Operative vs. conservative treatment of AC-Joint Dislocations Rockwood grade ≥ III -An economical and clinical evaluation-

Niehaus et al. Cost Effectiveness and Resource Allocation https://doi.org/10.1186/s12962-023-00468-2 (2023) 21:63 Cost Effectiveness and Resource Allocation Open Access RESEARCH Operative vs. conservative treatment of ACJoint Dislocations Rockwood grade ≥ III -An economical and clinical evaluationRichard Niehaus1,2*, Alisa Schleicher2, Ammann Elias2, Philipp Lenz KriechlingChristopher G.2, Michael Masanneck1, Sandro Hodel2 and Eid Karim2 Abstract Introduction Acromioclavicular joint dislocations (ACD) are one of the most common shoulder injuries. There is no consensus in how to treat higher graded ACD ≥ Rockwood grade III. This study compares operative versus conservative treatment regarding costs and clinical outcome parameters. Materials and Methods This retrospective, consecutive case-control-study includes 14 patients. Seven operatively treated patients were matched, by Rockwood grade, with seven conservatively treated patients. The cost was extracted out of the clinical- and insurance-based cost sheets and furthermore these include the loss of earnings. Clinical examination, demographic data as well as different outcome-questionnaires were recorded. Results There were no significant differences between operative and conservative treated patients for outcome Questionnaires. Of note, there was a significantly higher incidence of tenderness over the AC-joint (p = 0.0038) postoperatively. As expected, economical evaluation showed various findings in favor of the conservative treatment. The costs for medical services (11012.39vs.1163.81USD; p = 0.0061), days of hospitalization (3.3vs.0days; p < 0.0001); total cost for medical treatment (30262.17 vs. 7833.82 USD; p = 0.0358) were significantly higher in the operative group. Conclusion Even with a limited case number and a retrospective study design almost all clinical results were equal in both groups. Operative therapy of higher graded ACDs (Rockwood > III) compared to conservative is economically inefficient. Under consideration of clinical comparable results, indications for operative treatment should be set very carefully. Keywords AC –Joint, Cost analysis, Rockwood, Outcome, Acromioclavicular Joint JEL I 15 Health and Economic development. *Correspondence: Richard Niehaus 1 Apollon Hochschule für Gesundheitswirtschaft, Apollon Hochschule für Gesundheitswirtschaft, Universitätsallee 18, 28359 Bremen, Germany 2 Department of Orthopedic Surgery, Kantonsspital Baden, Im Ergel 1, Baden 5404, Switzerland © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Niehaus et al. Cost Effectiveness and Resource Allocation (2023) 21:63 Introduction AC-joint dislocations are common. In literature, these injuries are counted among the most common shoulder injuries with a share of 9% [1–3]. In young individuals who play contact sports the significance of AC-joint dislocations is correspondingly greater, accounting for a large proportion of 30–50% of all shoulder injuries [2–5]. In 2013, Chillemi et al. showed that the incidence for ACjoint dislocation is 1.8 per 10 000 people per year in an urban population [1]. The most common used classification of AC-joint injuries today is the Rockwood classification. A total of six degrees of severity are distinguished [3, 5–8]. Despite the availability of many therapeutic options, the acute injury of the acromioclavicular joint and the choice of adequate therapy is still a great challenge today. There is a broad consensus regarding less severe injuries, i.e. type Rockwood grade I and II. Usually these are treated conservatively with excellent clinical outcome [5, 7] Treatment usually consists of a short-term phase of immobilization, followed by gradual mobilization. However, a uniform standardized procedure for conservative treatment does not exist and is the domain of the physiotherapist [3, 7]. Studies have shown higher grade injuries, type Rockwood grade IV-VI, which are associated with complete rupture of all ligament structures and therefore significant instability of the clavicle should be treated operatively [7, 9]. Data on conservative therapy attempts for Rockwood grade IV and V injuries are hardly available [10]. One factor in favor of operative treatment may be a remaining visible protrusion of the clavicle [11, 12]. There is a variety of operative treatments but there is no gold standard [14, 15]. The common techniques are either open surgery or arthroscopically assisted, for example using AC TightRope [11]. Open surgery includes fixation using the Bosworth screw [16], clavicle hook plate osteosynthesis [17] or the Weaver-Dunn autograft [18]. The fixation can be reinforced in each case by additive material (anchors, sutures). The method of choice depends mainly on the preoperative situation, the medical center and the surgeons experience [3, 13, 14]. The decision on how to proceed with Rockwood grade III injuries remains controversial. Recent studies recommend conservative therapy. Nevertheless, these injuries are up to day frequently operated. Decision making is here often influenced by patient-specific aspects (traumatic hematoma, initial pain, cosmetic aspects, sportsactivities [3, 13, 14]. Due to the dilemma in choosing the optimal treatment options for higher-grade acromioclavicular joint dislocations, the aim of the study was to answer the following research question: Is it reasonable to perform surgical stabilization in a trauma level one public hospital of the Page 2 of 9 acromioclavicular joint in cases of higher-grade acromioclavicular joint dislocation, considering economic and clinical points of view? Materials and methods The data was collected at our level one trauma center, the study is a retrospective case-control study. All analysis conducted were provided after approval of the ethics committee in northwest- and central Switzerland (Swissethics ID 2020–02448). Patients included had AC-joint injuries Rockwood grade III - V between march 2017 (...truncated)