This document summarizes a presentation on AC joint and distal clavicle injuries. It discusses the classification of AC joint injuries, controversies around treatment of type III injuries, surgical techniques for repair and reconstruction, and recent biomechanical studies. While the literature is limited, current evidence suggests conservative treatment may be adequate for many type III injuries, with surgical intervention favored for more active patients or overhead athletes. Surgical techniques like the tightrope and anatomic reconstruction show promise but further research is still needed.
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
#aclsurgeryjaipur #aclsurgeryhindia #aclsurgerytaekwondo
Acl reconstruction in jaipur | Acl reconstruction in taekwondo | Acl injury in football player surgery | Acl reconstruction surgery in football | acl surgery | Acl surgery ke baad physiotherapy | Acl surgery in jaipur | acl surgery recovery | Best acl surgeon in jaipur | Best ligament doctor in hindi | Best acl surgeon in india | Meniscus repair surgery in jaipur | Sports injury doctor | Acl injury in football players | Acl injury in taekwondo | acl tear | Best knee surgeon in jaipur
#allinsideacl #internalbrace #drrajatjangir #bestaclsurgeon #aclexpert #bestkneesurgeon
To Know more about ACL Injury, Click the links below:
1. ACL surgery 7 different Techniques we do at our center - "Not single technique best for all"
https://youtu.be/oWkIr8IXvr8
2. Everything about ACL Injury tear surgery in Hindi I
https://youtu.be/bqpjkAkwZ14
3. Best Screw for ACL tear surgery in Hindi
https://youtu.be/1LGpU1NHiIs
4. ACL Injury Tear Surgery Recovery : All your questions & queries solved by Dr.Rajat Jangir
https://youtu.be/SIAPWiMbOqs
5. Partial ACL Tear Surgery or not ! ACL आधा टूटा हो तो क्या करें ?
https://youtu.be/NEJRPKskJTI
6. 5 Symptoms of ACL Injury tear इंजरी के पांच लक्षण ?
https://youtu.be/EXpgy19Jxzw
7. PRP injection therapy in Partial ACL TEARs
https://youtu.be/qyG1EYgS87E
Dr.RAJAT JANGIR(Asso Prof.)
Senior Consultant Arthroscopy and Joint Replacement
(Specialist in Shoulder Knee Hip Surgery)
Ligament and Joints Clinic
67/34 Mansarovar Jaipur
Whatsapp: shorturl.at/gnAEP
Appointment: +91 8104855900
Email: ligamentsurgeon@gmail.com
Google Page: https://g.page/KNEE-Shoulder-SURGERY?...
Facebook: https://www.facebook.com/Ligamentandj...
* Vast experience and specialisation in the field of Arthroscopy and sports surgery.
* M.S. orthopaedics from BJ Medical College, Civil hospital, Ahmedabad
* Fellowship in Arthroscopy and Sports injury with Prof Joon Ho Wang at Samsung Medical Center, South Korea
* Diploma in Sports Medicine from InternationaI Olympic Committee
* Invited as Athlete Medical Doctor at Rio Olympic 2016
* Done Rajasthan's first "All Inside Physeal Preserving ACL reconstruction" in 13 year old Athlete
Dr.Rajat is rated as one of the best orthopedic surgeon with with excellence in Knee Shoulder Arthroscopy surgeries as replacements'
Total Knee Arthroplasty | Knee Replacement | South Windsor, Rocky Hill, Glast...James Mazzara
https://hartfordsportsorthopedics.com/
In this presentation, Dr. Mazzara discusses total knee arthroplasty. His presentation highlights:
The anatomy of the knee
Normal articular cartilage
Causes and symptoms of osteoarthritis
Diagnosis of osteoarthritis
Non-surgical treatment for osteoarthritis
Candidates for total knee arthroplasty
Surgical approach to knee replacement
Potential complications of knee arthroplasty
Computer-assisted total knee replacement
Post-operative protocol
To learn more about total knee arthroplasty, please visit: https://hartfordsportsorthopedics.com/computer-guided-total-knee-replacement-south-windsor-rocky-hill-glastonbury-ct/
MENISCUS REPAIR I Dr.RAJAT JANGIR JAIPUR
#aclsurgeryjaipur #aclsurgeryhindia #aclsurgerytaekwondo
Acl reconstruction in jaipur | Acl reconstruction in taekwondo | Acl injury in football player surgery | Acl reconstruction surgery in football | acl surgery | Acl surgery ke baad physiotherapy | Acl surgery in jaipur | acl surgery recovery | Best acl surgeon in jaipur | Best ligament doctor in hindi | Best acl surgeon in india | Meniscus repair surgery in jaipur | Sports injury doctor | Acl injury in football players | Acl injury in taekwondo | acl tear | Best knee surgeon in jaipur
#allinsideacl #internalbrace #drrajatjangir #bestaclsurgeon #aclexpert #bestkneesurgeon
To Know more about ACL Injury, Click the links below:
1. ACL surgery 7 different Techniques we do at our center - "Not single technique best for all"
https://youtu.be/oWkIr8IXvr8
2. Everything about ACL Injury tear surgery in Hindi I
https://youtu.be/bqpjkAkwZ14
3. Best Screw for ACL tear surgery in Hindi
https://youtu.be/1LGpU1NHiIs
4. ACL Injury Tear Surgery Recovery : All your questions & queries solved by Dr.Rajat Jangir
https://youtu.be/SIAPWiMbOqs
5. Partial ACL Tear Surgery or not ! ACL आधा टूटा हो तो क्या करें ?
https://youtu.be/NEJRPKskJTI
6. 5 Symptoms of ACL Injury tear इंजरी के पांच लक्षण ?
https://youtu.be/EXpgy19Jxzw
7. PRP injection therapy in Partial ACL TEARs
https://youtu.be/qyG1EYgS87E
Dr.RAJAT JANGIR(Asso Prof.)
Senior Consultant Arthroscopy and Joint Replacement
(Specialist in Shoulder Knee Hip Surgery)
Ligament and Joints Clinic
67/34 Mansarovar Jaipur
Whatsapp: shorturl.at/gnAEP
Appointment: +91 8104855900
Email: ligamentsurgeon@gmail.com
Google Page: https://g.page/KNEE-Shoulder-SURGERY?...
Facebook: https://www.facebook.com/Ligamentandj...
* Vast experience and specialisation in the field of Arthroscopy and sports surgery.
* M.S. orthopaedics from BJ Medical College, Civil hospital, Ahmedabad
* Fellowship in Arthroscopy and Sports injury with Prof Joon Ho Wang at Samsung Medical Center, South Korea
* Diploma in Sports Medicine from InternationaI Olympic Committee
* Invited as Athlete Medical Doctor at Rio Olympic 2016
* Done Rajasthan's first "All Inside Physeal Preserving ACL reconstruction" in 13 year old Athlete
Dr.Rajat is rated as one of the best orthopedic surgeon with with excellence in Knee Shoulder Arthroscopy surgeries as replacements'
Total Knee Arthroplasty | Knee Replacement | South Windsor, Rocky Hill, Glast...James Mazzara
https://hartfordsportsorthopedics.com/
In this presentation, Dr. Mazzara discusses total knee arthroplasty. His presentation highlights:
The anatomy of the knee
Normal articular cartilage
Causes and symptoms of osteoarthritis
Diagnosis of osteoarthritis
Non-surgical treatment for osteoarthritis
Candidates for total knee arthroplasty
Surgical approach to knee replacement
Potential complications of knee arthroplasty
Computer-assisted total knee replacement
Post-operative protocol
To learn more about total knee arthroplasty, please visit: https://hartfordsportsorthopedics.com/computer-guided-total-knee-replacement-south-windsor-rocky-hill-glastonbury-ct/
clerked a case, presented to 5 orthopaedics professors for end of posting evaluation and here it is,with a thought of sharing online (eventho this is not a good one)
Percutaneous Pedicle Screw Fixation For Thoracolumbar injuries using a low co...Ansarul Haq
The goal of PPSI is to decrease the trauma associated with the standard open approach, which can lead to significant devascularization and denervatation of the paraspinal musculature. This tissue trauma may be a contributing factor to patients’ chronic pain after surgery
Winner of the Richard O'Connor Research Award from the Arthroscopy Association of North America 2017. This study demonstrates major improvement in the outcome of ACL reconstruction when an extra-articular procedure (ALL reconstruction) is also performed. The full manuscript is published in AJSM. Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI (Scientific ACL NeTwork International) Study Group
Arthroplasty: Present practices by DR. D. P. SWAMI DR. D. P. SWAMI
COMPARISON OF DIFFERENT APPROACHES FOR HIP REPLACEMENT, DIFFERENT ASPECTS OF OVERLAPPING SURGERIES IN TKR AND TEST FOR CONTAMINATION IN OPERATION THEATER
this is a talk about the ongoing debate of what to do in the management of pelvic fractures with haemodynamic instability
a revision of literature to see the best sequence of events ..
Muscle tears are extremely common and are often recurrent. They are not as simple as we used to think and the advent of better imaging has proven that the site, size and location of the tear, together with the presence or otherwise of the tendon is crucial information especially for elite or professional athletes, who need accurate information about return to play. Traditional treatments of electrotherapy are simply placebos. The challenge ahead is to optimise treatments for the various diagnostic categories.
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Hot Selling Organic intermediates
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
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The four main behavioral effects of AUD are impaired control over
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of the prevalence and harmful consequences of AUD in the U.S.,
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comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
AC Joint Injury Update
1. AC Joint Injury Update
Cherry Blossom Seminar
April 6, 2013
J.R. Rudzki, MD
Washington Orthopaedics & Sports Medicine
Clinical Assistant Professor
Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Washington, DC
2. Disclosure
Previous direct & indirect funding & support for
research & education from:
• Philips Medical Imaging
• Bristol-Myers-Squib
• Smith & Nephew
• NIH (CT Chen)
• HSS Institute for Sports Medicine Research
• Major League Baseball
Arthrex – Consultant
AJSM, JBJS – Reviewer
AAOS – Evaluation Committee
3. Introduction Background
High incidence of distal clavicular & A-C injuries in contact
sports at all levels.
Flik et al., AJSM 2005
Frequently amenable to
conservative management
Controversy regarding operative indications for
Type III AC Separations & Distal Clavicle Fractures
Potentially significant cause of
missed time from play
Emery et al., AJSM 2006
AC Separation & Dislocation:
- up to 40% of shoulder injuries in
elite athletes participating in
competitive contact sports
Mazzocca et al., AJSM 2007
4. • Resist 90% of A-P translation
& joint distraction
Fukuda et al., JBJS 1986; Klimkiewicz et al., JSES 1999
• Horizontal Stabilizer
• At large displacements, Trapezoid resists ~75% of AC joint
compression & Conoid is primary restraint to superior translation
• Vertical Stabilizer
Ligamentous Anatomy Background
• Posterior & Superior AC capsular
ligaments provide greatest stability
- clinically impt for distal clavicle resection
5. Newer Studies
Better Data
Enhanced Understanding of
Anatomy & Biomechanics
2013
Broader Array of Repair
& Reconstructive Options
Technological
Advances
More impt than ever to be clear on
indications for surgery & best approach
for each patient
6. Radiographic Assessment
AP
– 1.1-1.3 cm from
coracoid to clavicle
Zanca
– 10-15° cephalad
– AC joint 0.5-3mm
Axillary
– Anterior or posterior
displacement
Tauber & Resch et al., AJSM 2010
7. A-C Joint Injury Classification
Nuber & Bowen, JAAOS 1997
Williams GR, Nguyen VD, Rockwood CA Jr.
Classification and radiographic analysis of
acromioclavicular dislocations. Appl Radiol. 1989;12:29-34
Type I - AC ligament complex sprain
without ligamentous disruption
Type II - disruption of AC ligament
complex & capsule, up to 50%
vertical subluxation of distal clavicle
Type III - both AC & CC ligaments
disrupted, complete dislocation of
AC joint
Type IV - distal clavicle displaced
Posteriorly
Type V - extreme superior
displacement of clavicle (100%-300%)
complete disruption of delto-trapezial
fascia distally
Type VI - distal clavicle displaced
Subcoracoid or Subacromial
8. Types I & II
Conservative
Mgmnt
Sling x 1-2 wks
Passive Supine FE, ER
Gradual Progression to
AAROM
Return to Play ~2-6wks
AC Separation / Dislocation
Type III
Acute
*** Index of Suspicion
for Concomitant Intra-
articular Pathology ***
Berg et al.,
Arthroscopy 1997
Gladstone & Wilk et al.,
Oper Tech Sports Med, 1997
Role of
NSAIDs?
9. Types IV-VI
AC Separation / Dislocation
• Mod Weaver-Dunn +/- Graft
• Open Anatomic Reconstruction
• (Mazzocca Technique)
• Arthroscopic Reconstruction
Operative
Treatment
Type III
Chronic
&
Symptomatic
10. Treatment trends:
Schlegel T, et al.
Grade III acromioclavicular
separations in NFL quarterbacks.
NFL Physicians Annual Meeting.
Indianapolis; 2000.
–8 professional quarterbacks
over 10 yr period
–5 returned to play in 5 wks
treated conservatively
–3 required surgical treatment
Controversy Regarding Type III Outcomes
11. Controversy Regarding Type III Outcomes
Study Design: 20 pts with Grade III injuries followed for one
year with strength assessment & subjective questionnaire
•17 men, 3 women; Avg Age =36
• Variable age, work, & recreational activity levels
• Compared to 10 uninjured “controls”
Schlegel et al., AJSM 2001
• 16/20 pts (80%): “acceptable” outcome at one year
• 4/20 (20%): poor outcome; did not warrant surgical intervention
Results:
• 17% weaker on injured extremity 1 year after injury (Bench Press)
• But No difference in Rotational Strength
12. Controversy Regarding Type III Outcomes
Literature Review –
Swinging Pendulum
• Powers, CORR, 1974: 82% of Residency
Chairman treat Type III injuries operatively
• McFarland, Am J Orth, 1997: 69% of 42 MLB Team Physicians
Conservative Tx for professional throwers; 31% Operative Tx
• 80% of 20 Pitchers treated non-operatively – Full Fxn & Pain-Free
• 92% of 12 Pitchers treated operatively – Full Fxn & Pain-Free
• Phillips, CORR, 1998: 1172 pts studied in Meta Analysis
• 88% Operative
• 87% Conservative
Satisfactory Outcomes
13. Controversy Regarding Type III Outcomes
Literature Review
• Tibone, AJSM, 1992: 20 pts, Nonop Tx for Grade III
• No strength difference btwn injured/noninjuried UE’s
• 31% reported mild pain but “did not limit participation”
• Wojtys & Nelson, CORR, 1991: 22 pts,
Nonop Tx for Grade III
• No strength difference btwn injured/noninjuried UE’s
• 50% rated outcome as fair or poor
• Larsen, JBJS, 1986: 41 pts, Prospective Randomized
• No clinical difference in outcome
• Non-surgical patients returned to work earlier
15. Limitations of Literature
Difficult to define optimal management of these
injuries based on currently available literature
Numerous
• Small sample sizes; variable inclusion/exclusion criteria
• Short Follow-Up
• Retrospective Reviews, Case Series, Surveys…
• Recall Bias • Selection Bias
• Non-validated Outcomes Instruments
• Detection Bias
• Susceptibility Bias
16. Only 9 of 469 articles compare
Operative vs. Non-Operative Tx:
• 3 Prospective, Randomized Studies (Level II)
• 6 Retrospective Studies
CORR, 2006
Current Consensus:
While the treatment of Type III injuries remains controversial, the
data currently available indicate that the two treatments may be
equivalent, but non-operative management may be favorable for
its decreased risk of complications
17. Types I & II Types IV-VI
Conservative
Mgmnt
Sling x 1-2 wks
Passive Supine FE, ER
Gradual Progression to
AAROM
Return to Play ~2-6wks
AC Separation / Dislocation
• Mod Weaver-Dunn +/- Graft
• Open Anatomic Reconstruction
• (Mazzocca Technique)
• Arthroscopic Reconstruction
Operative
Treatment
Type III
Chronic
&
Symptomatic
Acute
20. AC Injury Summary
Key Take-Home Points
• Some advocate surgical intervention for
Type III & V in:
• Types I-III, V: Good-Excellent Results in
majority of players at all levels
• Minimal Functional Deficit, if any
• Relatively Rapid Return to Play
• Delayed reconstruction available if symptomatic
• Types IV & VI: Surgical intervention indicated
• Overhead athletes
• Laborers
• High-demand individuals
21. Growing body of evidence to support move away
from Modified Weaver-Dunn
Prospective cohort study of 24 pts
Mean F/U: 37 months
ASES & Constant Scores better in ST Graft Group (P<0.05)
Stress-loading more favorable in ST Group (P<0.05)
Non-anatomic
Less stable reduction
AJSM, 2009
Semitendinosus graft resulted in significantly superior clinical
& radiologic outcomes compared to modified Weaver-Dunn
22. In this study, better results were achieved by surgical treatment
with the hook plate.
Retrospective case-control study, 50 pts (82% follow-up @ 34 mos.)
24 pts – Hook Plate vs. 17 pts – Conservative Mgmt
Oxford & Constant Scores, SST
Stress Radiographs
Hook Plate Non-operative
Constant
Score
90.4 80.7
Mean CC
Distance
(stress XR)
12.1 mm 15.9 mm
(P <.05, Mann-Whitney U test & Student’s t test)
Gstettner & Resch et al., JSES 2008
Conclusions:
23. “pts were told that there were no evidence-based medical guidelines for treatment of
Rockwood type III injuries on the whole but that,
in the international literature, surgery was
recommended in young, active patients with high
demands on shoulder function.”
Retrospective case-control study, 50 pts (82% follow-up @ 34 mos.)
24 pts – Hook Plate vs. 17 pts – Conservative Mgmt
Oxford & Constant Scores, SST & Stress Radiographs
Gstettner & Resch et al., JSES 2008
Complications: 1 Hematoma
2 Infections (1 superficial)
1 Acromial Osteolysis
17%
24. Cadaveric Study, 2 Groups
- 60 matched pairs (Hamann-Todd)
- 19 fresh-frozen shoulders
Distance from lateral clavicle to medial
conoid tuberosity: ~45 mm (P < .05)
Distance to center of trapezoid
tuberosity: ~ 25 mm (P < .05)
Mazzocca et al., AJSM 2007
Background
25. JSES, 2009
Ligamentous Anatomy & Reconstruction
Resection of distal clavicle may be detrimental
Repair of AC Capsule appears to be beneficial
Biomechanical study, 6 matched pairs
Measurement of AC Joint Translation: AP & Superior-Inferior
- Compressive & Translational Loading
- AC & CC Ligament transection
Compression significantly decreased translation (P<0.05)
26. Biomechanical study, 5 cadaveric shoulders
Static loads (80 & 210 N) applied to
clavicle in 5 directions:
anterior, anterosuperior, superior,
posterosuperior, & posterior
in situ graft force measured:
1) intact AC ligaments
2) sectioned AC ligaments
3) distal clavicle excision
AJSM, 2010
27. Biomechanical study, 5 cadaveric shoulders
Static loads (80 & 210 N) applied to
clavicle in 5 directions:
anterior, anterosuperior, superior,
posterosuperior, & posterior
Distal clavicle excision
did not further increase
in situ graft forces
Distal clavicle excision
increased in situ
graft forces
For both magnitudes of load, in all directions,in situ graft
force with intact AC ligaments was significantly less (P<.001)
AJSM, 2010
Reconstruction of AC ligaments may serve impt role in
decreasing in situ graft force during healing
28. Surgical Techniques - Tightrope
Salzmann et al., AJSM 2010
Consecutive case series, 23 pts
Type III-V AC Injuries
Mean F/U: 31 months Mean Age: 38
VAS, Constant Score, SST, SF-36
VAS & Constant score showed significant
improvements from preoperative 4.5 +/- 1.9
and 34.3+/- 6.9 to postoperative 0.25 +/-
0.5 and 94.3 +/- 3.2 at 24 months,
respectively.
Postop radiographic AC alignment was
unsatisfactory in 8 cases with no different
clinical outcome when compared with the
remaining patients
29. Surgical Techniques - Tightrope
Salzmann et al., AJSM 2010
Consecutive case series, 23 pts
Mean F/U: 31 months Mean Age: 38
Tunnel and button placement are of utmost importance
to avoid postoperative failure or loss of reduction.
Immediate anatomical reduction of an acute AC
separation with flip-button devices provides
satisfactory clinical results at intermediate-term
follow-up.
1 Infection
1 Coracoid Fracture
1 Implant Failure
(?non-compliance)
30. Surgical Techniques - Graftrope
Preliminary Study
•10 Cases, 6 month F/U
• No infxn, hardware/graft failure,
or loss of reduction
Deberardino et al., JSES 2010
34. Surgical Techniques – Anatomic Reconstruction
Biomechanical Study; 30 Cadaveric Specimens
• Modified Weaver-Dunn
• Nonanatomic allograft
• Anatomic allograft
• Anatomic suture
• GraftRope
5 Groups + Control:
AJSM, 2011
Conclusion:
The anatomic allograft reconstruction has superior initial
biomechanical properties by comparison
Highest
load to failure
(P < 0.05)
2nd Highest
load to failure (646 N vs. 948 N)
35. Surgical Techniques – Anatomic
Reconstruction
• Anatomic Studies
• Biomechanical Data
• Limited Clinical Data
Current Data:
36. Not Currently a Clear Choice
AJSM, 2012
Level IV Case Series – 27 cases: 10 = Coracoid Tunnel & 17 = Loop
8 complications (80%) in Coracoid Tunnel Group:
- 2 coracoid fractures (20%)
- 5 pts with loss of reduction (> 5-mm increased CC interval displacement
on subsequent postop radiographs) (50%)
- 1 pt with an intraoperative failure of the coracoid button (10%).
6 pts developed complications in Coracoid Loop Group (35%):
- 3 clavicle fractures (18% within group, 11% overall)
- 2 pts with loss of reduction (12%)
- 1 infection (6%)
- 1 pt with adhesive capsulitis
37. AJSM, 2012
Level IV Case Series – 28 cases: 14 = Open & 14 = Scope-Assisted
Overall failure rate was 28.6% (8/28) at avg of 7.4 wks postop
Medialized bone tunnels were a significant predictor for early loss of reduction
38. Biomechanical Study; 6 Cadaveric Pairs
Mean AP translation of CC/AC reconstruction
50% or less than that of the CC reconstruction
in all loading conditions (P < .05)
No Difference for:
Mean superior-inferior translation
Overall load-to-failure testing
Intramedullary AC complex reconstruction utilizing free-tissue graft
for both CC & AC ligaments demonstrates significantly greater
initial horizontal stability & is similar to intact specimens
Conclusions:
AJSM, 2010
40. AC & Distal Clavicle Injury Update
Cherry Blossom Seminar
April 6, 2013
J.R. Rudzki, MD
Washington Orthopaedics & Sports Medicine
Clinical Assistant Professor
Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Washington, DC
Thank
You