Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red
Antecedentes: Las luxaciones acromioclaviculares (LAC) agudas grado III, IV y V de Rockwood en adultos se tratan con diversas opciones, sin haberse establecido un estándar de oro. Este estudio tiene como objetivo realizar una revisión sistemática y metaanálisis en red con ensayos clínicos aleatoriza...
- Autores:
-
Carrasco Vélez, Felipe
Gómez Contreras, Miguel Ángel
- Tipo de recurso:
- Tesis
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- spa
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/46350
- Acceso en línea:
- https://hdl.handle.net/10495/46350
- Palabra clave:
- Articulación acromioclavicular
Acromioclavicular joint
Luxaciones articulares
Joint dislocations
Tratamiento conservador
Conservative treatment
Procedimientos quirúrgicos operativos
Surgical procedures, operative
Revisión sistemática
Systematic review
Meta-análisis en red
Network meta-analysis
https://id.nlm.nih.gov/mesh/D000173
https://id.nlm.nih.gov/mesh/D004204
https://id.nlm.nih.gov/mesh/D000072700
https://id.nlm.nih.gov/mesh/D013514
https://id.nlm.nih.gov/mesh/D000078182
https://id.nlm.nih.gov/mesh/D000099094
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
- Rights
- embargoedAccess
- License
- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| title |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| spellingShingle |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red Articulación acromioclavicular Acromioclavicular joint Luxaciones articulares Joint dislocations Tratamiento conservador Conservative treatment Procedimientos quirúrgicos operativos Surgical procedures, operative Revisión sistemática Systematic review Meta-análisis en red Network meta-analysis https://id.nlm.nih.gov/mesh/D000173 https://id.nlm.nih.gov/mesh/D004204 https://id.nlm.nih.gov/mesh/D000072700 https://id.nlm.nih.gov/mesh/D013514 https://id.nlm.nih.gov/mesh/D000078182 https://id.nlm.nih.gov/mesh/D000099094 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| title_full |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| title_fullStr |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| title_full_unstemmed |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| title_sort |
Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en red |
| dc.creator.fl_str_mv |
Carrasco Vélez, Felipe Gómez Contreras, Miguel Ángel |
| dc.contributor.advisor.none.fl_str_mv |
Roca Díaz, Milena Paola Zamudio Burbano, Mario Andrés |
| dc.contributor.author.none.fl_str_mv |
Carrasco Vélez, Felipe Gómez Contreras, Miguel Ángel |
| dc.contributor.jury.none.fl_str_mv |
Woodcock Delgado, Santiago Monsalve, Francisco Javier |
| dc.subject.decs.none.fl_str_mv |
Articulación acromioclavicular Acromioclavicular joint Luxaciones articulares Joint dislocations Tratamiento conservador Conservative treatment Procedimientos quirúrgicos operativos Surgical procedures, operative Revisión sistemática Systematic review Meta-análisis en red Network meta-analysis |
| topic |
Articulación acromioclavicular Acromioclavicular joint Luxaciones articulares Joint dislocations Tratamiento conservador Conservative treatment Procedimientos quirúrgicos operativos Surgical procedures, operative Revisión sistemática Systematic review Meta-análisis en red Network meta-analysis https://id.nlm.nih.gov/mesh/D000173 https://id.nlm.nih.gov/mesh/D004204 https://id.nlm.nih.gov/mesh/D000072700 https://id.nlm.nih.gov/mesh/D013514 https://id.nlm.nih.gov/mesh/D000078182 https://id.nlm.nih.gov/mesh/D000099094 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D000173 https://id.nlm.nih.gov/mesh/D004204 https://id.nlm.nih.gov/mesh/D000072700 https://id.nlm.nih.gov/mesh/D013514 https://id.nlm.nih.gov/mesh/D000078182 https://id.nlm.nih.gov/mesh/D000099094 |
| dc.subject.ods.none.fl_str_mv |
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
Antecedentes: Las luxaciones acromioclaviculares (LAC) agudas grado III, IV y V de Rockwood en adultos se tratan con diversas opciones, sin haberse establecido un estándar de oro. Este estudio tiene como objetivo realizar una revisión sistemática y metaanálisis en red con ensayos clínicos aleatorizados para comparar la eficacia de las intervenciones quirúrgicas frente al manejo conservador. Métodos: Se realizó una búsqueda sistemática en MEDLINE, EMBASE, CENTRAL, Clinical Trials, LILACS y literatura gris. Se incluyeron ensayos clínicos aleatorizados de pacientes mayores de 16 años con LAC dentro de las seis semanas post-trauma, con seguimiento mínimo de seis meses y un desenlace funcional. El análisis de sesgos se realizó con la herramienta Risk of Bias 2 de Cochrane. Se utilizó metaanálisis en red frecuentista con modelos de efectos aleatorios, evaluando la certeza de la evidencia con la estrategia GRADE. Registro en PROSPERO CRD42023389869 Resultados: Se incluyeron 22 estudios con 1516 pacientes, evaluando 20 intervenciones. No se encontraron diferencias clínicamente significativas en el puntaje de la escala de Constant entre las intervenciones quirúrgicas y el tratamiento conservador. Conclusión: Con baja certeza de la evidencia, no se observaron diferencias significativas en el puntaje de la escala de Constant entre las intervenciones quirúrgicas y el tratamiento conservador. Se requieren ensayos clínicos con mayor poder estadístico y control de sesgos para determinar la mejor intervención. |
| publishDate |
2025 |
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2025-06-13T16:48:31Z |
| dc.date.issued.none.fl_str_mv |
2025 |
| dc.date.available.none.fl_str_mv |
2027-06-13 |
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Trabajo de grado - Especialización |
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Roca M, Contreras M, Carrasco F, Zamudio M. Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos: revisión sistemática y metaanálisis en red, [Trabajo de grado especialización]. Medellín, Colombia. Universidad de Antioquia; 2025. |
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https://hdl.handle.net/10495/46350 |
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Roca M, Contreras M, Carrasco F, Zamudio M. Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos: revisión sistemática y metaanálisis en red, [Trabajo de grado especialización]. Medellín, Colombia. Universidad de Antioquia; 2025. |
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https://hdl.handle.net/10495/46350 |
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spa |
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Abdelrahman AA, Ibrahim A, Abdelghaffar K, Ghandour TM, Eldib D. Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tightrope: randomized comparative study of clinical outcome and cost-effectiveness. J Shoulder Elbow Surg. 2019;28(11):2090–7. doi:10.1016/j.jse.2019.06.007 Arismendi A, Jaramillo JC, Fernández F, Vallejo A, Arango AA. Luxación acromioclavicular aguda: placa gancho vs. suturas coracoclaviculares. Rev Colomb Ortop Traumatol. 2011;25(4):337–44. Disponible en: https://sccot.org/pdf/RevistaDigital/25-04-2011/04Luxacion.pdf Bannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br. 1989;71(5):848–50. doi:10.1302/0301-620X.71B5.2684990 Beitzel K, Cote M, Apostolakos J, Solovyova O, Judson C, Ziegler C, et al. Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy. 2013;29(2):387–97. doi:10.1016/j.arthro.2012.11.023 Boström Windhamre H, von Heideken J, Une-Larsson V, Ekström W, Ekelund A. No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial. J Shoulder Elbow Surg. 2022;31(6):1122–36. doi:10.1016/j.jse.2021.12.003 Cai L, Wang T, Lu D, Hu W, Hong J, Chen H. Comparison of the Tight Rope technique and clavicular hook plate for the treatment of Rockwood type III acromioclavicular joint dislocation. J Investig Surg. 2018;31(3):226–33. doi:10.1080/08941939.2017.1305022 Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromioclavicular joint dislocation. J Orthop Trauma. 2015;29(11):479–87. doi:10.1097/BOT.0000000000000437 Chachan S, Sahu B. Combined intra-articular K-wire and coracoclavicular screw fixation for type III acromioclavicular joint dislocations: A randomized controlled study with minimum of 3 years follow-up. Int J Orthop. 2017;28(4):796–801. Disponible en: http://www.ghrnet.org/index.php/ijo/article/view/1936 Darabos N, Vlahovic I, Gusic N, Darabos A, Bakota B, Miklic D. Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury? Injury. 2015;46(Suppl 6):S113–8. doi:10.1016/j.injury.2015.10.060 Eskola A, Vainionpää S, Korkala S, Santavirta S, Grönblad M, Rokkanen P. Four-year outcome of operative treatment of acute acromioclavicular dislocation. J Orthop Trauma. 1991;5(1):9–13. doi:10.1097/00005131-199103000-00002 Jeong JY, Chun YM. Treatment of acute high-grade acromioclavicular joint dislocation. Clin Shoulder Elbow. 2020;23(3):159–65. doi:10.5397/cise.2020.00150 Joukainen A, Kröger H, Niemitukia L, Mäkelä EA, Väätäinen U. Results of operative and nonoperative treatment of Rockwood types III and V acromioclavicular joint dislocation: A prospective, randomized trial with an 18- to 20-year follow-up. Orthop J Sports Med. 2014;2(12):2325967114560130. doi:10.1177/2325967114560130 Kukkonen J, Kauko T, Vahlberg T, Joukainen A, Aärimaa V. Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. J Shoulder Elbow Surg. 2013;22(12):1650–5. doi:10.1016/j.jse.2013.05.002 Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation: A prospective, controlled, randomized study. J Bone Joint Surg Am. 1986;68(4):552–5. Disponible en: https://pubmed.ncbi.nlm.nih.gov/3514625 Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS. Management of acromioclavicular joint injuries. J Bone Joint Surg Am. 2014;96(1):73–84. doi:10.2106/JBJS.L.00734 Lu D, Wang T, Chen H, Sun LJ. A comparison of double Endobutton and triple Endobutton techniques for acute acromioclavicular joint dislocation. Orthop Traumatol Surg Res. 2016;102(7):891–5. doi:10.1016/j.otsr.2016.07.003 Mah JM, Canadian Orthopaedic Trauma Society (COTS). General health status after nonoperative versus operative treatment for acute, complete acromioclavicular joint dislocation: Results of a multicenter randomized clinical trial. J Orthop Trauma. 2017;31(9):485–90. doi:10.1097/BOT.0000000000000881 Martetschläger F, Kraus N, Scheibel M, Streich J, Venjakob A, Maier D. The diagnosis and treatment of acute dislocation of the acromioclavicular joint. Dtsch Arztebl Int. 2019;116(6):89–95. doi:10.3238/arztebl.2019.0089 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1 Morales LC, Murcia MA. Luxación acromioclavicular. Tratamiento quirúrgico mediante cerclaje con cinta de dacrón (Cervi-set®). Rev Colomb Ortop Traumatol. 2004;18(2):23–30. Disponible en: http://www.sccot.org.co/pdf/RevistaDigital/18-02-2004/04Luxacion.pdf Murray IR, Robinson PG, Goudie EB, Duckworth AD, Clark K, Robinson CM. Open reduction and tunneled suspensory device fixation compared with nonoperative treatment for type-III and type-IV acromioclavicular joint dislocations: The ACORN prospective, randomized controlled trial. J Bone Joint Surg Am. 2018;100(22):1912–8. doi:10.2106/JBJS.18.00412 Nolte PC, Lacheta L, Dekker TJ, Elrick BP, Millett PJ. Optimal management of acromioclavicular dislocation: Current perspectives. Orthop Res Rev. 2020;12:27–44. doi:10.2147/ORR.S218991 Rockwood CA Jr. Injuries to the acromioclavicular joint. In: Rockwood CA Jr, Green DP, editors. Fractures in adults. 2nd ed. Vol. 1. Philadelphia: JB Lippincott; 1984. p. 860–910. Stein T, Müller D, Blank M, Reinig Y, Saier T, Hoffmann R, et al. Stabilization of acute high-grade acromioclavicular joint separation: A prospective assessment of the clavicular hook plate versus the double-button suture procedure. Am J Sports Med. 2018;46(11):2725–34. doi:10.1177/0363546518788355 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi:10.1136/bmj.l4898 Stucken C, Cohen SB. Management of acromioclavicular joint injuries. Orthop Clin North Am. 2015;46(1):57–66. doi:10.1016/j.ocl.2014.09.003 Sun LJ, Lu D, Ma YF, Yu B. Minimally invasive procedure of acute acromioclavicular joint dislocation: One suture-button device versus two suture-button devices. Acta Orthop Belg. 2019;85(1):54–62. Disponible en: https://pubmed.ncbi.nlm.nih.gov/31023200/ Tauber M, Hoffelner T, Lehmann L, Kraus N, Scheibel M, Moroder P. Prospective multicenter randomized controlled trial of surgical versus nonsurgical treatment for acute Rockwood type 3 acromioclavicular injury. Orthop J Sports Med. 2023;11(8):23259671231190411. doi:10.1177/23259671231190411 Tuček M, Chochola A, Vaněček V, Bušková K. Chirurgická léčba akromioklavikulární luxace: Tahová cerkláž versus hákovitá dlaha [Surgical treatment of acromioclavicular dislocation: Tension band wiring versus hook plate]. Rozhl Chir. 2015;94(10):437–44. Verdano MA, Pellegrini A, Zanelli M, Paterlini M, Ceccarelli F. Modified Phemister procedure for the surgical treatment of Rockwood types III, IV, V acute acromioclavicular joint dislocation. Musculoskelet Surg. 2012;96(3):213–22. doi:10.1007/s12306-012-0221-4 Wang C, Wang Y, Zhu T, Sun X, Lin C, Gao B, et al. [Article in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2015;29(2):149–53. Disponible en: https://pubmed.ncbi.nlm.nih.gov/26455139/ Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med. 1995;23(3):324–31. doi:10.1177/036354659502300313 Wellmann M, Smith T. Epidemiologie, Anatomie, Biomechanik und Bildgebung von Akromioklavikulargelenkverletzungen [Epidemiology, anatomy, biomechanics and imaging of acromioclavicular joint injuries]. Unfallchirurg. 2012;115(10):867–71. doi:10.1007/s00113-012-2247-3 Ye G, Peng CA, Sun HB, Xiao J, Zhu K. Treatment of Rockwood type III acromioclavicular joint dislocation using autogenous semitendinosus tendon graft and endobutton technique. Ther Clin Risk Manag. 2016;12:47–51. doi:10.2147/TCRM.S81829 Yeranosian M, Rangarajan R, Bastian S, Blout C, Patel V, Lee B, et al. Anatomic reconstruction of acromioclavicular joint dislocations using allograft and synthetic ligament. JSES Int. 2020;4(3):515–21. doi:10.1016/j.jseint.2020.04.001 Yin J, Yin Z, Gong G, Zhu C, Sun C, Liu X. Comparison of hook plate with versus without double-tunnel coracoclavicular ligament reconstruction for repair of acute acromioclavicular joint dislocations: a prospective randomized controlled clinical trial. Int J Surg. 2018 Jun;54(Pt A):18-23. doi: 10.1016/j.ijsu.2018.04.017 Yin F, Sun Z, Wei X, Liu X, Zhou M, Zhuang Y, et al. [Article in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2016;30(5):532–6. doi:10.7507/1002-1892.20160107 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. doi: 10.1186/s13643-016-0384-4. Izcovich A, Chu DK, Mustafa RA, Guyatt G, Brignardello-Petersen R. A guide and pragmatic considerations for applying GRADE to network meta-analysis. BMJ. 2023;381:e074495. doi: 10.1136/bmj-2022-074495. Babhulkar A, Pawaskar A. Acromioclavicular joint dislocations. Curr Rev Musculoskelet Med. 2014;7:33-9. doi: 10.1007/s12178-013-9199-2. Kraus N, Hann C, Gerhardt C, Scheibel M. Dynamic instability of the acromioclavicular joint: a new classification for acute AC joint separation. Obere Extrem. 2018;13(4):279-85. doi: 10.1007/s11678-018-0469-x Malik AL, Rehman SU, Iqbal S, Zain-ul-Abidin M, Aslam F, Haq AU. Comparison of Conservative and Surgical Treatment of Grade III Acromio-Clavicular Dislocation. Pak J Med Health Sci. 2021;15(12):3358. doi: 10.53350/pjmhs2115123358. Bi AS, Robinson J, Anil U, Hurley ET, Klifto CS, Gonzalez-Lomas G, Alaia MJ, Strauss EJ, Jazrawi LM. Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023 Jun;32(6):1146-1158. doi: 10.1016/j.jse.2023.01.039. Epub 2023 Mar 5. PMID: 36871607. |
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Roca Díaz, Milena PaolaZamudio Burbano, Mario AndrésCarrasco Vélez, FelipeGómez Contreras, Miguel ÁngelWoodcock Delgado, SantiagoMonsalve, Francisco Javier2025-06-13T16:48:31Z2027-06-132025Roca M, Contreras M, Carrasco F, Zamudio M. Eficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos: revisión sistemática y metaanálisis en red, [Trabajo de grado especialización]. Medellín, Colombia. Universidad de Antioquia; 2025.https://hdl.handle.net/10495/46350Antecedentes: Las luxaciones acromioclaviculares (LAC) agudas grado III, IV y V de Rockwood en adultos se tratan con diversas opciones, sin haberse establecido un estándar de oro. Este estudio tiene como objetivo realizar una revisión sistemática y metaanálisis en red con ensayos clínicos aleatorizados para comparar la eficacia de las intervenciones quirúrgicas frente al manejo conservador. Métodos: Se realizó una búsqueda sistemática en MEDLINE, EMBASE, CENTRAL, Clinical Trials, LILACS y literatura gris. Se incluyeron ensayos clínicos aleatorizados de pacientes mayores de 16 años con LAC dentro de las seis semanas post-trauma, con seguimiento mínimo de seis meses y un desenlace funcional. El análisis de sesgos se realizó con la herramienta Risk of Bias 2 de Cochrane. Se utilizó metaanálisis en red frecuentista con modelos de efectos aleatorios, evaluando la certeza de la evidencia con la estrategia GRADE. Registro en PROSPERO CRD42023389869 Resultados: Se incluyeron 22 estudios con 1516 pacientes, evaluando 20 intervenciones. No se encontraron diferencias clínicamente significativas en el puntaje de la escala de Constant entre las intervenciones quirúrgicas y el tratamiento conservador. Conclusión: Con baja certeza de la evidencia, no se observaron diferencias significativas en el puntaje de la escala de Constant entre las intervenciones quirúrgicas y el tratamiento conservador. Se requieren ensayos clínicos con mayor poder estadístico y control de sesgos para determinar la mejor intervención.Background: different treatment options have been described for acute acromioclavicular dislocations (ACD) in adults Rockwood grade III, IV and V; without yet finding a gold standard. The objective of the present study is to perform a systematic review with network meta-analysis with randomized clinical trials to find the comparative effectiveness between different surgical interventions and conservative management. Methods: a systematic search was performed in MEDLINE, EMBASE, CENTRAL, Clinical Trials and LILACS and gray literature. Randomized clinical trials were included in patients over 16 years of age, with ACD six weeks after trauma, with a minimum followup of six months and a functional scale as an outcome. Bias analysis was performed with Cochrane's Risk of Bias 2 tool. Quantitative synthesis was performed for three outcomes in frequentist network meta-analysis with random effects models. The certainty of the evidence was assessed with the GRADE strategy for network meta-analysis. Results: 22 articles were included in the qualitative analysis, briging together a total of 1516 patients undergoing 20 interventions. No clinically significant differences were found in the Constant scale score for the interventions compared to conservative treatment. Conclusion: with low certainty of the evidence, no clinically significant differences in the Constant scale score were found for the interventions compared to conservative treatment. New clinical trials with greater statistical power and control of bias are required to establish the best intervention.EspecializaciónEspecialista en Ortopedia y Traumatología65 páginasapplication/pdfspaUniversidad de AntioquiaEspecialización en Ortopedia y TraumatologíaDepartamento de CirugíaMedellín, ColombiaFacultad de MedicinaCampus en el Área de la saludhttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/embargoedAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_f1cfEficacia comparativa entre diferentes intervenciones quirúrgicas y manejo conservador en el tratamiento de la luxación acromioclavicular aguda en adultos : revisión sistemática y metaanálisis en redTrabajo de grado - Especializaciónhttp://purl.org/coar/resource_type/c_46echttp://purl.org/redcol/resource_type/COtherTexthttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/otherinfo:eu-repo/semantics/draftAbdelrahman AA, Ibrahim A, Abdelghaffar K, Ghandour TM, Eldib D. Open versus modified arthroscopic treatment of acute acromioclavicular dislocation using a single tightrope: randomized comparative study of clinical outcome and cost-effectiveness. J Shoulder Elbow Surg. 2019;28(11):2090–7. doi:10.1016/j.jse.2019.06.007Arismendi A, Jaramillo JC, Fernández F, Vallejo A, Arango AA. Luxación acromioclavicular aguda: placa gancho vs. suturas coracoclaviculares. Rev Colomb Ortop Traumatol. 2011;25(4):337–44. Disponible en: https://sccot.org/pdf/RevistaDigital/25-04-2011/04Luxacion.pdfBannister GC, Wallace WA, Stableforth PG, Hutson MA. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br. 1989;71(5):848–50. doi:10.1302/0301-620X.71B5.2684990Beitzel K, Cote M, Apostolakos J, Solovyova O, Judson C, Ziegler C, et al. Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy. 2013;29(2):387–97. doi:10.1016/j.arthro.2012.11.023Boström Windhamre H, von Heideken J, Une-Larsson V, Ekström W, Ekelund A. No difference in clinical outcome at 2-year follow-up in patients with type III and V acromioclavicular joint dislocation treated with hook plate or physiotherapy: a randomized controlled trial. J Shoulder Elbow Surg. 2022;31(6):1122–36. doi:10.1016/j.jse.2021.12.003Cai L, Wang T, Lu D, Hu W, Hong J, Chen H. Comparison of the Tight Rope technique and clavicular hook plate for the treatment of Rockwood type III acromioclavicular joint dislocation. J Investig Surg. 2018;31(3):226–33. doi:10.1080/08941939.2017.1305022Canadian Orthopaedic Trauma Society. Multicenter randomized clinical trial of nonoperative versus operative treatment of acute acromioclavicular joint dislocation. J Orthop Trauma. 2015;29(11):479–87. doi:10.1097/BOT.0000000000000437Chachan S, Sahu B. Combined intra-articular K-wire and coracoclavicular screw fixation for type III acromioclavicular joint dislocations: A randomized controlled study with minimum of 3 years follow-up. Int J Orthop. 2017;28(4):796–801. Disponible en: http://www.ghrnet.org/index.php/ijo/article/view/1936Darabos N, Vlahovic I, Gusic N, Darabos A, Bakota B, Miklic D. Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury? Injury. 2015;46(Suppl 6):S113–8. doi:10.1016/j.injury.2015.10.060Eskola A, Vainionpää S, Korkala S, Santavirta S, Grönblad M, Rokkanen P. Four-year outcome of operative treatment of acute acromioclavicular dislocation. J Orthop Trauma. 1991;5(1):9–13. doi:10.1097/00005131-199103000-00002Jeong JY, Chun YM. Treatment of acute high-grade acromioclavicular joint dislocation. Clin Shoulder Elbow. 2020;23(3):159–65. doi:10.5397/cise.2020.00150Joukainen A, Kröger H, Niemitukia L, Mäkelä EA, Väätäinen U. Results of operative and nonoperative treatment of Rockwood types III and V acromioclavicular joint dislocation: A prospective, randomized trial with an 18- to 20-year follow-up. Orthop J Sports Med. 2014;2(12):2325967114560130. doi:10.1177/2325967114560130Kukkonen J, Kauko T, Vahlberg T, Joukainen A, Aärimaa V. Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery. J Shoulder Elbow Surg. 2013;22(12):1650–5. doi:10.1016/j.jse.2013.05.002Larsen E, Bjerg-Nielsen A, Christensen P. Conservative or surgical treatment of acromioclavicular dislocation: A prospective, controlled, randomized study. J Bone Joint Surg Am. 1986;68(4):552–5. Disponible en: https://pubmed.ncbi.nlm.nih.gov/3514625Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS. Management of acromioclavicular joint injuries. J Bone Joint Surg Am. 2014;96(1):73–84. doi:10.2106/JBJS.L.00734Lu D, Wang T, Chen H, Sun LJ. A comparison of double Endobutton and triple Endobutton techniques for acute acromioclavicular joint dislocation. Orthop Traumatol Surg Res. 2016;102(7):891–5. doi:10.1016/j.otsr.2016.07.003Mah JM, Canadian Orthopaedic Trauma Society (COTS). General health status after nonoperative versus operative treatment for acute, complete acromioclavicular joint dislocation: Results of a multicenter randomized clinical trial. J Orthop Trauma. 2017;31(9):485–90. doi:10.1097/BOT.0000000000000881Martetschläger F, Kraus N, Scheibel M, Streich J, Venjakob A, Maier D. The diagnosis and treatment of acute dislocation of the acromioclavicular joint. Dtsch Arztebl Int. 2019;116(6):89–95. doi:10.3238/arztebl.2019.0089Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1Morales LC, Murcia MA. Luxación acromioclavicular. Tratamiento quirúrgico mediante cerclaje con cinta de dacrón (Cervi-set®). Rev Colomb Ortop Traumatol. 2004;18(2):23–30. Disponible en: http://www.sccot.org.co/pdf/RevistaDigital/18-02-2004/04Luxacion.pdfMurray IR, Robinson PG, Goudie EB, Duckworth AD, Clark K, Robinson CM. Open reduction and tunneled suspensory device fixation compared with nonoperative treatment for type-III and type-IV acromioclavicular joint dislocations: The ACORN prospective, randomized controlled trial. J Bone Joint Surg Am. 2018;100(22):1912–8. doi:10.2106/JBJS.18.00412Nolte PC, Lacheta L, Dekker TJ, Elrick BP, Millett PJ. Optimal management of acromioclavicular dislocation: Current perspectives. Orthop Res Rev. 2020;12:27–44. doi:10.2147/ORR.S218991Rockwood CA Jr. Injuries to the acromioclavicular joint. In: Rockwood CA Jr, Green DP, editors. Fractures in adults. 2nd ed. Vol. 1. Philadelphia: JB Lippincott; 1984. p. 860–910.Stein T, Müller D, Blank M, Reinig Y, Saier T, Hoffmann R, et al. Stabilization of acute high-grade acromioclavicular joint separation: A prospective assessment of the clavicular hook plate versus the double-button suture procedure. Am J Sports Med. 2018;46(11):2725–34. doi:10.1177/0363546518788355Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi:10.1136/bmj.l4898Stucken C, Cohen SB. Management of acromioclavicular joint injuries. Orthop Clin North Am. 2015;46(1):57–66. doi:10.1016/j.ocl.2014.09.003Sun LJ, Lu D, Ma YF, Yu B. Minimally invasive procedure of acute acromioclavicular joint dislocation: One suture-button device versus two suture-button devices. Acta Orthop Belg. 2019;85(1):54–62. Disponible en: https://pubmed.ncbi.nlm.nih.gov/31023200/Tauber M, Hoffelner T, Lehmann L, Kraus N, Scheibel M, Moroder P. Prospective multicenter randomized controlled trial of surgical versus nonsurgical treatment for acute Rockwood type 3 acromioclavicular injury. Orthop J Sports Med. 2023;11(8):23259671231190411. doi:10.1177/23259671231190411Tuček M, Chochola A, Vaněček V, Bušková K. Chirurgická léčba akromioklavikulární luxace: Tahová cerkláž versus hákovitá dlaha [Surgical treatment of acromioclavicular dislocation: Tension band wiring versus hook plate]. Rozhl Chir. 2015;94(10):437–44.Verdano MA, Pellegrini A, Zanelli M, Paterlini M, Ceccarelli F. Modified Phemister procedure for the surgical treatment of Rockwood types III, IV, V acute acromioclavicular joint dislocation. Musculoskelet Surg. 2012;96(3):213–22. doi:10.1007/s12306-012-0221-4Wang C, Wang Y, Zhu T, Sun X, Lin C, Gao B, et al. [Article in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2015;29(2):149–53. Disponible en: https://pubmed.ncbi.nlm.nih.gov/26455139/Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med. 1995;23(3):324–31. doi:10.1177/036354659502300313Wellmann M, Smith T. Epidemiologie, Anatomie, Biomechanik und Bildgebung von Akromioklavikulargelenkverletzungen [Epidemiology, anatomy, biomechanics and imaging of acromioclavicular joint injuries]. Unfallchirurg. 2012;115(10):867–71. doi:10.1007/s00113-012-2247-3Ye G, Peng CA, Sun HB, Xiao J, Zhu K. Treatment of Rockwood type III acromioclavicular joint dislocation using autogenous semitendinosus tendon graft and endobutton technique. Ther Clin Risk Manag. 2016;12:47–51. doi:10.2147/TCRM.S81829Yeranosian M, Rangarajan R, Bastian S, Blout C, Patel V, Lee B, et al. Anatomic reconstruction of acromioclavicular joint dislocations using allograft and synthetic ligament. JSES Int. 2020;4(3):515–21. doi:10.1016/j.jseint.2020.04.001Yin J, Yin Z, Gong G, Zhu C, Sun C, Liu X. Comparison of hook plate with versus without double-tunnel coracoclavicular ligament reconstruction for repair of acute acromioclavicular joint dislocations: a prospective randomized controlled clinical trial. Int J Surg. 2018 Jun;54(Pt A):18-23. doi: 10.1016/j.ijsu.2018.04.017Yin F, Sun Z, Wei X, Liu X, Zhou M, Zhuang Y, et al. [Article in Chinese]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2016;30(5):532–6. doi:10.7507/1002-1892.20160107Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. doi: 10.1186/s13643-016-0384-4.Izcovich A, Chu DK, Mustafa RA, Guyatt G, Brignardello-Petersen R. A guide and pragmatic considerations for applying GRADE to network meta-analysis. BMJ. 2023;381:e074495. doi: 10.1136/bmj-2022-074495.Babhulkar A, Pawaskar A. Acromioclavicular joint dislocations. Curr Rev Musculoskelet Med. 2014;7:33-9. doi: 10.1007/s12178-013-9199-2.Kraus N, Hann C, Gerhardt C, Scheibel M. Dynamic instability of the acromioclavicular joint: a new classification for acute AC joint separation. Obere Extrem. 2018;13(4):279-85. doi: 10.1007/s11678-018-0469-xMalik AL, Rehman SU, Iqbal S, Zain-ul-Abidin M, Aslam F, Haq AU. Comparison of Conservative and Surgical Treatment of Grade III Acromio-Clavicular Dislocation. Pak J Med Health Sci. 2021;15(12):3358. doi: 10.53350/pjmhs2115123358.Bi AS, Robinson J, Anil U, Hurley ET, Klifto CS, Gonzalez-Lomas G, Alaia MJ, Strauss EJ, Jazrawi LM. Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023 Jun;32(6):1146-1158. doi: 10.1016/j.jse.2023.01.039. Epub 2023 Mar 5. PMID: 36871607.Articulación acromioclavicularAcromioclavicular jointLuxaciones articularesJoint dislocationsTratamiento conservadorConservative treatmentProcedimientos quirúrgicos operativosSurgical procedures, operativeRevisión sistemáticaSystematic reviewMeta-análisis en redNetwork meta-analysishttps://id.nlm.nih.gov/mesh/D000173https://id.nlm.nih.gov/mesh/D004204https://id.nlm.nih.gov/mesh/D000072700https://id.nlm.nih.gov/mesh/D013514https://id.nlm.nih.gov/mesh/D000078182https://id.nlm.nih.gov/mesh/D000099094ODS 3: Salud y bienestar. 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