This document discusses the management of AC joint dislocations. It notes that while literature indicates surgery for type 4, 5, and 6 dislocations, classification using radiographs is unreliable. Further, clinical results are comparable between operative and non-operative treatment, but complications are more common with surgery. The author's indications for surgery are for those who cannot cope functionally or with work/social demands, such as overhead athletes. His experience using the LARS ligament for AC joint reconstruction is described along with postoperative rehabilitation phases and results showing a mean 15% reduction in displacement and low complication rates. Revision procedures for failed reconstructions also have good results.

1. MANAGEMENT OF
ACJ DISLOCATIONS
Lennard Funk

2. DISCLAIMER:
I have not:
Received any funding or royalties from Corin
Been involved in the development of the LARS

3. DECISIONS:
Should we operate?
Why?
Who?
When?
(How?)

4. INDICATIONS FOR
STABILISATION
Literature = Type 4, 5 & 6

5. “The classi
fi
cation of AC joint injuries using a
radiographs has limited reliability and
consistency in clinical practice.”

6. CECCARELLI 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.“

7. BRADLEY & ELKOUSY,
CLIN SPORT MED, 2003
“The only advantage to operative intervention
consistently borne out in the literature is an
increased probability of anatomic reduction.
There is no correlation between reduction and
improvement in pain, strength, or motion.”

8. DECISIONS:
1. Grade not relevant
2. Many do well without surgery
3. High surgical complication rate
4. Some do not:
–
High functional demand
–
Locked scapula
–
Shocked Scapula (Unstable)

9. MY INDICATIONS
= ‘NON-COPER’
Can they cope with:
Functional Demands
Work demands
Society demands
Overhead Athlete

10. Review
3 weeks
APPROACH
Acute Injury
< 1 week
Review
3 months Surgery
Coping Not Coping

11. MY EXPERIENCE
2001 2008

12. REVISIONS !!!

13. ATHLETES

16. 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
fl
exion [Fialka et al. 2005;
Vascularisation & Fibrous ingrowth - Collagen Type 1
[Trieb et al. Eur Surg Res. 2004;Yu et al. 2005; Pelletier & Durand]

17. X-RAYS -
DAY 1, 3 WEEKS, 3 MONTHS, 1YR, 2YRS
Shoulderdoc.co.uk Shoulderdoc.co.uk

18. Shoulderdoc.co.uk Shoulderdoc.co.uk

20. 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-speci
fi
c rehabilitation - Plyometrics and pertubation training
Phase 3: (Level 3+ Exercises)
Regain scapula & glenohumeral stability working for shoulder joint control rather
than range
Gradually Strengthen
POST-OP

21. RESULTS
Three year period (2006-2010)
55 patients full data sets
12 Acute; 43 Chronic
Mean age of 36 yrs old
226 cases from 2006-2015

23. OUTCOME SCORES

24. REDUCTION
Mean post-op displacement =15%
B
A
Displacement = A/B x 100

25. COMPLICATIONS
Out of 226 cases from 2006-2015:
8 redisplacements [4%] - (over 3months then settles)
2 early failures after excess activity
2 late coracoid fractures (8m & 15m) - Rugby
1 Deep infection
1 late clavicle fracture (traumatic)

26. REVISION PROCEDURES
‘BICEP FLIP’
Vargas, JBJS, 1942
Brunelli, Int Orth, 1988
Crichton, IJSS, 2009
Strauss, 2010

27. OUR DATA
DESAIS, ROBINSON, PHANDIS, FUNK
IN PRINT, 2016
• 23 revisions betw. 2008 - 2015
• Mean Age = 32yrs (20-57)
• M:F = 18:5

28. Original Procedure N/23
Tightrope or equivalent 6
Lockdown / Surgilig 6
LARS 4
Weaver-Dunn 3
Hook Plate 3
Bosworth Screw 1
OUR DATA
DESAIS, ROBINSON, PHANDIS, FUNK
IN PRINT, 2016

29. RESULTS (FAILED
RECONSTRUCTIONS)
23 cases over 7 years
Follow-up = 37 months (24-48)
Constant Score = 51.8 pre to 85.2 post
10% re-displaced radiologically
13% super
fi
cial infections
No further revisions

30. RESULTS (FAILED EXCISIONS)
DESAIS, ROBINSON, PHANDIS, FUNK
IN PRINT, 2016
! 13 cases over 5 years
! Follow-up = 34 months (24-48)
! Constant Score = 26 pre to 73 post
! 1 re-displaced radiologically
! 1 chronic pain
! No further revisions

31. SUMMARY
Open - Repair all structures
LARS - Strongest,Anatomical, Biological
My Technique - Standard or Modi
fi
ed to Patient
Modi
fi
cations
Results

32. THANKYOU
lenfunk@shoulderdoc.co.uk