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εξελίξεις στην αρθροσκοπική χειρουργική της ακρωμιοκλειδικής

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εξελίξεις στην αρθροσκοπική χειρουργική της ακρωμιοκλειδικής

  1. 1. Advances inAdvances in Acromioclavicular JointAcromioclavicular Joint ArthroscopyArthroscopy Manos AntonogiannakisManos Antonogiannakis DirectorDirector Center for Arthroscopy &Center for Arthroscopy & Shoulder SurgeryShoulder Surgery IASO General HospitalIASO General Hospital www.shoulder.gr
  2. 2. The Shoulder GirdleThe Shoulder Girdle Three joints:Three joints:  glenohumeralglenohumeral  AcromioclavicularAcromioclavicular  ScapulothoracicScapulothoracic www.shoulder.gr
  3. 3. Acromioclavicular JointAcromioclavicular Joint AC joint is situated between theAC joint is situated between the clavicleclavicle andand acromionacromion motion in three planes:motion in three planes: - AP gliding of acromion during protraction & retraction of- AP gliding of acromion during protraction & retraction of scapulascapula - tilting of acromion during abduction & adduction of armtilting of acromion during abduction & adduction of arm - rotation of the claviclerotation of the clavicle whichwhich occurs during abduction &occurs during abduction & adduction of shoulder.adduction of shoulder. www.shoulder.gr
  4. 4. AnatomyAnatomy Consists of two sets ofConsists of two sets of ligaments:ligaments: - AC ligamentAC ligament superiorsuperior - posterior- posterior AC lig isAC lig is most important ligament inmost important ligament in stabilizing AC joint for normalstabilizing AC joint for normal daily activitiesdaily activities - CoracoclavicularCoracoclavicular ligaments:ligaments: ConoidConoid TrapezoidTrapezoid www.shoulder.gr
  5. 5. AC pathology that can beAC pathology that can be treated by arthroscopytreated by arthroscopy  Osteolysis of the clavicleOsteolysis of the clavicle  AC arthritisAC arthritis  AC infection/cystsAC infection/cysts  AC dislocationAC dislocation www.shoulder.gr
  6. 6. Osteolysis of the clavicleOsteolysis of the clavicle  Unclear PathogeneticUnclear Pathogenetic mechanismmechanism  Acute injury (type I/IIAcute injury (type I/II AC sprains)AC sprains)  Repetitive microtraumaRepetitive microtrauma  Usually in male athletesUsually in male athletes (weight-lifters)(weight-lifters) www.shoulder.gr
  7. 7. Osteolysis of the clavicleOsteolysis of the clavicle Unclear Pathogenetic mechanismUnclear Pathogenetic mechanism  autonomic neurovascular originautonomic neurovascular origin  synovial invasion of the subchondral bonesynovial invasion of the subchondral bone  Cahill proposed that repetitiveCahill proposed that repetitive microtrauma caused subchondral stressmicrotrauma caused subchondral stress fractures and remodelingfractures and remodeling JBJS(Am)1982JBJS(Am)1982 www.shoulder.gr
  8. 8. Osteolysis of the clavicleOsteolysis of the clavicle TreatmentTreatment  Consernative (Rest, NSAIDs,Consernative (Rest, NSAIDs, Corticosteroid injections)Corticosteroid injections)  Surgical (Open or Arthroscopic distalSurgical (Open or Arthroscopic distal clavicle excision)clavicle excision) www.shoulder.gr
  9. 9. AC ArthritisAC Arthritis  Post – TraumaticPost – Traumatic  DegenerativeDegenerative ConcommitantConcommitant lesion to RClesion to RC tearstears www.shoulder.gr
  10. 10. AC cystAC cyst O. Levy Arthroscopy 2007
  11. 11. Surgical TreatmentSurgical Treatment Open distal clavicle excisionOpen distal clavicle excision Described by Mumford and Gurd in 1941Described by Mumford and Gurd in 1941 www.shoulder.gr
  12. 12. Arthroscopic Distal Clavicle ExcisionArthroscopic Distal Clavicle Excision SnyderSnyder Arthroscopy 1995Arthroscopy 1995 BiglianiBigliani Arthroscopy 1992/2000Arthroscopy 1992/2000 FlatowFlatow JSES 1995JSES 1995 AugeAuge AJSM 1998AJSM 1998 Surgical TreatmentSurgical Treatment www.shoulder.gr
  13. 13. Arthroscopic vs Open DistalArthroscopic vs Open Distal Clavicle ExcisionClavicle Excision  Better cosmesisBetter cosmesis  Less PainLess Pain  Avoids Muscle WeaknessAvoids Muscle Weakness  Residual AC instabilityResidual AC instability  Comparable outcome resultsComparable outcome results JP Warner Arthroscopy 2009JP Warner Arthroscopy 2009 www.shoulder.gr
  14. 14. TechniqueTechnique  Patient positioning exactly the same asPatient positioning exactly the same as shoulder arthroscopyshoulder arthroscopy www.shoulder.gr
  15. 15. Skin Marking & PortalsSkin Marking & Portals www.shoulder.gr
  16. 16. Subacromial DebridementSubacromial Debridement www.shoulder.gr
  17. 17. AcromioplastyAcromioplasty www.shoulder.gr
  18. 18. Starting distal clavicle excisionStarting distal clavicle excision www.shoulder.gr
  19. 19. External depression of theExternal depression of the clavicleclavicle www.shoulder.gr
  20. 20. Establishing Anterior AC portalEstablishing Anterior AC portal www.shoulder.gr
  21. 21. Check Lateral PortalCheck Lateral Portal www.shoulder.gr
  22. 22. Scope in AC portalScope in AC portal www.shoulder.gr
  23. 23. Use 70˚ scope to completeUse 70˚ scope to complete excisionexcision www.shoulder.gr
  24. 24. Final AC space 5-8mmFinal AC space 5-8mm Zhang et al.Arthroscopy 2007 www.shoulder.gr
  25. 25. Check distance in abductionCheck distance in abduction and external rotationand external rotation www.shoulder.gr
  26. 26. AC dislocationAC dislocation Rockwood ClassificationRockwood Classification
  27. 27. AC dislocationAC dislocation  Conservative treatment for types I – IIConservative treatment for types I – II  Surgical treatment for types IV – VISurgical treatment for types IV – VI  What about type III ?What about type III ? www.shoulder.gr
  28. 28. AC dislocationAC dislocation  Treatment of acute Type III dislocationsTreatment of acute Type III dislocations remains controversialremains controversial “More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries” www.shoulder.gr
  29. 29. Arthroscopic AC reconstructionArthroscopic AC reconstruction Several techniques have been publishedSeveral techniques have been published either full arthroscopic or arthroscopicallyeither full arthroscopic or arthroscopically assisted by Wolf, Boileau, Lafosseassisted by Wolf, Boileau, Lafosse www.shoulder.gr
  30. 30. AC reconstruction usingAC reconstruction using synthetic graftsynthetic graft E. WOLF – W. PENINGTON ARTHROSCOPY 2001 First publication of all arthroscopic AC reconstruction www.shoulder.gr
  31. 31. Arthroscopic CA ligamentArthroscopic CA ligament transfertransfer LAFOSSE et al. ARTHROSCOPY 2005 www.shoulder.gr
  32. 32. Arthroscopic Weaver DunnArthroscopic Weaver Dunn P. BOILEAU et al. ARTHROSCOPY 2010 www.shoulder.gr
  33. 33. Our Experience in ACOur Experience in AC dislocationsdislocations We prefer open reduction – fixation of theWe prefer open reduction – fixation of the AC because ofAC because of  Small incisionSmall incision  Precise reductionPrecise reduction  Residual scaring seems to have effect onResidual scaring seems to have effect on stabilitystability www.shoulder.gr
  34. 34. Methods of FixationMethods of Fixation  For Acute dislocations use of syntheticFor Acute dislocations use of synthetic ligaments (Tightrope – Arthrex, Surgilig –ligaments (Tightrope – Arthrex, Surgilig – Surgicraft) along with ligament suturingSurgicraft) along with ligament suturing  For Chronic dislocations use of syntheticFor Chronic dislocations use of synthetic ligaments along with hamstrings autograftligaments along with hamstrings autograft www.shoulder.gr
  35. 35. Interesting CaseInteresting Case Patient has his 3Patient has his 3rdrd revision for ACrevision for AC dislocation (Surgilig along with hamstringsdislocation (Surgilig along with hamstrings autograft)autograft) www.shoulder.gr
  36. 36. Pre - op Post - op www.shoulder.gr
  37. 37. 6 months later after a fall from6 months later after a fall from his bikehis bike Note that the ac remains intact!!! www.shoulder.gr
  38. 38. Final Outcome (4Final Outcome (4thth operation)operation) www.shoulder.gr
  39. 39. Thank you!!!Thank you!!! www.shoulder.gr

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