Failed acj excision

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  • The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve. Reprinted from the article “Injuries to the Acromioclavicular Joint” by DeLee, Drez, and Miller in the book Delee & Drez’s Orthopaedic Sports Medicine: Principles and Practice, p. 916, Copyright 2003, with permission from Elsevier.\n\n
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  • Failed acj excision

    1. 1. Failed ACJ Excision Lennard Funk
    2. 2. 2
    3. 3. Plan:  Anatomy & Mechanics  ACJ Excision procedure  Complications  Management 3
    4. 4. Functional Anatomy 1.5mm Beardon 4
    5. 5. AC Ligaments Superior AC Lig = 56% Posterior Translation Posterior AC Lig = 25% Posterior Translation  Klimkiewikcz Superior AC Lig = Rotational Stability  Branch et al. Urist, JBJSA. 1946 5
    6. 6. AC Ligaments 6
    7. 7. AC Ligaments Attaches over 2.6cm of clavicle in men, 2.3cm in women  Renfree & Wright 6
    8. 8. AC Ligaments Attaches over 2.6cm of clavicle in men, 2.3cm in women  Renfree & Wright (1.5cm - Hearnden 2012) 6
    9. 9. AC Ligaments Attaches over 2.6cm of clavicle in men, 2.3cm in women  Renfree & Wright (1.5cm - Hearnden 2012) No difference if superior or inferior AC lig. cut (horizontal, vertical & rotatory)  Branch et al. AJSM 1996 6
    10. 10. AC Ligaments Attaches over 2.6cm of clavicle in men, 2.3cm in women  Renfree & Wright (1.5cm - Hearnden 2012) No difference if superior or inferior AC lig. cut (horizontal, vertical & rotatory)  Branch et al. AJSM 1996 Superior & Posterior not capable of stabilising clavicle - 32% incr. of posterior translation after Ant & Inf capsular resection  Corteen & Teitge 6
    11. 11. Normal Joint Space = 1-3mm 7
    12. 12. ACJ Angle 8
    13. 13. ACJ Excision Aims Remove arthritic surfaces Preserve AC superior & posterior Ligs. 9
    14. 14. Results Open:  76% Good-Excellent at 4.6yrs  Rabalais & MCarty, CORR 2007 Scope:  85% Good-Excellent  Elhassan et al, Arthroscopy 2009  Faster return to activities  Pensak et al. Arthroscopy 2010 10
    15. 15. Failed ACJ Excision (Basmania, 1995)1. Diagnostic Error2. Inadequate resection3. Joint Instability4. Weakness5. Miscellaneous 11
    16. 16. Failed ACJ Excision (Strauss et al. 2010)Common Causes Less Common CausesInstability Distal Clavicle FractureUnder Resection Suprascapular neuropathyOver Resection Other Cause - Neck pain, SLAP, etc.Stiffness (29%)Bony regrowthUntreated ConcomitantPathologyInfection 12
    17. 17. Failed ACJ Excision (Strauss et al. 2010)Common Causes Less Common CausesInstability Distal Clavicle FractureUnder Resection Suprascapular neuropathyOver Resection Other Cause - Neck pain, SLAP, etc.Stiffness (29%)Bony regrowthUntreated ConcomitantPathologyInfection 12
    18. 18. Failed ACJ Excision (Strauss et al. 2010)Common Causes Less Common CausesInstability Distal Clavicle FractureUnder Resection Suprascapular neuropathyOver Resection Other Cause - Neck pain, SLAP, etc.Stiffness (29%)Bony regrowthUntreated ConcomitantPathologyInfection 12
    19. 19. Excess ACJ Excision 13
    20. 20. Clavicle Excision 14
    21. 21. Clavicle Excision 11mm excision should not violate the Trapezoid ligament in 98%  Renfree & Wright 14
    22. 22. Clavicle Excision 11mm excision should not violate the Trapezoid ligament in 98%  Renfree & Wright >10mm excision detaches 10% of the Trapezoid ligament  Boehm et al. Acta Orth Scand. 2003 14
    23. 23. Clavicle Excision 11mm excision should not violate the Trapezoid ligament in 98%  Renfree & Wright >10mm excision detaches 10% of the Trapezoid ligament  Boehm et al. Acta Orth Scand. 2003 High incidence of post-op pain if >10mm resected  Eskola et al. JBJS 1996 14
    24. 24. Clavicle Excision Only 5mm of the distal clavicle needs to be resected to ensure that no bone-to-bone contact occurs in rotation  Corteen & Teitge  Edwards et al. Arthroscopy 2007 15
    25. 25. Recommended: Resect 5mm on clavicle side & acromial side  Corteen & Teitge 16
    26. 26. Also: Post-op pain correlates with Translation, but not amount of bone resected  Blazar et al. CORR. 1998 No difference if superior or inferior AC lig. cut (horizontal, vertical & rotatory instability)  Branch et al. AJSM 1996 17
    27. 27. Unstable ACJ 18
    28. 28. Management 19
    29. 29. Management  Each case is unique 19
    30. 30. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma 19
    31. 31. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma  Blame 19
    32. 32. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma  Blame  Medicolegal 19
    33. 33. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma  Blame  Medicolegal  Multiple Opinions 19
    34. 34. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma  Blame  Medicolegal  Multiple Opinions 19
    35. 35. Management  Each case is unique  May be multiple problems  Retained bone & unstable  Excess excision & scar neuroma  Blame  Medicolegal  Multiple Opinions  Diagnostic Injection 19
    36. 36. Retained bone & Unstable 20
    37. 37. 21
    38. 38. 22
    39. 39. Arthroscopic Stabilisation 23
    40. 40. Arthroscopic Stabilisation 23
    41. 41. Arthroscopic Stabilisation 23
    42. 42. Arthroscopic Stabilisation 23
    43. 43. Arthroscopic Stabilisation 23
    44. 44. Open Stabilisation 24
    45. 45. Open Stabilisation 24
    46. 46. Open Stabilisation 24
    47. 47. Open Stabilisation 24
    48. 48. Open Stabilisation 24
    49. 49. Open Reconstruction 25
    50. 50. Under Resection 26
    51. 51. Under Resection 26
    52. 52. Under Resection 26
    53. 53. Under Resection 26
    54. 54. Under Resection 26
    55. 55. Missed the joint 27
    56. 56. 28
    57. 57. Open ACJ 29
    58. 58. Failed ACJ Excision (Strauss et al. 2010)Common Causes Less Common CausesInstability Distal Clavicle FractureUnder Resection Suprascapular neuropathyOver ResectionStiffnessBony regrowthUntreated ConcomitantPathologyInfection 30
    59. 59. Pain - ? Neuroma Mazzocca, 2003 image from DeLee & Drez Orthopaedic Sports Medicine. Elsevier. 2003 31
    60. 60. Recognition Awareness Test for Horizontal & Vertical Instability Ultrasound X-Ray CT Scan Stabilise if unstable 32
    61. 61. THANK YOU

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