Purpose: To develop a consensus on diagnosis and treatment of acromioclavicular joint instability.Methods: A consensus process following the modified Delphi technique was conducted. Panel members were selected among the European Shoulder Associates of ESSKA. Five rounds were performed between October 2018 and November 2019. The first round consisted of gathering questions which were then divided into blocks referring to imaging, classifications, surgical approach for acute and chronic cases, conservative treatment. Subsequent rounds consisted of condensation by means of an online questionnaire. Consensus was achieved when ≥ 66.7% of the participants agreed on one answer. Descriptive statistic was used to summarize the data.Results: A consensus was reached on the following topics. Imaging: a true anteroposterior or a bilateral Zanca view are sufficient for diagnosis. 93% of the panel agreed on clinical override testing during body cross test to identify horizontal instability. The Rockwood classification, as modified by the ISAKOS statement, was deemed valid. The separation line between acute and chronic cases was set at 3 weeks. The panel agreed on arthroscopically assisted anatomic reconstruction using a suspensory device (86.2%), with no need of a biological augmentation (82.8%) in acute injuries, whereas biological reconstruction of coracoclavicular and acromioclavicular ligaments with tendon graft was suggested in chronic cases. Conservative approach and postoperative care were found similarConclusion: A consensus was found on the main topics of controversy in the management of acromioclavicular joint dislocation. Each step of the diagnostic treatment algorithm was fully investigated and clarified.Level of evidence: Level V.

Background: Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications. Purpose: To collect, examine, and provide a comprehensive review of the available evidence from randomized controlled trials and comparative studies on pain control after hip arthroscopy. Study Design: Systematic review. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature for postoperative pain control after hip arthroscopy was performed using electronic databases. Only comparative clinical studies with level 1 to 3 evidence comparing a method of postoperative pain control with other modalities or placebo were included in this review. Case series and studies without a comparative cohort were excluded. Results: Several methods of pain management have been described for hip arthroscopy. A total of 14 studies met our inclusion criteria: 3 on femoral nerve block, 3 on lumbar plexus block, 3 on fascia iliaca block, 4 on intra-articular injections, 2 on soft tissue surrounding surgical site injection, and 2 on celecoxib (4 studies compared 2 or more methods of analgesia). The heterogeneity of the studies did not allow for pooling of data. Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed. Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with increased risk of cutaneous nerve deficits. Patients receiving lumbar plexus block experienced significantly decreased pain compared with fascia iliaca block. Portal site and periacetabular injections provide superior analgesia compared with intra-articular injections alone. Preoperative oral celecoxib, compared with placebo, resulted in earlier time to discharge and provided significant pain relief up to 24 hours. Conclusion: Perioperative nerve blocks provide effective pain management after hip arthroscopy but must be used with caution to decrease risk of falls. Intra-articular and portal site injections with local anesthetics and preoperative celecoxib can decrease opioid consumption. There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.

Acromioclavicular (AC) joint instability is a common source of pain and disability. The injury is most commonly a result of a direct impact to the AC joint. The AC joint is surrounded by a capsule and has an intraarticular synovium and an articular cartilage interface. An articular disc is usually present in the joint, but this varies in size and shape. The AC joint capsule is quite thin, but has considerable ligamentous support; there are four AC ligaments: superior, inferior, anterior and posterior. The coracoclavicular (CC) ligament complex consists of the conoid and trapezoid ligaments. They insert on the posteromedial and anterolateral region of the undersurface of the distal clavicle, respectively. The coracoid origin of the trapezoid covers the posterior half of the coracoid dorsum; the conoid origin is more posterior on the base of the coracoid. Several biomechanical studies showed that horizontal stability of the AC joint is mediated by the AC ligaments while vertical stability is mediated by the CC ligaments. The radiographic classification of AC joint injuries described by Rockwood includes six types: in type I injuries the AC ligaments are sprained, but the joint is intact; in type II injuries, the AC ligaments are torn, but the CC ligaments are intact; in type III injuries both the AC and the CC ligaments are torn; type IV injuries are characterized by complete dislocation with posterior displacement of the distal clavicle into or through the fascia of the trapezius; type V injuries are characterized by a greater degree of soft tissue damage; type VI injuries are inferior AC joint dislocations into a subacromial or subcoracoid position. The diagnosis of AC joint instability can be based on historical data, physical examination and imaging studies. The cross body adduction stress test has the greatest sensitivity, followed by the AC resisted extension test and the O’Brien test. Proper radiographic evaluation of the AC joint is necessary. The Zanca view is the most accurate view for examining the AC joint. The axial view of the shoulder is important in differentiating a type III AC joint injury from a type IV injury.

Introduction: Shoulder arthroscopies are among the most frequently performed surgeries by orthopaedic surgeons. Little is known about complication rates among recently trained surgeons. The purpose of this study was to examine the type and frequency of complications of common arthroscopic shoulder procedures performed by candidates challenging the American Board of Orthopaedic Surgery: Part II, certification examination. Methods: Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2012 to 2016. In total, 27,072 procedures were reviewed. The database was queried to determine the type and frequency of complications for patients who underwent shoulder arthroscopy, including arthroscopic rotator cuff repair, labrum repair, biceps tenodesis, and bony/soft tissue débridement procedures. Complications were classified as surgical, anesthetic, or medical. Factors affecting complication rates were investigated including surgeon's fellowship training, geographic location, and patients’ age and sex. Results: Patients with surgical complications (n = 2,133; 7.9%) were more common than anesthetic (n = 263; 1.0%) or medical (n = 607; 2.2%) complications. There was a significant variation in the surgical complication rate among different arthroscopic shoulder procedures, ranging from 5.4% for labral repair to 10.3% for rotator cuff repair and biceps tenodesis. Stiffness/arthrofibrosis was the most commonly recorded surgical complication (2.2%). Surgical complication rates were lowest in the Northeast region (6.7%; P < 0.01) and in patients younger than 21 years (3.8%; P < 0.01). Women had significantly higher rate of complications than men (8.4% versus 7.6%; P = 0.02). Among anesthetic-related complications, 61.6% were related to regional nerve blocks. The overall revision surgery and readmission rates were 0.8% and 1.0%, respectively. Conclusion: The overall self-reported surgical complication rate for arthroscopic shoulder procedures was 7.9%, which is higher than the rates reported in the literature. Although the rate of anesthetic complications is low (1.0%), adverse events related to nerve blocks made up most of the overall anesthetic related complications.