Stress radiographs for evaluating acromioclavicular joint separations in an active-duty patient population: What have we learned?

Introduction: Acromioclavicular (AC) joint separation is a common entity in athletic patient populations. The surgical treatment of these injuries varies based upon extent of injury, with numerous imaging modalities recommended to differentiate injury severity and treatment options. The use of weighted stress radiographs is controversial in the diagnostic evaluation of AC separation with previous consensus recommending against their use. No study to date has investigated the clinical utilization of diagnostic studies in the evaluation of AC joint separations in a military surgeon population. Methods: Thirty-eight shoulder or sports medicine sub-specialty certified orthopaedic surgeons on active service in the Army, Air Force, and Navy were surveyed on their evaluation and treatment protocols for AC joint injuries. Specifically analyzed were imaging choice including the use of weighted stress radiographs as well as treatment recommendations based upon Rockwood grade. Responses were recorded in addition to surgeon descriptive data. Responses were analyzed with descriptive statistics. Results: Thirty-seven of the identified thirty eight surgeons responded to the survey, for a 97% response rate. Of the group, 70% of surgeons were within 10 years of completing fellowship with an estimated average of 15 AC joint separations treated annually. Plain radiographic examination was relied upon by 48% of surgeons for treatment of AC joint separation with 13% using weighted stress radiographs. Overall, 10% of surgeon stated that their treatment plan would vary based upon results from a weighted stress view. 51% of surgeons included magnetic resonance imaging in their diagnostic approach of these injuries. Treatment recommendation varied according to injury severity with 78% preferring nonoperative treatment for acute Grade III injuries with 86% waiting a minimum of 3 months before proceeding with operative treatment. For Grade V injuries, 81% of surgeon preferred operative treatment, with 59% incorporating a soft-tissue graft in their repair or reconstructive procedure. Discussion: This study identified substantial practice variation amongst military surgeons treating a relatively homogenous population with AC joint separations, reflective of a lack of definitive evidence to guide diagnosis and treatment. Overall, nonoperative management is the preferred initial approach for Type III injuries and operative treatment is the preferred initial approach for Type V injuries. The diagnostic evaluation varied across the surgeon cohort, but 87% elected against the use of weighted stress radiographs for the evaluation of AC joint separations, with only 10% relying upon them to dictate their recommended treatment. Future research identifying optimal diagnosis and treatment of AC joint separations is needed.