Abstract
Objectives:
Treatment of acromioclavicular (AC) joint separations remains a topic that lacks consensus between providers. AC joint injuries can be classified based on several criteria. Historically, low-grade injuries respond well to conservative measures, and although high-grade injuries may end up requiring surgical intervention, many are also successfully treated non-operatively. As a result, initial non-operative treatment of AC joint separations is often recommended for all but the most severe injuries. Patients who fail non-operative treatment may be offered surgery, but the effect of the timing of surgery in respect to original injury on clinical outcomes remains unclear. It is possible that soft tissue healing potential may differ depending on time from the initial injury. We hypothesized that clinical outcome measures would worsen as the time between AC joint separation and surgery increased.
Methods:
A large nationwide insurance claims database was queried using ICD-9 and ICD-10 codes for patients who sustained an AC joint separation from 2010 to 2022. Patients who underwent surgical management of this injury were identified using CPT codes to represent AC joint repair (23550) and AC joint reconstruction (23552). Patients were separated into cohorts based on time between date of initial AC joint separation diagnosis and date of surgery. Temporal subgroups were defined based on the following parameters: 0-4 weeks (acute), 4 weeks3 months (subacute), 3 months-1 year (chronic), and after 1 year (delayed). Clinical outcomes, including complications, infections, and fractures, were compared between temporal subgroups. Fractures codes were limited to those specific to the coracoid or clavicle. Outcomes were compared using chi-squared tests.
Results:
A total of 13,194 patients met inclusion criteria and were included in the study, of which 8,639 received surgical management of their AC joint dislocation within 4 weeks of initial injury diagnosis, 2,210 between 4 weeks and 3 months after injury diagnosis, 1,264 between 3 months and 1 year after injury diagnosis, and 1,081 more than 1 year after injury diagnosis. Results for instance and rate of measured clinical outcomes can be seen in Table 1. Overall, as time from injury to surgery increased, rates of complications, infections, and fractures increased (Figure 1). Surgical treatment within 4 weeks of diagnosis was associated with significantly lower complications (14.41%), infections (4.31%), and fractures (13.75%) than surgical treatment after 3 months (complications 16.61%, infections 5.30%, fractures 14.08%, p<0.001) or after one year (complications 19.5%, infections 6.01%, fractures 15.08%, p<0.001). Subacute surgical treatment (between 4 weeks and 3 months) was associated with significantly lower complication (15.70% vs 19.52%, p=0.002) and fracture rates (12.62% vs 15.08%, p=0.003) than delayed treatment.
Conclusions:
Increased time between diagnosis of AC joint separation and time to surgical management appears to negatively impacts clinical outcome. Acute surgical management demonstrates significantly lower rates of complications, infections, and fractures than surgical management of chronic or delayed injuries. Prolonged non-operative management of symptomatic acromioclavicular separations may not be benign, and further work is necessary to stratify which patients may be best served by early surgical intervention.
