Tightrope and Clavicular Hook Plate Technique: A Commentary

This article refers to:

Comparison of the Radiological and Functional Results of Tight Rope and Clavicular Hook Plate Technique in the Treatment of Acute Acromioclavicular Joint Dislocation

Although acromioclavicular joint dislocations are relatively common as the sequelae from trauma or sports related injuries, more severe injuries requiring surgical treatment often remain scarce [1]. In addition, controversy remains regarding type III injuries in particular, and patient factors remain critical to deciding on optimal management technique(s) [2].

This investigation assessed type III and V injuries treated either with a Tightrope device or hook plate and screw device [3]. There were significantly more type III injuries than type V in the series, with only type V injuries noted. This limits the applicability of the conclusions to type V, but with thirty type III patients, more of a solid conclusion can be made regarding this subset of acromioclavicular joint injuries. The authors found a strong correlation with accuracy of reduction and functional outcome, and most interestingly, there was no difference between the two implants in regards to either measurement. This differs slightly from some of the existing data and a recent meta-analysis that found increased shoulder scores and pain levels with use of suspensory loop suture techniques with devices such as the Tightrope [4]. This may be due to improved techniques with the series in this investigation or limitations in ability to detect differences due to the relatively small patient cohort size; the differences may also not be noted with type III injuries and/or may be different with each grade change of acromioclavicular joint dislocation.

The aforementioned recent meta-analysis reported a 1.69-fold increase in complications with suspensory loop suture techniques for the acromioclavicular joint dislocation [4]. With the decreased operative time required for hook plate application noted in this investigation [3], the functional outcomes then remain the most important remaining factor to determine optimal implant choice. As this investigation shows no difference in functional scores post-operatively, it appears that in the investigators’ hands, the hook plate would be the ideal implant for type III injuries, but we cannot state this definitively for type V injuries with the small numbers. With other studies also noting significantly increased surgical duration to use the suture devices [5], there must be improved outcomes with an acceptable risk profile to warrant use of these often more expensive devices. As they are flexible, they do tolerate some iatrogenic malreduction of the joint, similar to use for ankle syndesmotic fixation, as the flexible nature will allow the distal clavicle to move in an anteroposterior direction to self-reduce. This device then would theoretically allow more surgeon error for successful outcomes, but would not allow the same improvements with errors in the cephalad-caudal direction, or even with malrotation of the clavicle. The plate and screw device requires a more direct reduction approach and by appropriate selection of the implant size, the surgeon has more direct control of the final joint reduction and therefore outcome, as noted in this investigation [3].

Disclosure statement

No potential conflict of interest was reported by the author(s).