The document discusses the classification and treatment of AC joint injuries. It notes that the Rockwood classification of these injuries using radiographs alone has limitations. For grade III separations, the literature finds comparable results between operative and non-operative treatments, though complications are more common with surgery. For high-demand athletes, ongoing symptoms are reported in a high percentage even with minor grades of injury. The document outlines surgical procedures for AC joint injuries, including coracoclavicular ligament reconstruction techniques, and notes the author's experience with the LARS ligament reconstruction.

1. 23/03/2013
ACJ Injury Rugby
Lennard Funk
1 2
3 4
Rockwood
Questions:
Classification
 What is the Grade?
 Should we operate?
 Why?
 When?
 How?
5 6
1

2. 23/03/2013
What Grade?
 We conclude that the classification of AC joint
injuries using a radiograph alone has limited
reliability and consistency in clinical practice.
7 8
Indications for Stabilisation Treatment?
 Literature = Type 4, 5 & 6
 Operative
 Non-operative
When?
9 10
Ceccarelli et al. 2008 Bradley & Elkousy, Clin Sport Med, 2003
 The only advantage to operative
intervention consistently borne out in the
 From the literature evaluation, clinical results seem to be comparable
between the operative and the conservative treatments, literature is an increased probability of
but complications are more evident in the surgery group.
anatomic reduction.
Since there is not a preponderance of positive papers showing the benefits
 There is no correlation between reduction

of a surgical technique over conservative therapy, the nonoperative treatment is
still considered a valid procedure in the grade III acromioclavicular separation.
and improvement in pain, strength, or
 More prospective randomized studies using validated outcome measures are
needed to identify the suitable operation techniques for the acute injuries. motion, however.
11 12
2

3. 23/03/2013
Athletes Rangger et al. Orthopade 2002
Jun;31(6):587-90
High Demand Cox. Am J Sports Med, 1981
 Following ACJ Dislocations:
 30% of overhead athletes had  164 US Naval Cadets
to reduce sport
 Ongoing symptoms at 6 months:
 9% had to change sport
 36% of Grade 1
 Climbers and patients
performing strength training  48% of Grade 2
had to reduce their activities or  Major in 13%
give up sports  Minor in 35%
 Altered activities in overhead  69% of Grade 3
ball sports
13 14
What about rugby? Indications
 Often able to play
 Unable to train • Symptoms(
 Modern day expectations • Pa+ent(Demands(
– Work(demands(
– Society(demands(
• Overhead(Athlete(
15 16
Approach Surgical procedures
Acute Injury
< 1 week
Review
3 weeks
Coping Not Coping
Review
3 months Surgery
17 18
3

4. 23/03/2013
Coracoclavicular
Harris et al. AJSM 2000
Ligaments
Harris et. al. Am J Sports Med. 2000
 Strength – 500N (+/- 134)
 Stiffness – 103N/mm (+/-
30)
 Uniaxial Tension 25mm/min
None of the reconstruction techniques analyzed
in the present study were able to restore the
normal mechanical function of the intact
coracoclavicular ligament complex
19 20
ACJ Ligaments
Fukuda et al. JBJSA. 1986
Dynamic Stability
 Two thirds of the superior  Delto-trapezial fascia
stability for lesser Fukuda et al. JBJSA. 1986: Copeland & Kessel.
Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
displacements
 90% the posterior stability
Lizaur et al. JBJS. 1994
21 22
My Experience
2001 2006
23 24
4

5. 23/03/2013
LARS Ligament (Corin) LARS Ligament
 Braided Polyethylenetraphthalate
 1500N tensile strength (30 LAC)
 No reduction in mechanical resilience
after over 10 million wear cycles loaded
in torsion, traction and flexion [Fialka et al. 2005;
 Vascularisation & Fibrous ingrowth -
Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005;
Pelletier & Durand]
25 26
3 weeks post-op LARS Ligament Outcomes
Wright & Funk, 2010. BESS
27 28
LARS Ligament Outcomes LARS Ligament Outcomes
 All patients returned to their previous level of work &  The median postoperative residual displacement of the ACJ
sports post LARS reconstruction in a mean time of 3 was 15%.
months
 The mean patient satisfaction score was 93%
 In one patient who did not follow the prescribed
rehabilitation protocol the reconstruction failed in the
early postoperative period.
29 30
5

6. 23/03/2013
31
6