Is surgery always warranted for high-grade acromioclavicular dislocations?

BACKGROUND: The optimal management of high-grade acromioclavicular (AC) joint dislocations remains controversial. While surgical treatment improves radiographic alignment, its impact on functional outcomes remains debated. This study prospectively evaluated clinical and radiographic outcomes following clinically guided treatment allocation in patients with Rockwood type III-V injuries.

METHODS: In this prospective observational cohort study, 49 consecutive patients with Rockwood type III-V AC dislocations were managed according to predefined clinical criteria and shared decision-making. Surgical treatment was proposed in cases of non-reducible AC joint, persistent scapulothoracic dyskinesis, absence of early subjective symptomatic improvement, or cosmetic concerns. Functional outcomes were assessed using the Shoulder Subjective Value (SSV), Constant Score, and Acromioclavicular Joint Instability score. Standardized bilateral radiographs were analyzed at final follow-up. Regression analyses explored associations between radiographic parameters and clinical outcomes.

RESULTS: Twenty-nine patients were initially managed conservatively and 20 surgically; 3 patients (10%) required delayed surgical reconstruction after failed conservative treatment. Baseline SSV did not differ significantly between groups (40 ± 16 vs. 35 ± 10; P = .26). At a median follow-up of 28 months, no significant difference was observed in SSV between groups (93 ± 7 nonoperative vs. 86 ± 16 operative; P = .30). The Constant Score was slightly higher in the nonoperative group (95 ± 6 vs. 91 ± 6; P < .05), without clinically meaningful difference. Acromioclavicular Joint Instability scores were higher in the surgical group (90 ± 19 vs. 58 ± 9; P < .001), reflecting improved radiographic alignment. Regression analyses demonstrated minimal correlation between radiographic parameters and functional outcomes. The surgical complication rate was 17%, with no revision procedures required.

CONCLUSION: In this prospectively followed, clinically allocated cohort, surgical treatment improved radiographic alignment but did not demonstrate superior functional outcomes compared with conservative management. When guided by predefined clinical criteria, conservative treatment was associated with satisfactory results and a low crossover rate. These findings support individualized, clinically driven decision-making in high-grade AC dislocations.