23/03/2013

1

1

ACJ Injury Rugby

Lennard Funk

2

3 4

Questions:

  What is the Grade?   Should we operate?

  Why?   When?   How?

5

Rockwood Classification

6

23/03/2013

2

What Grade?

7

  We conclude that the classification of AC joint injuries using a radiograph alone has limited reliability and consistency in clinical practice.

8

Indications for Stabilisation   Literature = Type 4, 5 & 6

9

Treatment?

  Operative

  Non-operative

10

When?

Ceccarelli et al. 2008

  “From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, but complications are more evident in the surgery group.

  Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation.

  More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.”

11

Bradley & Elkousy, Clin Sport Med, 2003

  “The only advantage to operative intervention consistently borne out in the literature is an increased probability of anatomic reduction.

  There is no correlation between reduction and improvement in pain, strength, or motion, however.”

12

23/03/2013

3

Athletes   Following ACJ Dislocations:

  30% of overhead athletes had to reduce sport

  9% had to change sport   Climbers and patients

performing strength training had to reduce their activities or give up sports

  Altered activities in overhead ball sports

Rangger et al. Orthopade 2002 Jun;31(6):587-90

13

  164 US Naval Cadets

  Ongoing symptoms at 6 months:   36% of Grade 1

  48% of Grade 2   Major in 13%

  Minor in 35%

  69% of Grade 3

Cox. Am J Sports Med, 1981

14

High Demand

What about rugby?   Often able to play   Unable to train

  Modern day expectations

15

Indications

•  Symptoms(•  Pa+ent(Demands(

– Work(demands(–  Society(demands(

•  Overhead(Athlete(

16

Review 3 weeks

Approach

Acute Injury < 1 week

Review 3 months Surgery

Coping Not Coping

17

Surgical procedures

18

23/03/2013

4

Coracoclavicular Ligaments

  Strength – 500N (+/- 134)   Stiffness – 103N/mm (+/-

30)   Uniaxial Tension 25mm/min

Harris et. al. Am J Sports Med. 2000

19

Harris et al. AJSM 2000

“None of the reconstruction techniques analyzed in the present study were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”

20

ACJ Ligaments

  Two thirds of the superior stability for lesser displacements

  90% the posterior stability

Fukuda et al. JBJSA. 1986

21

Dynamic Stability

  Delto-trapezial fascia Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.

Lizaur et al. JBJS. 1994

22

23

My Experience

2001 2006

24

23/03/2013

5

LARS Ligament (Corin)

  Braided Polyethylenetraphthalate   1500N tensile strength (30 LAC)

  No reduction in mechanical resilience after over 10 million wear cycles loaded in torsion, traction and flexion [Fialka et al. 2005;

  Vascularisation & Fibrous ingrowth - Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005; Pelletier & Durand]

25 26

LARS Ligament

3 weeks post-op

27

LARS Ligament Outcomes

28

Wright & Funk, 2010. BESS

LARS Ligament Outcomes   All patients returned to their previous level of work &

sports post LARS reconstruction in a mean time of 3 months

  The mean patient satisfaction score was 93%

  In one patient who did not follow the prescribed rehabilitation protocol the reconstruction failed in the early postoperative period.

29

LARS Ligament Outcomes   The median postoperative residual displacement of the ACJ

was 15%.

30

23/03/2013

6

31