This document discusses the importance of the acromioclavicular joint (ACJ) for overhead athletes and its potential implications following injuries. It notes that 30% of overhead athletes had to reduce their sport and 9% had to change sports following ACJ dislocations. The document also examines indications for ACJ stabilization, different surgical procedures, post-operative rehabilitation protocols, and modifications to standard repair techniques.

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AC Joint "
Dislocations & Instability
!
Is the ACJ Important?
Rangger et al. Orthopade 2002 Jun;
31(6):587-90
! YES – for overhead athletes:
! Following ACJ Dislocations:
! 30% of overhead athletes had to
reduce sport
! 9% had to change sport
! Climbers and patients performing
strength training had to reduce their
activities or give up sports
! Altered activities in overhead ball sports
Is the ACJ Important?
Cox. Am J Sports Med, 1981
! YES – for high demand professions:
! Following ACJ Injuries:
! 164 US Naval Cadets
! Residual symptoms found at 6 month follow-up:
! 36% of Grade 1
! 48% of Grade 2
! Major in 13%
! Minor in 35%
! 69% of Grade 3
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Indications for Stabilisation
! Literature = Type 4, 5 & 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. "
! Since there is not a preponderance of positive papers showing the benefits of a
surgical technique over conservative therapy, the nonoperative treatment is still
considered a valid procedure in the grade III acromioclavicular separation.
! More prospective randomized studies using validated outcome measures are needed to
identify the suitable operation techniques for the acute injuries.
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What are we trying to achieve?
• A pain free & stable shoulder "
that has enough mobility, strength "
& muscle control for a patient s "
desired level of activity & participation
• Peter Rheinlaender
My indications
! Patient Demands
! Work demands
! Society demands
! Overhead Athlete
Approach
Acute Injury
< 1 week
Review
3 weeks
Coping
Not Coping
Review"
3 months
Surgery
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Surgical procedures
Coracoclavicular "
Ligaments
Harris et. al. Am J Sports Med. 2000
! Strength – 500N (+/- 134)
! Stiffness – 103N/mm (+/- 30)
! Uniaxial Tension 25mm/min
Harris et al. AJSM 2000
• None of the reconstruction techniques analyzed in
the present study were able to restore the normal
mechanical function of the intact coracoclavicular
ligament complex
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ACJ Ligaments
Fukuda et al. JBJSA. 1986
! Two thirds of the superior stability
for lesser displacements
! 90% the posterior stability
Dynamic Stability
! Delto-trapezial fascia
Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury.
1980; DePalma. 1973; Urist. JBJS 1963.
Lizaur et al. JBJS. 1994
My Experience
2001
2008
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Revisions !!!
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
flexion [Fialka et al. 2005;
! Vascularisation & Fibrous ingrowth - Collagen Type 1
[Trieb et al. Eur Surg Res. 2004; Yu et al. 2005; Pelletier & Durand]
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Standard repair
Shoulderdoc.co.uk
Modification 1
Shoulderdoc.co.uk
Modification 2
Shoulderdoc.co.uk
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Closure
! Repair the Superior AC Ligaments
! Repair the Delto-Trapezial Fascia
x-rays - "
Day 1, 3 weeks, 3 months, 1yr, 2yrs
Shoulderdoc.co.uk
Shoulderdoc.co.uk
Shoulderdoc.co.uk
Shoulderdoc.co.uk
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POST-OP
! 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-specific rehabilitation - Plyometrics and pertubation training
! Phase 3: (Level 3+ Exercises)
! Regain scapula & glenohumeral stability working for shoulder joint control
rather than range
! Gradually Strengthen
THANK YOU
• lenfunk@shoulderdoc.co.uk
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