Lennard Funk
Three Myths Debunked!
@theshoulderdoc
AC Joint Injuries
Type 1 Type 2 Type 3
Type 4 Type 5 Type 6
Normal
Rockwood ClassificationFractures in Adults, 1991
“there is a general consensus for nonoperative treatment of Rockwood type I and type II lesions, initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions”
Arthroscopy. Feb, 2013.
Case 1: Would you Fix this?A. Yes
B. No
C. Abstain
Case 2: Would you Fix this?A. Yes
B. No
C. Abstain
“The extent to which beliefs are based on evidence is very much less than believers suppose”
Bertrand Russell The Skeptical Essays, 1928
Myth 1. “Treat according to Grade”
The Grade does not matter
Indications for StabilisationLiterature = Type 4, 5 & 6
The classification of AC joint injuries using radiographs alone has limited reliability and consistency in clinical practice.
Inter-Observer Reliability: • Rockwood classification
–Mean inter-observer agreement = 64.6%–Weighted kappa = 0.258
• Tossy and Allman classification–Mean inter-observer agreement = 68.1%–Weighted kappa = 0.309
Intra-Observer Reliability: • Rockwood classification
–Mean inter-observer agreement = 59.4%–Weighted kappa = 0.150
• Tossy and Allman classification–Mean inter-observer agreement = 67.4%–Weighted kappa = 0.113
“The Rockwood classification system has limited interobserver and intraobserver reliability, even with the help of 3D CT.
Inconsistent agreement with use of this system limits its role in clinical decision-making.”
2014 23:665-70
Clinical Grade?
Clinical Grade?
Instability?
3 months Pain free FROM
Case 1
Case 2
3 months Painful ++
Myth 2. “The clavicle is displaced”
It is a Scapula Injury
‘SICK’ Scapula
Scapular malposition Inferior medial border prominence Coracoid pain & malposition dysKinesis of scapular
Gumina et al. Arthroscopy. 2009
70.6% of patients exhibited scapular dyskinesis 58.3% met criteria for SICK scapular syndrome Patients with dyskinesis = lower Constant & Simple Shoulder Scores
‘Locked Scapula’ (stable)
‘Shocked Scapula’ (unstable)
Myth 3. “Reconstruct the CC Ligaments”
It’s not just about the Coracoclavicular Ligaments
Coracoclavicular Ligaments
Strength – 500N (+/- 134)
Stiffness – 103N/mm (+/- 30)
Uniaxial Tension 25mm/min
Harris et. al. Am J Sports Med. 2000
ACJ Ligaments Two thirds of the superior stability for lesser displacements
90% the posterior stability
Fukuda et al. JBJSA. 1986
Dynamic StabilityDelto-trapezial fascia
Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
“Many unsatisfactory results could be due to lack of repair of the trapezius and deltoid.
Lizaur et al. JBJS. 1994
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”
My Approach:Scapula Injury:
Separation of the Axial And Appendicular segments
Look for:
Locked Scapula
Shocked Scapula Don’t make decisions on X-Rays or scans
Don’t be hasty to operate
Review:
Coper
Non-coper
My indicationsPatient Demands
Work demands
Society demands
Overhead Athlete
Review 3 weeks
ManagementAcute Injury < 1 week
Review3 months Surgery
Coping Not Coping
Scapula Rehab
Scapula Rehab
Nottingham Approach
Shoulderdoc.co.uk
Standard repair
Shoulderdoc.co.uk
Modification 1 (2008)
Shoulderdoc.co.uk
Modification 2
Shoulderdoc.co.uk
ClosureRepair the Superior AC Ligaments
Repair the Delto-Trapezial Fascia
KSSTA, 2014
KSSTA, 2014
THANK YOU
“The extent to which beliefs are based on evidence is very much less than believers suppose”
Bertrand Russell
@theshoulderdoc
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