ac joint dislocation

1. SUKESH .A N
JUNIOR RESIDENT ORTHOPAEDICS
TDMC ALAPUZHA
case

2.  Mathew 55 yrs
 h/0 RTA 1 week
 c/o pain & swelling left shoulder
 Bony prominence over lateral end of left
clavicle
 Difficulty in raising left arm
 ACROMIO-CLAVICULAR JOINT DISLOCATION

3. MATHEW

4. Preop x ray

5. STRAP INCISION

6. JOINT DISLOCATION

7. JOINT REDUCTION

8. CLAVICLE TO BASE OF
CORACOID

10. K WIRE FIXATION

11. Post op xray

12. Acromioclavicular Joint
update

13.  9% of shoulder girdle injuries
 Generally occurs in males age 20-
30

14. ANATOMY
 The AC joint is a diarthrodial joint.
 Located between the lateral end of the clavicle
and the medial acromion.
 The AC ligaments (anterior, posterior, superior,
inferior) strengthen the thin capsule
 Fibers of the deltoid and trapezius muscles blend
with the superior AC ligament to strengthen the
joint
 The horizontal stability of the AC joint - by the AC
ligaments.
 The vertical stability - by the CC /coracoclavicular
ligaments.

15. MECHANISM OF INJURY
 Direct: This is the most common mechanism,
resulting from a fall onto the shoulder with the
arm adducted.
 Indirect: A fall onto an outstretched hand with
force transmission through the humeral head and
into the AC articulation

16. PHYSICAL FINDINGS
 Pain over lateral clavicle / AC joint
 Prominent distal clavicle
 May have skin abrasions
 Unable to lift arm.
 A mobile distal clavicle

17. Radiographic Evaluation of the
Acromioclavicular Joint
 Anteroposterior view
 Stress veiw (3-4kg weight tied to
wrist for complete muscle relaxation
)
 Zanca view (15 degree cephalic tilt)

18. CLASSIFICATION
 Initially classified by both Allman and Tossy et
al. into three types (I, II, and III).
 Rockwood added types IV, V, and VI, so that
now six types are recognized.
 Classified depending on the degree and
direction of displacement of the distal clavicle.

19. Type I
 Sprain of
acromioclavicular
ligament
 AC joint intact
 Coracoclavicular
ligaments intact
 Deltoid and trapezius
muscles intact

20.  AC joint disrupted
 < 50% Vertical
displacement
 Sprain of the
coracoclavicular
ligaments
 CC ligaments intact
 Deltoid and trapezius
muscles intact
Type II

21. Type III
 AC ligaments and CC
ligaments all disrupted
 AC joint dislocated and
the shoulder complex
displaced inferiorly
 CC interspace greater
than the normal
shoulder(25-100%)
 Deltoid and trapezius
muscles usually
detached from the
distal clavicle

22. Type III Variants
 “Pseudo-dislocation” through an intact
periosteal sleeve
 Physeal injury
 Coracoid process fracture

23. Type IV
 AC and CC ligaments
disrupted
 AC joint dislocated and
clavicle displaced
posteriorly into or
through the trapezius
muscle
 Deltoid and trapezius
muscles detached
from the distal clavicle

24. Type V
 AC ligaments disrupted
 CC ligaments disrupted
 AC joint dislocated and
gross disparity
between the clavicle
and the scapula (100-
300%)
 Deltoid and trapezius
muscles detached from
the distal half of
clavicle

25. Type VI
 AC joint dislocated and
clavicle displaced
inferior to the acromion
or the coracoid process
 AC and CC ligaments
disrupted
 Deltoid and trapezius
muscles detached from
the distal clavicle

26. TREATMENT
 Type I: Rest for 7 to 10 days, ice packs,
sling. Refrain from full activity until
painless, full range of motion (2 weeks).
 Type II: Sling for 1 to 2 weeks, gentle
range of motion as soon as possible.
Refrain from heavy activity for 6 weeks

27.  Type III:
 For inactive, nonlaboring patients nonoperative
treatment is indicated:
 Younger, more active patients with more severe
degrees of displacement and laborers who use their
upper extremity above the horizontal plane may
benefit from operative stabilization.
 Type IV, V,& IV:
 Open reduction and surgical repair of the
coracoclavicular ligaments are performed for
vertical stability

28.  Type III Injuries: Need for acute surgical
treatment remains controversial.
 Most surgeons recommend conservative
treatment except in the throwing athlete or
overhead worker.
 Repair generally avoided in contact athletes
because of the risk of reinjury.

29. Literature unable to support operative or
nonoperative treatment as superior
 Functional outcomes appear similar.
 Cosmesis not different (scar vs bump)
 Only 50% of surgical cases reduced at follow-up.
 10% complications after surgery.
Ceccarelli et al. J Orthopaed Traumatol
2008;9:105-108.

30. SURGICAL MANAGEMENT
 Should fulfill 3 requirements:
 1. ac joint must be exposed & debrided
 2.coracoclavicular & acromioclavicular ligaments
must be repaired or reconstructed
 3.stable reduction of ac joint
Campell 12th edition chapter 60 page 30

31. MANAGEMENT
 5 major categories:
1.Ac reduction & fixation
2.Ac reduction,cc ligament repair & cc
fixation
3.Combination of 1 & 2
4.Distal clavicle excision
5.Muscle transfers
Campell 12th edition chapter 60 page 3029

32.  Campell describe,
 MAZZOCCA TECHNIQUE
-anatomic reconstruction of conoid &
trapezoid ligaments
-autologous semitendinosus graft
preferred,reconstruction with suture
tape
-biomechanical studies by mazzoca
demonstrated superior fixation
compared with pin fixation or repair

33. BOSWORTH TECHNIQUE

34. CLAVICULAR HOOK PLATE

35. REPAIR & TIGHT ROPE AUGMENTATION

38. LARS LIGAMENT
 Synthetic Ligament
 Made of polyethylene terephthalate
 Longitudinal-running fibres that match the
structure of native human tissue.
 LARS ligament reproduces the anatomy and
mechanics of the torn coracoclavicular ligament

39. SURGILIG RECONSTRUCTION

40. SURGILIG RECONSTRUCTION
 Surgilig is an artificial ligament
 It is made of double braided
polyester with a patented weave
design which acts as a scaffold
encouraging tissue in-growth

41. Other neo ligaments
 ROTA LOK system
 KEIO LEEDS system
 All are poly ester artificial ligaments

42. Techniques for Late Surgical
Treatment of Acromioclavicular
Injuries
 Reduction of AC joint and repair of AC and CC
ligaments
 Resection of distal clavicle and reconstruction of
CC ligaments (Weaver-Dunn Procedure)

43. WEAVER-DUNN PROCEDURE
 The distal clavicle is
excised.
 The CA ligament is
transferred to the distal
clavicle.
 The CC ligaments are
repaired and/or augmented
with a coracoclavicular
screw or suture.
 Repair of deltotrapezial
fascia
 Young patients,elderly with

44. Surgery versus Sling for AC Joint
Dislocations
 Study finds hook plate fixation is not superior to
nonsurgical treatment for acute injuries
(AAOS Now December 2012 .Maureen
Leahy)

45. Reconstruction for neglected
cases
 Grafts used
 Semitendinosis
 Gracilis
 Allografts
• Used as a single or double bundle to
reconstruct the coracoclavicular ligament.
• Synthetic ligaments like LARS or Surgilig
can be used for reconstruction

46. Complications of AC Joint
dislocations
 AC joint Arthritis
 Cosmetic
 Scapular Dyskinesia
 SICK scapula syndrome
 # Clavicle ,# Coracoid
 Implant Failure
 Infection
 Shoulder stiffness
 Rotator cuff problems

47. SICK Scapula syndrome
 SICK Scapula syndrome
 S- Scapular malposition
 I-I nferomedial prominence of Scapula
 C- Coracoid pain
 K- Kinesial abnormalities of scapula

48. Arch Orthop Trauma Surg. 2013 Jul;133(7):
 In addition to the correct type of injury therapy
strategies should be adapted to patient's demands
and compliance.
 A certain debate is still ongoing regarding type III
injuries
 non-operative treatment of type III injuries results to
provide equal functional outcomes as compared to
surgical treatment associated with less complications
 If surgical treatment is indicated, open surgical
procedures using pins, PDS-slings or hook plates
are still widely used concurring with recent minimally
invasive, arthroscopic techniques using new
implants designed to remain in situ.

49. 2013 Arthroscopy Association of North America. Published by
Elsevier Inc
 3 considerations in determining treatment options for
patients with acromioclavicular (AC) joint dislocations:
 (1) operative versus nonoperative management,
 (2) early versus delayed surgical intervention, and
 (3) anatomic versus non anatomic techniques
-There is a lack of evidence to support treatment options
for patients with AC joint dislocations.
- Although there is a general consensus for nonoperative
treatment of Rockwood type I and II lesions,
-initial nonsurgical treatment of type III lesions, and
operative intervention for Rockwood type IV to VI lesions,
-further research is needed to determine if differences
exist regarding early versus delayed surgical
intervention and anatomic vs nonanatomic surgical
techniques

50. Journal of Orthopaedic Surgery and Research 2015
 Treatment options should be thoroughly
discussed with patients, weighing all
subjective, objective and radiographic
outcomes and the relative advantages of
each option.

51. THANK YOU