SUKESH .A N

JUNIOR RESIDENT ORTHOPAEDICS

TDMC ALAPUZHA

case

Mathew 55 yrs

h/0 RTA 1 week

c/o pain & swelling left shoulder

Bony prominence over lateral end of left

clavicle

Difficulty in raising left arm

ACROMIO-CLAVICULAR JOINT DISLOCATION

MATHEW

Preop x ray

STRAP INCISION

JOINT DISLOCATION

JOINT REDUCTION

CLAVICLE TO BASE OF

CORACOID

K WIRE FIXATION

Post op xray

Acromioclavicular Joint

update

9% of shoulder girdle injuries

Generally occurs in males age 20-

30

ANATOMY

The AC joint is a diarthrodial joint.

Located between the lateral end of the clavicle

and the medial acromion.

The AC ligaments (anterior, posterior, superior,

inferior) strengthen the thin capsule

Fibers of the deltoid and trapezius muscles blend

with the superior AC ligament to strengthen the

joint

The horizontal stability of the AC joint - by the AC

ligaments.

The vertical stability - by the CC /coracoclavicular

ligaments.

MECHANISM OF INJURY

Direct: This is the most common mechanism,

resulting from a fall onto the shoulder with the

arm adducted.

Indirect: A fall onto an outstretched hand with

force transmission through the humeral head and

into the AC articulation

PHYSICAL FINDINGS

Pain over lateral clavicle / AC joint

Prominent distal clavicle

May have skin abrasions

Unable to lift arm.

A mobile distal clavicle

Radiographic Evaluation of the

Acromioclavicular Joint

Anteroposterior view

Stress veiw (3-4kg weight tied to wrist for complete muscle relaxation )

Zanca view (15 degree cephalic tilt)

CLASSIFICATION

Initially classified by both Allman and Tossy et al. into three types (I, II, and III).

Rockwood added types IV, V, and VI, so that now six types are recognized.

Classified depending on the degree and direction of displacement of the distal clavicle.

Type I

Sprain of acromioclavicularligament

AC joint intact

Coracoclavicularligaments intact

Deltoid and trapeziusmuscles intact

AC joint disrupted

< 50% Vertical

displacement

Sprain of the

coracoclavicular

ligaments

CC ligaments intact

Deltoid and trapezius

muscles intact

Type II

Type III

AC ligaments and CC ligaments all disrupted

AC joint dislocated and the shoulder complex displaced inferiorly

CC interspace greater than the normal shoulder(25-100%)

Deltoid and trapezius muscles usually detached from the distal clavicle

Type III Variants

“Pseudo-dislocation” through an intact

periosteal sleeve

Physeal injury

Coracoid process fracture

Type IV

AC and CC ligaments

disrupted

AC joint dislocated and

clavicle displaced

posteriorly into or

through the trapezius

muscle

Deltoid and trapezius

muscles detached

from the distal clavicle

Type V

AC ligaments disrupted

CC ligaments disrupted

AC joint dislocated and

gross disparity

between the clavicle

and the scapula (100-

300%)

Deltoid and trapezius

muscles detached from

the distal half of

clavicle

Type VI

AC joint dislocated and clavicle displaced inferior to the acromionor the coracoid process

AC and CC ligaments disrupted

Deltoid and trapeziusmuscles detached from the distal clavicle

TREATMENT

Type I: Rest for 7 to 10 days, ice packs,

sling. Refrain from full activity until

painless, full range of motion (2 weeks).

Type II: Sling for 1 to 2 weeks, gentle

range of motion as soon as possible.

Refrain from heavy activity for 6 weeks

Type III:

For inactive, nonlaboring patients nonoperative

treatment is indicated:

Younger, more active patients with more severe

degrees of displacement and laborers who use their

upper extremity above the horizontal plane may

benefit from operative stabilization.

Type IV, V,& IV:

Open reduction and surgical repair of the

coracoclavicular ligaments are performed for

vertical stability

Type III Injuries: Need for acute surgical

treatment remains controversial.

Most surgeons recommend conservative

treatment except in the throwing athlete or

overhead worker.

Repair generally avoided in contact athletes

because of the risk of reinjury.

Literature unable to support operative or

nonoperative treatment as superior

Functional outcomes appear similar.

Cosmesis not different (scar vs bump)

Only 50% of surgical cases reduced at follow-up.

10% complications after surgery.

Ceccarelli et al. J Orthopaed Traumatol

2008;9:105-108.

SURGICAL MANAGEMENT

Should fulfill 3 requirements:

1. ac joint must be exposed & debrided

2.coracoclavicular & acromioclavicular ligaments

must be repaired or reconstructed

3.stable reduction of ac joint

Campell 12th edition chapter 60 page 3029

MANAGEMENT

5 major categories:

1.Ac reduction & fixation

2.Ac reduction,cc ligament repair & cc

fixation

3.Combination of 1 & 2

4.Distal clavicle excision

5.Muscle transfers

Campell 12th edition chapter 60 page 3029

Campell describe,

MAZZOCCA TECHNIQUE

-anatomic reconstruction of conoid &

trapezoid ligaments

-autologous semitendinosus graft

preferred,reconstruction with suture

tape

-biomechanical studies by mazzoca

demonstrated superior fixation

compared with pin fixation or repair

BOSWORTH TECHNIQUE

CLAVICULAR HOOK PLATE

REPAIR & TIGHT ROPE AUGMENTATION

LARS LIGAMENT

Synthetic Ligament

Made of polyethylene terephthalate

Longitudinal-running fibres that match the

structure of native human tissue.

LARS ligament reproduces the anatomy and

mechanics of the torn coracoclavicular ligament

SURGILIG RECONSTRUCTION

SURGILIG RECONSTRUCTION

Surgilig is an artificial ligament

It is made of double braided

polyester with a patented weave

design which acts as a scaffold

encouraging tissue in-growth

Other neo ligaments

ROTA LOK system

KEIO LEEDS system

All are poly ester artificial ligaments

Techniques for Late Surgical

Treatment of Acromioclavicular

Injuries

Reduction of AC joint and repair of AC and CC

ligaments

Resection of distal clavicle and reconstruction of

CC ligaments (Weaver-Dunn Procedure)

WEAVER-DUNN PROCEDURE

The distal clavicle is excised.

The CA ligament is transferred to the distal clavicle.

The CC ligaments are repaired and/or augmented with a coracoclavicularscrew or suture.

Repair of deltotrapezialfascia

Young patients,elderly with painful, disabled,degenerative ac

Surgery versus Sling for AC Joint

Dislocations

Study finds hook plate fixation is not superior to

nonsurgical treatment for acute injuries

(AAOS Now December 2012 .Maureen

Leahy)

Reconstruction for neglected

cases

Grafts used

Semitendinosis

Gracilis

Allografts

• Used as a single or double bundle to

reconstruct the coracoclavicular ligament.

• Synthetic ligaments like LARS or Surgilig

can be used for reconstruction

Complications of AC Joint

dislocations

AC joint Arthritis

Cosmetic

Scapular Dyskinesia

SICK scapula syndrome

# Clavicle ,# Coracoid

Implant Failure

Infection

Shoulder stiffness

Rotator cuff problems

SICK Scapula syndrome

SICK Scapula syndrome

S- Scapular malposition

I-I nferomedial prominence of Scapula

C- Coracoid pain

K- Kinesial abnormalities of scapula

Arch Orthop Trauma Surg. 2013 Jul;133(7):

In addition to the correct type of injury therapy

strategies should be adapted to patient's demands

and compliance.

A certain debate is still ongoing regarding type III

injuries

non-operative treatment of type III injuries results to

provide equal functional outcomes as compared to

surgical treatment associated with less complications

If surgical treatment is indicated, open surgical

procedures using pins, PDS-slings or hook plates

are still widely used concurring with recent minimally

invasive, arthroscopic techniques using new

implants designed to remain in situ.

2013 Arthroscopy Association of North America. Published by

Elsevier Inc

3 considerations in determining treatment options for patients with acromioclavicular (AC) joint dislocations:

(1) operative versus nonoperative management,

(2) early versus delayed surgical intervention, and

(3) anatomic versus non anatomic techniques

-There is a lack of evidence to support treatment options for patients with AC joint dislocations.

- Although there is a general consensus for nonoperativetreatment of Rockwood type I and II lesions,

-initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions,

-further research is needed to determine if differences exist regarding early versus delayed surgical intervention and anatomic vs nonanatomic surgical techniques

Journal of Orthopaedic Surgery and Research 2015

Treatment options should be thoroughly

discussed with patients, weighing all

subjective, objective and radiographic

outcomes and the relative advantages of

each option.

THANK YOU