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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 47  |  Issue : 3  |  Page : 95-101

Role of loop suture technique for treatment of acute acromioclavicular joint dislocation


1 Department of Orthopedic Surgery, Menshawy General Hospital, Tanta, Egypt
2 Department of Orthopedic Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission26-Jul-2017
Date of Acceptance28-Feb-2018
Date of Web Publication23-Jan-2021

Correspondence Address:
MSc Ahmed M Ezz
Department of Orthopedic Surgery, Menshawy General Hospital, El-Gharbia, Marawan St Cross Motawakel St., Tanta, 31111
Egypt
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DOI: 10.4103/tmj.tmj_69_17

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  Abstract 


Background Acromioclavicular joint has an important role in suspensory mechanism of shoulder joint to the axial skeleton. Acromio-Clavicular Joint (ACJ) dislocation is not a common injury, yet it may cause limitations. In this study, a modified novel loop technique is evaluated.
Aim The aim of the study is to assess the outcome of double-loop Ethibond sutures in ACJ dislocations of grades IV, V, and VI and some cases of grade III.
Patients and methods This prospective randomized study was conducted on 21 patients with acute dislocations of ACJ. All the patients were treated by loop suture technique using Ethibond sutures.
Results All patients presented with acute ACJ. The final results were analyzed, and it was found that the grade of dislocation is inversely proportional with end results. Earlier operated patients got better results. Time of pins removal, compliance to physical therapy, and postoperative exercises affect the final results.
Conclusion The results show high incidence of good outcome. It could not be proven that the good results are owing to CC ligament healing or Ethibond sutures.

Keywords: acromioclavicular dislocation, coracoclavicular, Ethibond, loop, suturing


How to cite this article:
Ezz AM, Hamed HM, Megahed AHA, Lashin MF. Role of loop suture technique for treatment of acute acromioclavicular joint dislocation. Tanta Med J 2019;47:95-101

How to cite this URL:
Ezz AM, Hamed HM, Megahed AHA, Lashin MF. Role of loop suture technique for treatment of acute acromioclavicular joint dislocation. Tanta Med J [serial online] 2019 [cited 2021 May 17];47:95-101. Available from: http://www.tdj.eg.net/text.asp?2019/47/3/95/307636




  Introduction Top


Acromioclavicular joint dislocations may not be a common injury, yet it may cause limitations in activities. Acromioclavicular joint injuries may occur as a result of a direct force applied to the tip of the shoulder with the arm adducted or owing to indirect trauma such as a fall on the outstretched hand [1].

Many procedures have been described for the treatment of complete acromioclavicular joint dislocations through literature. However, the most widespread technique is fixation across the acromioclavicular joint with wires, threaded pins, screws, or hooked plates [2].

However, serious concerns still exist regarding pin migration or breakage, pin-site infection, fixation failure, and redislocation after pin removal. Several authors have proposed various cerclage, sling, or loop techniques to fashion a coracoclavicular loop that tethers the coracoid to the clavicle using wire suture [3],[4].

The main advantage of this technique is that the surgeon can control both the anteroposterior and vertical displacement, placing the clavicle at its anatomical position and allowing the disrupted ligaments to heal easily. In addition, the use of the nonabsorbable suture allows avoidance of the metallic implants with the various adverse effects and reoperation for removal [1].


  Aim Top


The aim of the study is to assess the outcome of double-loop Ethibond sutures in acromioclavicular joint dislocations of grades IV, V, and VI and some cases of grade III.


  Patients and methods Top


After the approval of Tanta Ethical Committee for the research before starting it and a consent from the patients, 21 patients diagnosed with acute Acromio-Clavicular Joint (ACJ) dislocations were included and treated surgically by double-loop suture technique using Ethibond number 5 sutures in Department of Orthopedic surgery and Traumatology Tanta Faculty of Medicine.

After stay suturing the two stumps of CC ligaments, two strands of Ethibond were passed under the coracoid process and through two drilled holes in the clavicle. After reducing the clavicle into its anatomical position, the Ethibond strands are tied over the clavicle, and the sutures of CC ligaments are tied. Two k-wires are inserted through the ACJ to augment the fixation. These wires were removed 3–6 weeks postoperatively.

Inclusion criteria

The following were the inclusion criteria:
  1. Acromioclavicular joint dislocation grades (III, IV, V, and VI).
  2. Injuries within less than 6 weeks.
  3. Athletes and manual workers who need rapid recovery for their daily working activities.
  4. Range of age from 18 to 60 years.


Exclusion criteria

The following were the exclusion criteria:
  1. Acromioclavicular joint dislocation grades I and II.
  2. Neglected injuries for more than 6 weeks.
  3. Patients with bleeding or coagulation disorders.
  4. Patients with adhesive capsulitis ‘frozen shoulder’.
  5. Immunocompromised patients.
  6. Upper limb comorbidity.
  7. Age below 18 and more than 60 years.


All patients included in the study were subjected to the following:
  1. Full history taking.
  2. Examination.
  3. Investigations:
    1. Antero-Possterior (AP) with 10° cranial tilt of the beam (Zanca view).
    2. True axillary in a supine position.
    3. Comparative stress radiography of both acromioclavicular joints.


Surgical technique

  1. Position: supine with 45° elevation of the shoulders (beach chair).
  2. C-shaped 4 cm incision was made over the tip of the acromion.
  3. Superficial dissection of the skin and subcutaneous tissue.
  4. Exposure and stay suturing of the torn ends of the coracoclavicular ligaments on vicryl sutures.
  5. Using a 90° artery forceps, two threads of number 5 Ethibond were passed under the neck of the coracoid process.
  6. Two holes were drilled at 1.5 and 3 cm from the lateral end of the clavicle using 2.7-mm drill bit.
  7. The ends of the Ethibond threads were passed from the holes from down upward and then tied in a double knot (one in 8 shaped manner and the other in box manner) over the upper surface of the clavicle to reduce the distal end to its anatomical position.
  8. The two ends of the coracoclavicular joint are sutured together.
  9. Acromioclavicular joint capsule was sutured by vicryl in figure-of-8 manner.
  10. Two k-wires were drilled from the lateral tip of the acromion into the distal clavicle and ensured in position by intraoperative imaging by C-arm.
  11. Closure of the subcutaneous tissue and skin in layers.
  12. Betadine damping and dressing on the main incision and the k-wires entry point.
  13. Patients’ arms were put in an arm sling.


Follow-up

  1. Arm slings for operated arms were put for 4 weeks.
  2. One-day postoperative radiographs in Zanca view and axillary view and repeated 2 and 4 weeks postoperative.
  3. After 10–14 days, the skin sutures were removed.
  4. After 3–6 weeks, the two k-wires were removed.
  5. During first 2 weeks postoperatively, only mild flexion and extension of the shoulders were allowed.
  6. During third and fourth weeks postoperatively, pendulum movement of the shoulder is allowed to avoid stiffness.
  7. After k-wires removal, full active range of motion (ROM) for the shoulder is encouraged.


Statistical analysis

Statistical analysis was performed by SPSS statistics version 20.0.0 (IBM Corp. Released 2011, IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.), multicomputer software. Hypothesis tests were used to test the validity of a claim that is made about a population. The claim that is on trial, in essence, is called the null hypothesis, and the alternative hypothesis is the one which would be believed if the null hypothesis is concluded to be untrue. P value helped to determine the significance level of results, and Student t-test is used in comparison between both hips measurements.


  Results Top


According to the modified The University of California at Los Angeles (UCLA) [5] shoulder rating scale, the functional end results were graded as excellent in 11 (52.4%) patients, good in seven (33.3%), and fair in three (14.3), with no poor results. The excellent and good results were considered as satisfactory ones, whereas the unsatisfactory included the fair results and the poor results. Thus, satisfactory results were found in 18 (85.7%) patients, and unsatisfactory in three (14.3%) patients.

Results based on the modified UCLA shoulder rating scale [5] revealed that there is highly significant improvement (P<0.001) of the final end results. The mean preoperative score was 13.67, and the mean postoperative score was 33.38 points. Results improved by a mean of 19.71.

In this study, the mean age of patients with excellent results was 34.75, good results was 23.6, and fair results was 33.33. Nineteen (90.5%) males were operated; 10 (47.6%) had excellent results, seven (33.3%) had good results, and two (9.5%) had fair results. Two (9.5%) female patients were operated; one (4.8%) had excellent result and one (4.8%) had fair results. Fifteen (71.4%) right shoulders and six (28.6%) left shoulders were operated. There were 14 (66.7%) dominant shoulders and seven (33.3%) nondominant shoulders. There were eight (38.1%) low-demand shoulders and 13 (61.9%) high-demand shoulders.

In this study, there were five (23.8%) patients with grade III ACJ dislocations who had excellent results. In grade IV ACJ dislocations, two (9.5%) patients had good results and two (9.5%) patients had excellent results. In grade V ACJ dislocations, three (14.3%) patients had fair results, five (23.8%) patients had good results, and four (19%) patients had excellent results (P=0.002).

Time from trauma to surgery ranged from 3 days up to 14 days, with a mean of 7.14 days. Best results were found in patients operated before 5 days; eight (38.1%) patients had excellent results and one (4.8%) patient with good result. In patients operated in 5–9 days, three (14.3%) patient had excellent results and three (14.3%) patients had good results. In patients operated after 10 days from the trauma, three (14.3%) had fair results and three (14.3%) had good results (P<0.001).

In this study, 17 (81%) patients complied with early ROM of the operated shoulder, where 11 (52.4%) had excellent results and six (28.6%) had good results. Four (19%) patients did not comply with early ROM of the operated shoulder, where one (4.8%) had good results and the other three (14.3%) got fair results (P<0.001).

Time of pin removal ranged from 3 to 6 weeks, with a mean of 4.33 weeks. Fifteen (71.4%) patients who had their pins removed early at 4 weeks postoperatively had excellent and good results. However, the three (14.3%) patients who came late in the follow-up and had the pins removed after 6 weeks had fair results. Pins removal after 5 weeks showed good results in three (14.3%) patients (P<0.001).

In this study, patients with excellent and good results had no need for special physical therapy in rehabilitation, whereas patients with fair results went through special rehabilitation program. The study of the relation between physical therapy and the functional end results revealed to be statistically significant (P<0.001).

In this study, the found complications were pin-tract infection in four (19%) patients, slight loss of the reduction after pin removal in one (4.8%) patient, wound infection in two (9.5%) patients, and stiff shoulder in two (9.5%) patients, which was statistically significant (P<0.001; [Table 1]).
Table 1 Functional end results and the modified UCLA

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  Discussion Top


In this study, 21 patients could be followed up and constituted the basis of this study. The shortest follow-up period was 6 months, whereas the longest was 9 months, with a mean follow-up period of 6.71 months.

In this study according to the modified UCLA [5] shoulder rating scale, the mean preoperative score was 13.67 (39%), and the mean postoperative score was 33.38 (95.4%) points. The results significantly improved by a mean of 19.71.

The functional end results of this study was comparable to the results of Abdelaziz and El-Rosasy [6] who operated 15 patients with acute ACJ dislocation grade III with open reduction and synthetic coracoclavicular loop to stabilize the ACJ. The follow-up period was at least 2 years postoperatively, with end results of 12 (80%) patients had excellent (91–100) grades, two (13.3%) with good (81–90) results, and one (6.67%) with fair (61–80) results using Imatani et al. [7] evaluation system.

Moreover, the functional end results were comparable to those of Mardani-Kivi et al. [8] who operated 21 patients with grades III-VI dislocations by ACJ reconstruction using Ethibond suture. The mean follow-up period was 25.7 months (range: 12–49 months). The mean Constant and Murley score [9] was 91±1 at the final follow-up. There were 71.4% of patients with excellent results, 19.1% with good results, and 9.5% with fair results.

Morsy and Waly [10] obtained comparable results by operating on 25 patients with acute ACJ dislocation using coracoacromial ligament transfer combined with coracoclavicular suture loop and acromioclavicular suture fixation. The mean follow-up was 19 months, and the mean Constant and Murley [9] score significantly improved to 96 points.

Dimakopoulos et al. [2] also obtained comparable results by operating on 34 patients with acute, complete acromioclavicular joint dislocations (grade III, IV and V) who underwent surgical reconstruction with the coracoclavicular loop stabilization technique by using two pairs of Ethibond No. 5. At a mean follow-up of 33.2 months (range: 18–59 months), the Constant and Murley [9] score significantly improved to 93.5 points (range: 73–100 points).

El-Shewy and Azizi [1] operated − using suture repair using loop technique − 21 cases of acute acromioclavicular joint dislocation, and the results according to the modified UCLA score [5] showed a significant improvement in pain, function, active forward elevation, strength of forward flexion, and patient satisfaction. The mean total score significantly improved by mean of 14.77. The follow-up period ranged from 6 to 9.5 years. The end results were lower than those of this study because of the short-term follow-up period of this study.

Hou et al. [11] compared single-tunnel and two-tunnel techniques in the treatment of acromioclavicular joint dislocation by tendon grafts. The overall mean follow-up time was 16 months, and the overall mean modified UCLA rating score [5] was 14.1 (40.3%) (range: 8–20). The percentage of good-to-excellent outcomes was significantly higher for patients with the two-tunnel technique than for those with the one-tunnel technique (70 vs. 18%). A total of 11 (52%) patients rated the outcome as good to excellent, 3 (14%) rated it as fair, and 7 (33%) rated it as poor. The results were lower than that of this study because of the long deltopectoral incision and more soft tissue manipulation.

Torkman et al. [12] included 28 patients who underwent surgical management by the double-button fixation system for acute AC joint dislocation. The mean follow-up time was 16.17±4.38 months. The Constant [5] score significantly improved by a mean of 55.82±3.6. There were no significant differences between the right and left CC. The results were slightly lower than that of this study.

Andreani et al. [13] included 19 patients who were treated with the tight-rope system and nine patients using hook plate. Results according to the UCLA score [5] showed a significant improvement in pain, function, active forward elevation, strength of forward flexion, and patient satisfaction. The mean total score improved from 52 to 95% in the tight-rope system group, whereas in the hook plate group, it was from 33 to 80%. The results of the first group is comparable to this study, and the results of the second group is lower because of the presence of metallic implant.

In this study, the pain improved according to the modified UCLA score [5] by mean of 6.71 out of 10 points, from mean of 2.43 preoperatively to 9.14 postoperatively. These results were comparable to the results of El-Shewy and Azizi [1] using suture repair using loop technique, which stated that the pain improved by 5.8 (16.57%) points.

The results are higher than the results of Morsy and Waly [10] who stated that the mean score of pain improved by mean of 12.3. Torkaman et al. [12] stated that pain declined by mean VAS score [14] of six out of 10. Sharifi et al. [15] compared tension band wiring with CC screw fixation and stated that 65% (eight patients with tension band and five with hook plate) patients did not complain of any pain, 5% (one patient with tension band) had slight pain, 25% (two patients with tension band and three with hook plate) had moderate pain, and 5% (one patient with tension band) had severe, constant, disabling pain. This may be because of the smaller incision and less soft tissue manipulation.

In this study, function improved according to the modified UCLA score [5] by mean of 4.41 out of five points, from mean of 5.24 preoperatively to 9.65 postoperatively.

The results are higher than that of El-Shewy and Azizi [1] where function improved according to the modified UCLA score [5] by mean of 2.5 points. This could be explained by the short follow-up period of 6–9 months compared with 6–9 years in the other study. Sharifi et al. [15] stated that the function according to Oxford shoulder score (111) had 50% excellent results (seven patients with tension band and three with hook plate), 10% good results (one patient with tension band and one with hook plate), 20% good results (three patients with tension band and one with hook plate), and 20% poor results (two patients with tension band and two with hook plate). The presence of metallic implants explains the declined results compared with the results of this study.

In this study, the ROM improved according to the modified UCLA score [5]. The active forward flexion improved by a mean of 2.19 out of five points, from mean of 2.73 preoperatively to 4.92 postoperatively, and the strength of forward flexion by mean of 2.41 of five points, from mean of 2.51 preoperatively to 4.92 postoperatively. The results are comparable to that of Morsy and Waly [10] where the mean ROM improved by mean of 20.35 out of 40 points on Constant and Murley [9] shoulder score.

The results are higher than that of El-Shewy and Azizi [1] where the active forward flexion improved by 1.5 points, and the strength of forward flexion improved by 1.8 points. Dimakopoulos et al. [2] reported that only one (2.9%) patient showed restricted shoulder motion 28 months after the procedure, whereas other patients regained the same ROM before injury. This could be explained by the short follow-up period.

The results are lower than those of Sharifi et al. [16] who reported 85% excellent results (eight patients with tension band and nine with hook plate), 10% good results (one patient with tension band and one with hook plate), 5% fair results (one patient with tension band), and no poor results. Metallic implants increase the stability and thus increase the ROM.

In this study, the overall patient satisfaction improved according to the modified UCLA score [5] by 4.82 out of five points from mean of zero preoperatively to 4.82 postoperatively. The results are comparable to that of El-Shewy and Azizi [1] where the overall patient satisfaction improved by 4.8 points. Morsy and Waly [10] stated that all patients were satisfied and returned to normal life at a mean of 2.5 months postoperatively (2–3 months in this study).

Neither this study nor the other mentioned studies showed any statistical or clinical correlation between the functional end results and age, sex, side of injury, dominance of side of injury, occupation, and mode of trauma.

In this study, there were five (23.8%) patients with grade III ACJ dislocations who had excellent results. In grade IV ACJ dislocations, two (9.5%) patients had good results and two (9.5%) patients had excellent results. In grade V ACJ dislocations, three (14.3%) patients had fair results, five (23.8%) patients had good results, and four (19%) patients had excellent results. There was a significant statistical correlation between the Rockwood grade of ACJ dislocation and the functional end results.

It was noticed that the less the grade of dislocation the better the functional end results are. It could be attributed to the less damage to the surrounding tissues supporting the ACJ such as deltoid muscle and clavipectoral fascia.

In this study, time elapsed between trauma ranged from 3 days up to 14 days, with a mean of 7.14 days. Best results were found in patients operated before 5 days, as eight (38.1%) patients had excellent results and one (4.8%) patient had good result. In patients operated in 5–9 days, three (14.3%) patient had excellent result and three (14.3%) patients had good results. In patients operated after 10 days from the trauma, three (14.3%) had fair results and three (14.3%) had good results.

El-Shewy and Azizi [1] stated that there was an interval of 2.14 days before operation. Mardani-Kivi et al. [8] stated that the mean time between the injury and surgery was 5.7±2 days. Morsy and Waly [10] stated that the surgeries were performed with 2 weeks from the injury. Dimakopoulos et al. [2] stated that the operations were performed within the first 10 days after the injury. Torkaman et al. [12] stated that the mean time of hospitalization before the surgery was 2.7±1.4 days (range: 1–5 days). Andreani et al. [13] stated that the duration between the time of injury and the date of surgery varied between 2 and 21 days, with an average of 7.2 days.

The time between trauma and surgery in the aforementioned studies was comparable to this study.

It is noticed that the shorter the time between trauma and surgery, the better the functional end results are, because of the stiffness and lack of ROM that happen and also the plasticity and fibrosis occurring with long preoperative time play a role.

In this study regarding the postoperative rehabilitation plan, pins were removed 4–6 weeks postoperatively. Mardani-Kivi et al. [8] stated that the pins were removed at the end of 6 weeks, with no affection to the final end results. The patients could return to normal life activities within 6–8 weeks postoperative and to strenuous activities after 3 month postoperatively. Mardani-Kivi et al. [8] stated that return to intense activity was allowed at the end of the third month.

It is found that the optimum time for wires removal is 4 weeks postoperatively. In addition, the gradually increasing ROM of the shoulder has a big effect on the functional end results. The patients were afraid to move the operated shoulder with wires appearing from the skin.

In this study, the found complications were pin-tract infection in four (19%) patients, slight loss of the reduction after pin removal in one (4.8%) patient, superficial wound infection in two (9.5%) patients treated by daily dressings and oral antibiotics, and stiff shoulder in two (9.5%) patients. One (4.8%) patient had slight subluxation in the ACJ postoperatively but without effect on functional end results. No patients complained of ACJ arthritis.

El-Shewy and Azizi [1] reported one (4.8%) patient who sustained a recurrence, and the patient was seen 6 weeks postoperatively without any deformity. Mardani-Kivi et al. [8] reported only six (29%) patients had 25% subluxation of ACJ without any functional affection. Morsy and Waly [10] stated that no intraoperative or postoperative complications were encountered. Dimakopoulos et al. [2] reported complications included one (2.9%) case with superficial infection and one (2.9%) patient (basketball player) with persistent tenderness in the acromioclavicular joint without signs of secondary arthritis. The incidence of periarticular ossification was 17.6%, and it did not affect the final outcome. Secondary degenerative changes were not detected.

Abdelaziz and El-Rosasy [6] stated no wound complications in that series, and perfect reduction was achieved in all the patients. There was no deterioration of the reduction or functional outcome by time.

Hou et al. [11] noted that complications were observed in 14.3%; two patients in the two-tunnel group had infection and one patient in the single-tunnel group had a coracoid fracture. Calcification of the CC ligament occurred in one case, but it did not appear to cause symptoms. No patient had neurovascular or post-traumatic arthritis of the injured AC joint. Torkaman et al. [12] reported two (7.14%) cases with heterotrophic ossifications.

Andreani et al. [13] stated that residual asymptomatic slight loss of reduction in eight (28.6%) patients. None showed deltoid atrophy or detachment, and none experienced pain or paresthesia over the clavicular buttons. One (3.5%) patient had hypertrophic scars. The coracoclavicular calcifications have appeared in a low percentage of cases but showed no correlation to clinical results. Two (7.1%) patients developed at 5 years postoperatively radiological evidence of asymptomatic AC arthritis.


  Conclusion Top


This technique is good for acute cases. The results show high incidence of good outcome. It could not be proven that the good results are owing to CC ligament healing or Ethibond sutures. The patients were able to return to their daily activities and even to contact sports without any noticeable deformity, feeling of weakness, pain, or limitation of ROM (compared with the contralateral side). The technique does not involve the use of metallic implants, which require a second surgery to be removed, or the use of expensive synthetic graft or a graft harvested from a distant donor site.

As long as the grade of dislocation is lower, the functional end results is higher, that is, grade III had better end results than grades IV and V. Moreover, the time of surgery affects the end results; the earlier the surgery is performed the better the results. Time of pins removal and compliance to the physical therapy and shoulder ROM postoperative highly affect the final end results. Longer period of follow-up was needed for better evaluation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
El Shewy MT, El Azizi H. Suture repair using loop technique in cases of acute complete acromioclavicular joint dislocation. J Orthop Traumatol 2011; 12:29–35.  Back to cited text no. 1
    
2.
Dimakopoulos P, Panagopoulos A, Syggelos SA, Panagiotopoulos E, Lambiris E. Double-loop suture repair for acute acromioclavicular joint disruption. Am J Sports Med 2006; 34:1112–1119.  Back to cited text no. 2
    
3.
Lindsey RW, Gutowski WT. The migration of a broken pin following fixation of the acromioclavicular joint: a case report and review of the literature. Orthopedics 1986; 9:413–416.  Back to cited text no. 3
    
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Mayr E, Braun W, Eber W, Ruter A. Treatment of acromioclavicular joint separations: central Kirschner-wire and PDS-augmentation. Unfallchirurg 1999; 102:278–286.  Back to cited text no. 4
    
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Abdelaziz WF, El-Rosasy MA. Repair of acute acromioclavicular dislocation type III using coracoclavicular synthetic loop. Tanta Med J 2005; 33:661.  Back to cited text no. 6
    
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Imatani RJ, Hanlon JJ, Cady GW. Acute, complete acromioclavicular separation. J Bone Joint Surg Am 1975; 57:328–332.  Back to cited text no. 7
    
8.
Mardani-Kivi M, Mirbolook A, Salariyeh M, Hashemi-Motlagh K, Saheb-Ekhtiari K. The comparison of Ethibond sutures and semitendinosus autograft in the surgical treatment of acromioclavicular dislocation. Acta Orthop Traumatol Turc 2013; 47:307–310.  Back to cited text no. 8
    
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Constant CR, Murley AG. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987; 214:160–164.  Back to cited text no. 9
    
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Morsy MG, Waly AH. Triple fixation for acute acromioclavicular joint dislocation. Egypt Orthop J 2014; 49:108.  Back to cited text no. 10
    
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Hou Z, Graham J, Zhang Y, Strohecker K, Feldmann D, Bowen TR et al. Comparison of single and two-tunnel techniques during open treatment of acromioclavicular joint disruption. BMC Surg 2014; 14:1.  Back to cited text no. 11
    
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Torkaman A, Bagherifard A, Mokhatri T, Haghighi MH, Monshizadeh S, Taraz H, Hasanvand A. Double-button fixation system for management of acute acromioclavicular joint dislocation. Arch Bone Jt Surg 2016; 4:41.  Back to cited text no. 12
    
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Andreani L, Bonicoli E, Parchi P, Piolanti N, Michele L. Acromio-clavicular repair using two different techniques. Eur J Orthop Surg Traumatol. 2014; 24:237–242.  Back to cited text no. 13
    
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Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain 1983; 16:87–101.  Back to cited text no. 14
    
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Sharifi SR, Shorin HR, Birjandinejad A, Shojaee B, Mirkazemi M. Comparison between two surgical techniques acromioclavicular tension band wiring and coracoclavicular screw in acromioclavicular dislocations. Razavi Int J Med 2014; 2:e20336.  Back to cited text no. 15
    
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