n=40) or the hook plate group (n=40). Ultimately, 31 and 33 patients in each group completed follow-up, respectively. The loop titanium plate group underwent fixation using the FixButtonTM suspension system with 2.4 mm bone tunnels; the hook plate group received open reduction and internal fixation with a clavicular hook plate. Outcome measures included operative time, incision length, blood loss, hospitalization costs, visual analog scale (VAS) for pain, Constant-Murley score, coracoclavicular distance, acromioclavicular distance, and complication rates, with a follow-up of 6 months. RESULTS AND CONCLUSION: The loop titanium plate group had longer operative time, shorter incisions, less blood loss, but higher hospitalization costs (P < 0.05). At 6 months postoperatively, the excellent-to-good rate in the loop titanium plate group (94%) was significantly higher than that in the hook plate group (82%) (P < 0.05); VAS scores were lower and Constant-Murley scores were higher (P < 0.05); coracoclavicular and acromioclavicular distances were better restored (P < 0.05). The total complication rate in the loop titanium plate group (6%) was lower than that in the hook plate group (12%) (P < 0.05). These findings suggest that although the modified arthroscopic loop titanium plate technique requires longer operative time and higher costs, it significantly reduces trauma, alleviates pain, improves shoulder function, and lowers complication risk, offering superior short-term clinical efficacy. Despite higher upfront costs, the potential reduction in secondary surgeries may confer long-term economic benefits. This technique is more suitable for patients with high demands for cosmetic incisions and functional recovery. Future studies with larger sample sizes and longer follow-up are needed to further validate these conclusions.

1. Introduction

Acute acromioclavicular joint dislocation is a common shoulder injury, typically caused by high-energy direct or indirect trauma to the upper limb. It manifests as local deformity and pain at the distal clavicle, and in severe cases, restricted shoulder movement and dysfunction. Timely and effective treatment is crucial to restore shoulder stability and function. The Rockwood classification is widely used for clinical typing, with types I-II generally managed conservatively and types IV-VI treated surgically due to severe injury. However, the optimal treatment for type III injuries remains controversial.

To date, more than ten surgical techniques have been described for acromioclavicular joint dislocation. Among them, clavicular hook plate fixation is commonly used due to its relatively simple procedure and biomechanical compatibility. Nevertheless, this technique is associated with a high incidence of postoperative complications, particularly 'implant irritation'. In recent years, with the advancement of shoulder arthroscopy and elastic fixation techniques, the use of loop titanium plates has emerged as an alternative, but its long-term efficacy and cost-effectiveness require systematic evaluation.

Currently, the two mainstream arthroscopic elastic fixation techniques are TightRope and Endobutton loop titanium plate fixation. TightRope involves placing titanium buttons on the clavicle and beneath the coracoid, connected by sutures through bone tunnels to reconstruct the coracoclavicular ligament. Endobutton involves drilling from approximately 3 cm medial to the distal clavicle to the base of the coracoid, placing loop titanium plates beneath the coracoid and above the clavicular tunnel, with the loop exiting from the clavicle to reconstruct the coracoclavicular ligament. These techniques aim to provide stable fixation while minimizing invasiveness.