09/12/2012               AC Joint "               Dislocations & Instability                                              ...
09/12/2012         2
09/12/2012Indications for Stabilisation     !    Literature = Type 4, 5 & 6Ceccarelli et al. 2008!      From the literatur...
09/12/2012What are we trying to achieve?    •     A pain free & stable shoulder "         that has enough mobility, streng...
09/12/2012      Surgical proceduresCoracoclavicular "Ligaments      Harris et. al. Am J Sports Med. 2000!     Strength – 5...
09/12/2012     ACJ Ligaments                Fukuda et al. JBJSA. 1986!     Two thirds of the superior stability      for l...
09/12/2012Revisions !!!     LARS Ligament (Corin)!    Braided Polyethylenetraphthalate!    1500N tensile strength (30 LAC)...
09/12/2012Standard repair              Shoulderdoc.co.ukModification 1                Shoulderdoc.co.ukModification 2       ...
09/12/2012Closure!    Repair the Superior AC Ligaments!    Repair the Delto-Trapezial Fasciax-rays - "Day 1, 3 weeks, 3 mo...
09/12/2012POST-OP!    Phase 1: (Level 1-2 Exercises)     !    Core stability & Scapula control     !    Proprioceptive exe...
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Acj instability mac 2012

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Acj instability mac 2012

  1. 1. 09/12/2012 AC Joint " Dislocations & Instability ! Is the ACJ Important? Rangger et al. Orthopade 2002 Jun; 31(6):587-90 !  YES – for overhead 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 Is the ACJ Important? Cox. Am J Sports Med, 1981!  YES – for high demand professions:!  Following ACJ Injuries: !  164 US Naval Cadets !  Residual symptoms found at 6 month follow-up: !  36% of Grade 1 !  48% of Grade 2 !  Major in 13% !  Minor in 35% !  69% of Grade 3 1
  2. 2. 09/12/2012 2
  3. 3. 09/12/2012Indications for Stabilisation !  Literature = Type 4, 5 & 6Ceccarelli 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. 3
  4. 4. 09/12/2012What are we trying to achieve? •  A pain free & stable shoulder " that has enough mobility, strength " & muscle control for a patient s " desired level of activity & participation •  Peter RheinlaenderMy indications !  Patient Demands !  Work demands !  Society demands !  Overhead AthleteApproach Acute Injury < 1 week Review 3 weeks Coping Not Coping Review" 3 months Surgery 4
  5. 5. 09/12/2012 Surgical proceduresCoracoclavicular "Ligaments Harris et. al. Am J Sports Med. 2000!  Strength – 500N (+/- 134)!  Stiffness – 103N/mm (+/- 30)!  Uniaxial Tension 25mm/minHarris 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 5
  6. 6. 09/12/2012 ACJ Ligaments Fukuda et al. JBJSA. 1986!  Two thirds of the superior stability for lesser displacements!  90% the posterior stability Dynamic Stability !  Delto-trapezial fascia Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963. Lizaur et al. JBJS. 1994 My Experience 2001 2008 6
  7. 7. 09/12/2012Revisions !!! 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] 7
  8. 8. 09/12/2012Standard repair Shoulderdoc.co.ukModification 1 Shoulderdoc.co.ukModification 2 Shoulderdoc.co.uk 8
  9. 9. 09/12/2012Closure!  Repair the Superior AC Ligaments!  Repair the Delto-Trapezial Fasciax-rays - "Day 1, 3 weeks, 3 months, 1yr, 2yrs Shoulderdoc.co.uk Shoulderdoc.co.uk Shoulderdoc.co.uk Shoulderdoc.co.uk 9
  10. 10. 09/12/2012POST-OP!  Phase 1: (Level 1-2 Exercises) !  Core stability & Scapula control !  Proprioceptive exercises (minimal weightbearing below 90 degrees) !  Active ROM as comfortable !  Do not force or stretch !  No resistance exercises !  Phase 2: (Level 2-3 Exercises) !  Progress to light resistance exercises as tolerated !  Sports-specific rehabilitation - Plyometrics and pertubation training!  Phase 3: (Level 3+ Exercises) !  Regain scapula & glenohumeral stability working for shoulder joint control rather than range !  Gradually Strengthen THANK YOU •  lenfunk@shoulderdoc.co.uk 10

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