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Appendices

Appendix 1. Search strategies for this update (date of search: June 2019)

CENTRAL (CRS Web)

Search 1

1 MESH DESCRIPTOR Acromioclavicular Joint AND CENTRAL: TARGET (45)
2 (acromioclavic* or coracoclavic* or AC joint ): AB,EH,KW,KY,MC,MH,TI,TO AND 3 CENTRAL: TARGET (119)
3 #1 OR #2 (119)

Search 2 (top‐up search)

Lines 1 to 3 as above
4 20/08/2018_To_17/06/2019:CRSCREATED AND CENTRAL:TARGET (270097)
5 #4 AND #3 (42)

MEDLINE: Ovid MEDLINE(R)

Search 1

1 ACROMIOCLAVICULAR JOINT/ (1901)
2 (acromioclavic* or coracoclavic* or AC joint).tw. (2133)
3 1 or 2 (2641)
4 Randomized controlled trial.pt. (466407)
5 Controlled clinical trial.pt. (92552)
6 randomi?ed.ti,ab. (469940)
7 placebo.ab. (174425)
8 Clinical trials as topic/ (184490)
9 randomly.ab. (253639)
10 trial.ti. (161749)
11 4 or 5 or 6 or 7 or 8 or 9 or 10 (1091561)
12 exp Animals/ not Humans/ (4486177)
13 11 not 12 (997810)
14 3 and 13 (110)
15 ("2009*" or "2010*" or "2011*" or "2012*" or "2013*" or "2014*" or "2015*" or "2016*" or "2017*" or "2018*").ed,dc. (7648309)
16 14 and 15 (76)

Search 2 (top‐up search)

Lines 1 to 14 as above
15 (201808* or 201809* or 201810* or 201811* or 201812* or 2019*).ed,dt. (1738451)
16 14 and 15 (23)

Embase: Ovid Embase

Search 1

1 Acromioclavicular joint/ (2062)
2 Acromioclavicular dislocation/ (772)
3 (acromioclavic* or coracoclavic* or ac joint).tw. (2607)
4 1 or 2 or 3 (3405)
5 exp Randomized controlled trial/ (504384)
6 Clinical Trial/ (939186)
7 Double blind procedure/ (148573)
8 Single blind procedure/ (31924)
9 Crossover procedure/ (55868)
10 Randomization/ (78722)
11 Placebo/ (307097)
12 Prospective study/ (461060)
13 ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw. (1091445)
14 (random* adj7 (allocat* or allot* or assign* or basis* or divid* or order*)).tw. (272957)
15 ((singl* or doubl* or trebl* or tripl*) adj7 (blind* or mask*)).tw. (209854)
16 (cross?over* or (cross adj1 over*)).tw. (92019)
17 ((allocat* or allot* or assign* or divid*) adj3 (condition* or experiment* or intervention* or treatment* or therap* or control* or group*)).tw. (372499)
18 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 (2591375)
19 limit 18 to human (2238288)
20 4 and 19 (396)
21 (2009* or 2010* or 2011* or 2012* or 2013* or 2014* or 2015* or 2016* or 2017* or 2018*).dc,yr. (13296554)
22 20 and 21 (254)

Search 2 (top‐up search)

Lines 1 to 20 as above
21 (2018* or 2019*).dc,yr. (2680741)
22 20 and 21 (61)

LILACS (BIREME)

(mh:(“acromioclavicular joint”)) OR (tw:(acromioclavic*)) OR (tw:(coracoclavic*)) OR (tw:("AC joint")) AND (instance:"regional") AND ( db:("LILACS")) (159)

WHO ICTRP

Acromioclavicular Joint OR acromioclavic* OR coracoclavic* OR AC joint (54)

ClinicalTrials.gov

Acromioclavicular Joint OR acromioclavic* OR coracoclavic* OR AC joint | First posted from 02/01/2009 to 06/17/2019 (130)

Appendix 2. Report of search results in previous version of the review

2010, Issue 8 (Date of Search: February 2009)

We searched the Cochrane Bone, Joint andMuscle Trauma Group Specialised Register (to February 2009), the Cochrane Central Register of Controlled Trials (TheCochrane Library 2009, Issue 1), MEDLINE (1966 to February 2009), EMBASE (1988 to February 2009), and the Latin American andCaribbeanHealth Sciences database (LILACS) (1982 to February 2009). We also searched theWHO International Clinical Trials Registry Platform Search Portal (to February 2009), Current Controlled Trials (to February 2009), and the UK National Research Register (NRR) Archive (up to September 2007) for ongoing and recently completed trials.

Our search found 171 references. The numbers of records identified via our searches of individual databases for the first version of the review were as follows: Cochrane Bone, Joint andMuscle Trauma Group Specialised Register (6 records), The Cochrane Central Register of Controlled Trial (The Cochrane Library (Wiley InterScience)) (39 records), MEDLINE (PubMed) (35 records)), EMBASE (Elsevier) (76 records)), LILACS (Bireme) (14 records) and Grey Literture (1 record).

After removing duplicates and screening of titles and abstracts we excluded 165 articles. The remaining six potentially relevant studies were evaluated from full trial reports and one of these studies (Sehmisch 2008) was translated into English. We excluded three studies: two prospective studies (Sehmisch 2008; Sternick 1991) were neither randomised nor quasi‐randomised, and one study (Galpin 1985) was retrospective. The remaining three studies were either randomised or quasi‐randomised controlled trials that reported relevant outcomes (Bannister 1989; Imatani 1975; Larsen 1986). In addition, two ongoing trials were identified from trial registers.

Appendix 3. Previous 'Types of outcome measures' (Tamaoki 2010)

Types of outcome measures

Primary outcomes

  • Health‐related quality of life;

  • Pain;

  • Shoulder function (preferably patient‐reported);

  • Return to previous activities, including work, sport and activities of daily living;

  • Treatment failure and other serious adverse effects of treatment such as requirement for a subsequent operation.

Examples of validated patient‐assessed instruments for measuring the first three outcomes are:

  • Short Form‐36 (SF‐36) (Ware 1992) for health related quality of life;

  • VAS (visual analogue scale) (Revill 1976) for pain;

  • Disability of the Arm, Shoulder, and Hand (DASH) Questionnaire (Hudak 1996) for upper‐limb function.

A commonly used instrument for assessing shoulder function is the Constant score (Constant 1987), which is a composite score for shoulder function which includes pain and activities of daily living, and range of movement and strength.

Secondary outcomes
Clinical outcomes

  • Shoulder range of motion;

  • Strength;

  • Cosmetic appearance;

  • Patient satisfaction with treatment.

Radiological outcomes

  • Residual deformity (distance between coracoid and clavicle or acromion and clavicle).

Resource use

  • Hospital admission and length of stay, number of outpatient attendances and other costs of treatment;

  • Time off work or education.

Safety (success or failure of treatment and adverse events)

  • Complications:

    • Early (e.g. wound or skin breakdown or skin necrosis under strapping, fixation failure, migration of wires, residual deformity, infection, requirement for reoperation);

    • Late (e.g. traumatic arthritis, calcification of coracoclavicular ligament, requirement for reoperation).

Study flow diagram for update.
Figuras y tablas -
Figure 1

Study flow diagram for update.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 1 DASH questionnaire (0 (best function) to 100 (worst function)).
Figuras y tablas -
Analysis 1.1

Comparison 1 Surgical intervention versus conservative intervention, Outcome 1 DASH questionnaire (0 (best function) to 100 (worst function)).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 2 Constant score (0 (worst function) to 100 (best function)).
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Analysis 1.2

Comparison 1 Surgical intervention versus conservative intervention, Outcome 2 Constant score (0 (worst function) to 100 (best function)).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 3 UCLA score at 18 to 20 years (2 (worst function) to 35 (best function)).
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Analysis 1.3

Comparison 1 Surgical intervention versus conservative intervention, Outcome 3 UCLA score at 18 to 20 years (2 (worst function) to 35 (best function)).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 4 Oxford Shoulder Score (0 (worst function) to 48 (best function)).
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Analysis 1.4

Comparison 1 Surgical intervention versus conservative intervention, Outcome 4 Oxford Shoulder Score (0 (worst function) to 48 (best function)).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 5 Unsatisfactory function (only 'poor' or 'fair' category ) at 1 year.
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Analysis 1.5

Comparison 1 Surgical intervention versus conservative intervention, Outcome 5 Unsatisfactory function (only 'poor' or 'fair' category ) at 1 year.

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 6 Pain: presence of pain (slight or moderate).
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Analysis 1.6

Comparison 1 Surgical intervention versus conservative intervention, Outcome 6 Pain: presence of pain (slight or moderate).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 7 Treatment failure (usually requiring a subsequent operation).
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Analysis 1.7

Comparison 1 Surgical intervention versus conservative intervention, Outcome 7 Treatment failure (usually requiring a subsequent operation).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 8 Number of participants to return to work/sport.
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Analysis 1.8

Comparison 1 Surgical intervention versus conservative intervention, Outcome 8 Number of participants to return to work/sport.

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 9 Health‐related quality of life: SF‐36 or SF‐12 (0 (worst quality of life) to 100 (best quality of life)).
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Analysis 1.9

Comparison 1 Surgical intervention versus conservative intervention, Outcome 9 Health‐related quality of life: SF‐36 or SF‐12 (0 (worst quality of life) to 100 (best quality of life)).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 10 Adverse events ‐ individual complications.
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Analysis 1.10

Comparison 1 Surgical intervention versus conservative intervention, Outcome 10 Adverse events ‐ individual complications.

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 11 Participants with adverse events (includes treatment failure).
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Analysis 1.11

Comparison 1 Surgical intervention versus conservative intervention, Outcome 11 Participants with adverse events (includes treatment failure).

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Comparison 1 Surgical intervention versus conservative intervention, Outcome 12 Patient dissatisfied (unhappy) with the cosmetic result.
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Analysis 1.12

Comparison 1 Surgical intervention versus conservative intervention, Outcome 12 Patient dissatisfied (unhappy) with the cosmetic result.

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Summary of findings for the main comparison. Surgical intervention compared to conservative intervention for treating acromioclavicular dislocation of the shoulder in adults

Surgical intervention compared to conservative intervention for treating acromioclavicular dislocation of the shoulder in adults

Patient or population: adults with acute acromioclavicular dislocation of the shouldera
Setting: hospital (tertiary care)
Intervention: surgery (e.g. hook plate, Kirschner wires fixation, Bosworth screw, or tunnelled suspensory device)
Comparison: conservative intervention (e.g. sling)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Risk with conservative intervention

Risk with surgical intervention

DASH questionnaire (0 (best function) to 100 (worst function)) ‐ at 1 year

The mean DASH questionnaire score at 1 year ranged from 4.67 to 9.2.

MD 0.73 higher
(2.70 lower to 4.16 higher)

‐

112

(2 studies)

⊕⊕⊝⊝b,c
low

This does not represent a clinically important difference. The MCID of the DASH questionnaire is 10 points.d

Pain: presence of pain (slight or moderate) at 1 year

Study population

RR 1.32
(0.54 to 3.19)

79

(1 study)

⊕⊝⊝⊝b,c,f
very low

None of the studies reported pain measured via a visual analogue scale.

175 per 1000e

231 per 1000
(95 to 559)

Treatment failure (usually requiring a subsequent operation) at 1 year

Study population

RR 0.99
(0.51 to 1.94)

342
(6 studies)

⊕⊝⊝⊝a,b
very low

The main sources of treatment failure in the conservatively treated group were persistent symptoms and discomfort from acromioclavicular dislocation, and in the surgical group problems related to hardware.

87 per 1000e

87 per 1000
(45 to 169)

Number of participants to return to work/sport ‐ at 1 year

Study population

RR 0.96
(0.85 to 1.10)

137
(2 studies)

⊕⊕⊝⊝b,c

low

There is, however, low‐quality but consistent evidence of an earlier recovery after conservative treatment compared with surgery.

886 per 1000e

851 per 1000
(754 to 975)

Health‐related quality of life: SF‐36 or SF‐12 (0 (worst quality of life) to 100 (best quality of life)) ‐ physical component score at 1 year

The mean health‐related quality of life (SF‐36 or SF‐12) physical component scores at 1 year ranged from 52.61 to 55.1.

MD 0.63 lower
(2.63 lower to 1.37 higher)

‐

122

(2 studies)

⊕⊕⊝⊝b,c
low

This does not represent a clinically important difference. The MCID of the overall SF‐36 ranges from 2.0 to 7.8 points (scale 0 to 100).

Participants with adverse events at 1 year

Study population

RR 2.82

(1.65 to 4.82)

342

(6 studies)

⊕⊝⊝⊝b,c,g
very low

The derivation of this outcome (number of people with 1 or more adverse events), which includes people with treatment failure for whatever reason, varied across studies. Hardware complication or discomfort, or both, was the most frequent problem in the surgical group (31/168 (18.5%), range 0% to 39%; 6 studies) and persistent symptoms or discomfort, or both, in the conservatively treated group (9/126 (7.1%); 4 studies). Infection or dehiscence, or both, occurred only in the surgical group (11/126 (8.7%); 4 studies). The majority of surgical complications were in studies testing now‐outdated devices known for their high risk of complications.

92 per 1000e

260 per 1000

(152 to 444)

Patient dissatisfaction with the cosmetic result at 1 yearh

Study population

RR 0.34

(0.07 to 1.62)

70

(1 study)

⊕⊝⊝⊝b,i
very low

One of the treatment failures in each of the conservatively treated groups of 2 other studies was for cosmetic reasons.

157 per 1000e

54 per 1000

(11 to 255)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; DASH: Disability of the Arm, Shoulder, and Hand questionnaire; MCID: minimal clinically important difference; MD: mean difference; RR: risk ratio; SF‐12: 12‐item Short Form Health Survey; SF‐36: 36‐item Short Form Health Survey

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate quality: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low quality: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aThe study populations were predominantly male and young adults; the mean ages in the trials ranged from 23.6 to 37.6 years.
bAll studies had methodological flaws; in particular, all studies were at high risk of performance bias and, depending on type pf outcome, were at high or unclear risk of detection bias due to lack of blinding. All outcomes were downgraded one level for serious risk of bias.
cThere was serious imprecision reflecting wide confidence intervals and small numbers of participants.
dSimilar findings applied where function was assessed using other patient‐reported measures. However, there is low‐quality evidence of a small but clinically important difference in function in favour of conservative treatment at six weeks (DASH score: MD 15.10 points, 95% CI 7.87 to 22.33; 115 participants, 2 studies), as the 95% CI overlaps the MCID. This is consistent with other evidence that may indicate an earlier recovery in the conservatively treated group.
eThe estimated control group (conservative treatment) risk is based on the overall risk from the pooled control groups for the individual outcome.
fThere was serious indirectness reflecting the suboptimal definition or measurement of the outcome.
gThere was considerable heterogeneity (I2 = 51%), thus we downgraded the quality of the evidence by one level for serious inconsistency.

hAlthough our intended outcome was patient satisfaction, the study only reported on the numbers who were unhappy with their cosmetic result.

iThere was very serious imprecision reflecting wide confidence intervals and very few events.

Figuras y tablas -
Summary of findings for the main comparison. Surgical intervention compared to conservative intervention for treating acromioclavicular dislocation of the shoulder in adults
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Table 1. Rockwood classification of injury types

Type

Description

Type I

A mild injury involving spraining of the acromioclavicular ligaments while leaving the joint intact

Type II

Injury where the acromioclavicular ligaments are torn and acromioclavicular joint is disrupted, whilst the coracoclavicular ligaments are intact

Type III

Injury involves complete tearing of both the acromioclavicular and coracoclavicular ligaments with 100% dislocation of the joint.

Type IV

Injury is a complete acromioclavicular dislocation with posterior displacement of the clavicle through or into the trapezius fascia.

Type V

Injury is a complete acromioclavicular dislocation with 100% to 300% superior dislocation of the clavicle. It can involve significant disruption of the deltotrapezial fascia.

Type VI

Injury involves inferior displacement of the clavicle into a subacromial or subcoracoid position.

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Table 1. Rockwood classification of injury types
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Comparison 1. Surgical intervention versus conservative intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 DASH questionnaire (0 (best function) to 100 (worst function)) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

1.1 At 6 weeks

2

115

Mean Difference (IV, Fixed, 95% CI)

15.10 [7.87, 22.33]

1.2 At 3 months

2

112

Mean Difference (IV, Fixed, 95% CI)

8.38 [2.62, 14.14]

1.3 At 6 months

2

116

Mean Difference (IV, Fixed, 95% CI)

1.70 [‐2.98, 6.39]

1.4 At 1 year

2

112

Mean Difference (IV, Fixed, 95% CI)

0.73 [‐2.70, 4.16]

1.5 At 2 years

1

55

Mean Difference (IV, Fixed, 95% CI)

‐1.61 [‐5.67, 2.45]

2 Constant score (0 (worst function) to 100 (best function)) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2.1 At 6 weeks

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.2 At 3 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.3 At 6 months

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.4 At 1 year

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.5 At 2 years

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

2.6 At 18 to 20 years

1

Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

3 UCLA score at 18 to 20 years (2 (worst function) to 35 (best function)) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Oxford Shoulder Score (0 (worst function) to 48 (best function)) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Unsatisfactory function (only 'poor' or 'fair' category ) at 1 year Show forest plot

3

160

Risk Ratio (M‐H, Fixed, 95% CI)

1.49 [0.75, 2.95]

5.1 Score included pain, motion, and function

2

81

Risk Ratio (M‐H, Fixed, 95% CI)

1.54 [0.76, 3.12]

5.2 Score included pain, motion, and strength

1

79

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.07, 15.83]

6 Pain: presence of pain (slight or moderate) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

7 Treatment failure (usually requiring a subsequent operation) Show forest plot

6

342

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.51, 1.94]

8 Number of participants to return to work/sport Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1 Return at 6 weeks

2

137

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.37, 1.08]

8.2 Return at 1 year

2

137

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.85, 1.10]

9 Health‐related quality of life: SF‐36 or SF‐12 (0 (worst quality of life) to 100 (best quality of life)) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

9.1 Physical component score at 6 weeks

1

58

Mean Difference (IV, Fixed, 95% CI)

‐4.60 [‐8.58, ‐0.62]

9.2 Physical component score at 3 months

1

69

Mean Difference (IV, Fixed, 95% CI)

‐6.38 [‐9.15, ‐3.61]

9.3 Physical component score at 6 months

1

73

Mean Difference (IV, Fixed, 95% CI)

‐2.89 [‐5.23, ‐0.55]

9.4 Physical component score at 1 year

2

122

Mean Difference (IV, Fixed, 95% CI)

‐0.63 [‐2.63, 1.37]

9.5 Physical component score at 2 years

1

50

Mean Difference (IV, Fixed, 95% CI)

1.89 [‐0.78, 4.56]

9.6 Mental component score at 6 weeks

1

58

Mean Difference (IV, Fixed, 95% CI)

1.98 [‐3.66, 7.62]

9.7 Mental component score at 3 months

1

69

Mean Difference (IV, Fixed, 95% CI)

3.60 [‐1.14, 8.34]

9.8 Mental component score at 6 months

1

73

Mean Difference (IV, Fixed, 95% CI)

0.16 [‐3.10, 3.42]

9.9 Mental component score at 1 year

2

122

Mean Difference (IV, Fixed, 95% CI)

0.47 [‐1.51, 2.44]

9.10 Mental component score at 2 years

1

49

Mean Difference (IV, Fixed, 95% CI)

‐0.98 [‐4.24, 2.28]

10 Adverse events ‐ individual complications Show forest plot

6

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

10.1 Local infection or dehiscence, or both

4

252

Risk Ratio (M‐H, Fixed, 95% CI)

7.76 [1.54, 39.00]

10.2 Hardware irritation and/or prominence and/or complication

6

342

Risk Ratio (M‐H, Fixed, 95% CI)

12.93 [3.70, 45.21]

10.3 Restriction of range of movement

2

167

Risk Ratio (M‐H, Fixed, 95% CI)

5.29 [0.63, 44.45]

10.4 Other (various)

4

252

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.31, 1.74]

11 Participants with adverse events (includes treatment failure) Show forest plot

6

342

Risk Ratio (M‐H, Fixed, 95% CI)

2.82 [1.65, 4.82]

12 Patient dissatisfied (unhappy) with the cosmetic result Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. Surgical intervention versus conservative intervention
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