Surgical vs. Nonsurgical Treatment for Rockwood Type 3 ACJ Injuries: Key Findings and Critique

A recent prospective, multicenter randomized controlled trial (RCT) compared surgical and nonsurgical treatments for acute Rockwood Type 3 acromioclavicular joint (ACJ) injuries. The results revealed that surgical intervention did not lead to superior functional outcomes compared to nonsurgical treatment. Surprisingly, neither younger age nor horizontal instability were associated with worse outcomes following nonsurgical management. However, surgical treatment resulted in a slower recovery, higher complication rates, and increased revision surgeries. Link: https://pubmed.ncbi.nlm.nih.gov/37655239/

Key Findings:

1. No Significant Advantage of Surgery: The study found no functional benefits of surgical intervention over nonsurgical treatment.
2. Complications: Surgical patients experienced slower recoveries, more complications, and higher revision rates compared to nonsurgical counterparts.
3. No Link Between Age or Instability and Worse Outcomes: Younger patients or those with horizontal instability did not fare worse with nonsurgical approaches.

Critical Issues:

1. Small Sample Size: The trial included 85 participants, which might limit the ability to detect smaller yet clinically significant differences between groups. A larger sample size would increase the robustness of the results.
2. Patient Crossovers: Eight patients in the nonsurgical group crossed over to the surgical group. This raises the possibility of selection bias, where patients who changed treatments may have had more severe injuries or different characteristics than those who stayed in their assigned groups.
3. Loss to Follow-up: A total of 7 participants (4 from the surgical group, 3 from the nonsurgical group) were lost to follow-up, which can introduce bias, especially if these patients had different outcomes compared to those who completed the study. We have published an article highlighting that concern: https://pubmed.ncbi.nlm.nih.gov/24970318/
4. Unequal Follow-up Counts: The number of participants analysed at the end of the trial was uneven, with 47 in the surgical group and 31 in the nonsurgical group. This disparity can skew the results and makes direct comparisons more difficult.
5. Lack of Detail on Exclusions: While exclusions were noted (e.g., chronic contralateral instability, worker’s compensation claims), the rationale behind these exclusions was not fully explained. This lack of clarity raises concerns about potential biases in patient selection.
6. Missed Follow-ups: Some participants missed follow-up appointments, potentially affecting the quality of the data, particularly if key outcomes were supposed to be measured at those visits.

Final Thoughts:

This study provides valuable insights into the management of Rockwood Type 3 ACJ injuries but also highlights the need for caution when interpreting the results due to confounding variables, patient crossovers, and sample size limitations. Personally, I follow the Coping/Non-coping approach as below and would continue to do so.