This document discusses ACJ revision surgery. It provides information on the functional anatomy of the AC joint, causes of failed ACJ excision or reconstruction, and describes a technique for ACJ revision surgery. The technique involves removing scar tissue from previous procedures, taking micro samples, performing an anatomical reconstruction of the CC and AC ligaments using LARS ligaments and a biceps flip or CAL transfer, and performing a delto-trapezial reefing. Results from 23 revision cases over 7 years showed improved Constant scores, low rates of re-displacement and infection, and no need for further revision after a mean follow up of 37 months.

1. ACJ Revision Surgery
Lennard Funk

3. Functional Anatomy
3
1.5mm
Beardon

4. ! Superior AC Lig = 56% Posterior Translation
! Posterior AC Lig = 25% Posterior Translation
! Klimkiewikcz
! Superior AC Lig = Rotational Stability
! Branch et al.
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AC Ligaments
Urist, JBJSA. 1946

5. AC Ligaments
5
! Attaches over 2.6cm of clavicle in men, 2.3cm in
women
! Renfree & Wright
! (1.5cm - Hearnden 2012)
! No difference if superior or inferior AC lig. cut
(horizontal, vertical & rotatory)
! Branch et al. AJSM 1996
! Superior & Posterior not capable of stabilising
clavicle - 32% incr. of posterior translation after
Ant & Inf capsular resection
! Corteen & Teitge

6. Failed ACJ Excision (Basmania, 1995)
1. Diagnostic Error
2. Inadequate resection
3. Joint Instability
4. Weakness
5. Miscellaneous
6

7. Failed ACJ Excision (Strauss et al. 2010)
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Common Causes Less Common Causes
Instability Distal Clavicle Fracture
Under Resection Suprascapular neuropathy
Over Resection Other Cause
- Neck pain, SLAP, etc.
Stiffness (29%)
Bony regrowth
Untreated Concomitant
Pathology
Infection

8. Failed ACJ Excision (Funk, 2014)
8
Common Causes Less Common Causes
Instability - 22% Distal Clavicle Fracture
Under Resection - 3% Suprascapular neuropathy
Over Resection - 8% Other Cause
- Neck pain, SLAP, etc.
Stiffness - 12%
Bony regrowth
Untreated Concomitant
Pathology - 4%
Infection - 0.8%

9. Also:
! Post-op pain correlates with Translation,
but not amount of bone resected
! Blazar et al. CORR. 1998
! No difference if superior or inferior AC lig.
cut (horizontal, vertical & rotatory instability)
! Branch et al. AJSM 1996
9

10. Unstable ACJ
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11. ACJ Reconstructions
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>100 PUBLISHED!!

12. 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”
12

13. Our Data
Desais, Robinson, Phandis, Funk
In print, 2016
• 23 revisions betw. 2008 - 2015
• Mean Age = 32yrs (20-57)
• M:F = 18:5
13

14. 14
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

15. Revision Technique
! Anatomical Reconstruction
! Very strong, but flexible
! Allows early Rehab.
! Biological
! Avoid donor site
! Allows variable options
15

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 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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17. Incision
17
Shoulderdoc.co.uk

18. Nottingham Approach
18
Shoulderdoc.co.uk

19. Procedure(s)
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"# Remove all previous fix & Scar tissue
$# Micro samples
%# CC Ligs - LARS anatomical + ‘Biceps Flip’
&# AC Ligs - LARS + Reverse CAL Transfer
'# Delto-trapezial Reefing

20. 20
Procedure(s)

21. Results (failed Reconstructions)
Desais, Robinson, Phandis, Funk
In print, 2016
! 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% superficial infections
! No further revisions
21

22. 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

23. Summary
! Awareness
! Test for Horizontal & Vertical Instability
! Ultrasound
! CT Scan
! Revise if Symptomatic
! Strong
! Anatomical
! Biological
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24. THANK YOU