The document discusses injuries to the acromioclavicular (AC) joint. It covers the anatomy of the AC joint and surrounding ligaments. It then discusses the classification system for AC joint injuries, which ranges from Grade I to Grade VI, with higher grades indicating greater ligament disruption and bone displacement. Treatment options are covered, including initial immobilization for lower grades and surgical reconstruction or fixation for higher grades. Surgical techniques like ligament repair/reconstruction and coracoclavicular screw fixation are summarized. Associated shoulder issues like fractures are also mentioned.
i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department.
hope you enjoy
Fahad Al Hulaibi
Orthopedic Resident
NGH-A
Total Hip replacement for Ankylosing Spondylitis: Planning & Execution Vaibhav Bagaria
Performing Total Hip replacement in Ankylosing Spondylitis requires a well thought of strategy. Preoperative planning, Inventory ordering, positioning, cup and stem orientation all play a role.
Arthroscopic surgical instruments,Arthroscopic Instruments at Delhi Institute of Trauma & Orthopaedics (DITO),Sant Parmanand Hospital
Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients.
Details at http://delhiarthroscopy.com/index.html
Evolution of tunnel placement in ACL reconstructionDhananjaya Sabat
One of my talks at Delhi Arthroscopy Club....... this presentation provides a insight regarding the conceptual evolution in tunnel placement during ACL reconstruction.
i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department.
hope you enjoy
Fahad Al Hulaibi
Orthopedic Resident
NGH-A
Total Hip replacement for Ankylosing Spondylitis: Planning & Execution Vaibhav Bagaria
Performing Total Hip replacement in Ankylosing Spondylitis requires a well thought of strategy. Preoperative planning, Inventory ordering, positioning, cup and stem orientation all play a role.
Arthroscopic surgical instruments,Arthroscopic Instruments at Delhi Institute of Trauma & Orthopaedics (DITO),Sant Parmanand Hospital
Dr. Shekhar Srivastav is an Orthopedic Surgeon attached to Sant Parmanand Hospital, Delhi with special interest in Knee & Shoulder surgery. After obtaining his M.S. Orthopedics degree he has undergone training in various centers in India and Abroad which has helped him in understanding the Orthopedics problems and their Management. He did his AO/ ASIF fellowship at University Hospital, Salzburg, Austria in 2006 and recieved training in Arthroscopy & Sports Medicine at TUM, Munich (Germany) & Rush Orthopedics Centre, Chicago( USA). He has an experience of more than fifteen years of diagnosing and treating Orthopedics & Trauma patients.
Details at http://delhiarthroscopy.com/index.html
Evolution of tunnel placement in ACL reconstructionDhananjaya Sabat
One of my talks at Delhi Arthroscopy Club....... this presentation provides a insight regarding the conceptual evolution in tunnel placement during ACL reconstruction.
Acromioclavicular (AC) joint injury is a term used to describe an injury to the top of the shoulder, where the front of the shoulder blade (acromion) attaches to the collarbone (clavicle).
Distal femur fractures are traumatic injuries involving the region extending from the distal metaphyseal-diaphyseal junction to the articular surface of the femoral condyles.
Diagnosis is made radiographically with CT studies often required to assess for intra-articular extension.
Treatment is generally operative with ORIF, intramedullary nail, or distal femur replacement depending on available bone stock, age of patient, and patient activity demands.
Patella Fractures are traumatic knee injuries caused by direct trauma or rapid contracture of the quadriceps with a flexed knee that can lead to loss of the extensor mechanism.
Diagnosis can be made clinically with the inability to perform a straight leg raise and confirmed with radiographs of the knee.
Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism.
Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum).
Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension.
Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
4. Applied Anatomy
• A plane synovial joint, located between medial margin
of acromion and lateral end of clavicle
• Within the AC joint, there is a fibro cartilaginous disc
5.
6. Acromioclavicular Ligaments
• Consists of anterior, posterior, superior, and inferior
ligaments, surround the AC joint
• Stabilize the joint in horizontal plane
• Superior AC ligament- strongest of capsular ligaments,
blend with fibers of the deltoid and trapezius muscles
adding stability to AC joint.
7. Coracoclavicular Ligament
• Very strong ligament from outer inferior surface of
clavicle to base of the coracoid process of scapula.
• Two components—conoid and trapezoid ligaments
• Vertical stability of AC joint
8.
9. • The only connection between the upper extremity
and the axial skeleton is through the clavicular
articulations at the AC and SC joints.
• SC ligaments support clavicles suspended away from
the body
• CC ligament suspend upper extremities from distal
clavicles
10. • CC ligament helps to
couple glenohumeral
abduction/flexion to
scapular rotation on thorax
during overhead elevation
• Clavicle rotates around 40-
50 degrees during full
overhead elevation--
simultaneous scapular
rotation and AC joint
motion
11. Overview
• Injuries to either AC or SC joints can result in a wide
range of shoulder dysfunction.
• Both can be injured by similar mechanisms, present
with overlapping clinical complaints, and in some
cases result in injury to both locations
• Acromioclavicular injures are more common, and
sternoclavicular injuries are rare
12. Risk groups
• often occur in male patients less than 30 years of age
• associated with contact sports or athletic activity in which direct blow
to lateral aspect of shoulder occurs.
• The contact or collision athlete represents a “high-risk” individual
(football, rugby, and hockey)
• RTA
13. Mechanisms of Injury
• Direct force on acromium or direct fall on the dome of
shoulder
• Falling on an outstretched arm, locked in extension at
the elbow, can drive humeral head superiorly into
acromion--low-grade AC joint injuries
• A medially directed force to lateral shoulder that
drives acromion into and underneath the distal
clavicle(when getting checked into the boards during
a hockey game)- higher degrees of injury and
subsequently more displacement.
14. • More commonly described pattern- falling or being
tackled onto lateral aspect of the shoulder with the arm
in an adducted position which produces a compressive
(medial) and shear (vertical) force across the joint-
typically produces higher degree of displacement enough
to tear both AC and CC ligaments.
15. • The injury force which drives acromion medially and downward
produces a progressive injury pattern; first disruption of AC ligaments,
followed by disruption of CC ligaments, and finally disruption of fascia
overlying the clavicle that connects deltoid and trapezius muscle
attachments.
• Complete AC dislocation- the upper extremity has lost its suspensory
support from clavicle and scapula- inferior displacement of the
shoulder secondary to forces of gravity.
16. Nontraumatic or Chronic Overuse
• AC joint arthrosis—weight lifting, laborer, repetitive overhead activity
• Repetitive low-grade AC joint injuries
• Medical cause: rheumatoid arthritis, hyperparathyroidism,
scleroderma
17.
18. Clinical presentation
• Young-aged male
• Contact or collision athlete
• H/O direct trauma
• Clinical deformity, focal tenderness and swelling
• Commonly the patient describes pain originating from the anterior-
superior aspect of the shoulder
19. Diagnosis
• Examination should be in sitting or standing w/o support for the injured
arm
• Check for tenderness to palpation at the AC joint and the CC interspace
• If patient can tolerate check joint for stability
• Check to see if reducible
• Examine SC joint as well
• Neurologic exam to r/o brachial plexus injury
20.
21. Clinical triad
• point tenderness at the AC joint,
• pain exacerbation with cross-arm adduction, and
• relief of symptoms by injection of local anesthetic
agent confirm injury to the AC joint.
22. Imaging
• Good-quality radiographs of the AC joint require one-
third to one-half the beam penetration to image the
glenohumeral joint.
• Radiographs of the AC joint taken using routine
shoulder technique will be overpenetrated (i.e.dark),
and small fractures may be overlooked.
Therefore,specifically requested to take radiographs
of “AC joint” rather than the “shoulder.”
• AP VIEW
• ZANCA VIEW
• STRESS VIEW
23. Radiographic Normal Joints
• Width and configuration of AC joint in coronal plane
may vary significantly from individual to individual. So,
a normal variant should not be mistaken as an injury.
• Normal width of AC joint in coronal plane is 1 to 3 mm.
AC joint space diminishes with increasing age (0.5 mm
in older than 60 years is conceivably normal). Joint
space of greater than 7 mm in men and 6 mm in
women is pathologic.
• Average CC distance 1.1 to 1.3 cm. An increase in CC
distance of 50% over normal side signifies Complete AC
dislocation (has been seen with as little as 25% increase
in CC distance).
24. Zanca View
• Beam placed 10
degrees cephalad
• Obtained using soft
tissue technique in
which voltage is cut
into half
• quantifying CC
distance, and
percentage
displacement of distal
clavicle above
acromion.
29. • Children and adolescents may
sustain a variant of complete
AC dislocation (most often
Salter–Harris type I or II)
• Radiographs reveal
displacement of distal
clavicular metaphysis
superiorly (through a dorsal
rent in periosteal sleeve) with
increase in CC interspace.
Epiphysis and intact AC joint
remain in their anatomic
locations
30.
31. Treatment goals
• Pain-free shoulder movement in a range-of-motion arc approaching
normal
• Unimpaired daily activities
32. Treatment Options
Nonoperative Treatment
• Immobilisation with strapping and sling for
3 weeks
• No lifting of weights for 6 weeks
Indications-
Type I,II,III AC injuries
• Relative contraindications-
-Chronic symptomatic injury
-Failed nonoperative management, athlete,
polytrauma, heavy
33. During 1st week of treatment
• Immobilization device (Arm slings, adhesive tape strappings, braces
and plaster)-
To support the weight of upper extremity and reduce the stress
placed upon the injured ligaments
• Ice and analgesics
To reduce pain and inflammation
34. After 1 to 2 weeks
• Strengthening exercises commenced with particular focus on
periscapular muscles that are important to shoulder
biomechanics.
• Heavy stresses, lifting, and contact sports should be delayed
until there is full range of motion and no pain to joint palpation.
This process can take up to 2 to 4 weeks
• Athletes who desire an earlier return to sports should be
encouraged to use protective padding over the AC joint. An
earlier return to sports that sustains a second injury to the AC
joint, prior to complete ligament healing, can change a partially
subluxated AC joint into a complete AC dislocation. Given this
possible sequela, a forewarning must be provided to all athletes
wishing to return to play at an earlier time. This decision is a
balance between the desire to return to play early and the risk
of reinjury.
35. DISADVANTAGES OF NON OPERATIVE
TREATMENT
• SKIN PRESSURE AND ULCERATION
• RECURRENCE OF DEFORMITY
• WEARINGA BRACE FOR LONG TIME(8
WEEKS)
• POOR PATIENT COOPERATION
• INTERFERENCE WITH DAILYACTIVITIES
• LOSS OF SHOULDER AND ELBOW MOTION
• SOFT TISSUE CALCIFICATIONS
• LATEACROMIOCLAVICULAR ARTHRITIS
• LATE MUSCULAR ATROPHY,FATIGUEAND
WEAKNESS.
36. Type III- operative or nonoperative ?
• In prospective randomized studies between operative and
nonoperative treatment of type III AC joint injuries, patients treated
nonoperatively demonstrated a quicker return of function and
sustained fewer complications than patients treated operatively.
• Patients treated conservatively returned to work on average 2.1
weeks from injury and the strength and ROM of the injured shoulder
were comparable to the contralateral uninjured shoulder with a
mean follow-up of 2.6 years (Wojtys and Nelson)
• Operatively treated AC injuries showed a significantly higher
incidence of osteoarthritis and CC ligament ossification
• A proportion of conservatively treated patients will have persistent
pain and inability to return to their sport or job. Subsequent surgical
stabilization has allowed return to sport or work in such cases
37. Reasons for lower-grade AC joint injuries being
symptomatic –
• posttraumatic arthritis
• posttraumatic osteolysis of the distal clavicle,
• recurrent AP subluxation,
• torn capsular ligaments trapped within the joint,
• loose pieces of articular cartilage,
• detached intra-articular meniscus or associated intra-
articular fracture fragment.
38. Chronic Acromioclavicular Injuries
• Chronic pain after type I and II injuries- NSAIDS, avoidance of painful
activity or positions, and intra-articular injection with corticosteroid
• Type I-
Operative excision of distal clavicle (limited to less than 10 mm )-open or
arthroscopic
• Type II-
Distal clavicle excision + AC capsular reconstruction or coracoacromial
ligament transfer
• Chronic pain and instability after types III, IV, and V- Distal clavicle
excision + Transfer of acromial attachment of coracoacromial ligament to
the resected surface of distal clavicle and concurrent CC stabilization
39. Operative Treatment
Indications -
• Patients (types I,II,III) who have failed a minimum 6
weeks of shoulder stabilization–directed physical
therapy (delayed surgical reconstruction using a
tendon graft)
• Active healthy patients with complete AC joint injuries
(types IV, V, and VI)- significant morbidity associated
with the injury pattern- persistently dislocated,
unstable AC joint, with change in scapular kinematics,
and shoulder dysfunction.
• Fracture of coracoid extending intra-articularly into
glenoid (5 mm or more of glenoid displacement )
40. • Fixation acrossAC joint
• Fixation between coracoid and
clavicle
• Ligament reconstruction
• Distal clavicle excision
41. ANY SURGICAL PROCEDURE FOR AC JOINT
DISLOCATION SHOULD FULFILL THREE REQUIREMENTS
• AC JOINT MUST BE EXPOSED AND DEBRIDED
• CC AND AC LIGAMENTS MUST BE
REPAIRED OR RECONSTRUCTED
• STABLE REDUCTION OF THEAC JOINT MUST BE
OBTAINED
Achievingthese three goals , no matter how the joint is
fixed , should give acceptable results.
42. DISADVANTAGES OF SURGICAL
MANAGEMENT
• INFECTION
• HEMATOMA FORMATION
• ANAESTHETIC RISK
• SCAR FORMATION
• RECURRENCE OF DEFORMITY
• METAL BREAKAGE,
LOOSENING,MIGRATION
• SECOND SURGERY FOR REMOVAL
• BREAKAGE OR LOOSENING OF
SUTURES
• EROSION OR FRACTURE OF DISTAL
CLAVICLE
46. Fixation between coracoid and clavicle
• Bosworth popularized the use of a screw for fixation
of the clavicle to the coracoid
• This technique initially did not include
recommendation for repair or reconstruction of the CC
ligaments
• T
oday the use of screws and suture loops has been
described alone and in combo with ligament
reconstruction
• Placement of synthetic loops between the coracoid and
clavicle can be done arthroscopically, main advantage:
doesn’t require staged screw removal
49. Ligament reconstruction
• Weaver and Dunn were the 1st to describe transfer for the
native CA ligament to reestablishAC joint stability
• Their technique described excision of the distal clavicle with this
ligament transfer
• Construct can be augmented with a suture loop for protection until
the
transferred ligament heals
Open orArthroscopy
53. Anatomic Ligament Reconstruction
MAZZOCCA ET AL
• Alternative technique is use of semitendinosus autograft for
reconstruction
– Loop around or fix into coracoid, then fix through two separate clavicle
bone tunnels to approximate normal anatomic location of CC
ligaments
• Recent biomechanical studies have demonstrated the superiority
of this
construct
54. Anatomic Coracoclavicular Ligament Reconstruction
• ACCR technique attempts to restore biomechanics of
AC joint complex as treatment for painful or unstable
dislocations
• Rationale- to reconstruct both CC ligaments by
anatomically fixing a tendon graft in two clavicle
tunnels placed in the anatomic insertion site of conoid
and trapezoid ligaments.
• In addition, AC ligaments are reconstructed with the
remaining limb of the graft exiting the more lateral
trapezoid tunnel.
55. ACCR technique: patient positioning
• Far lateral position with shoulder free to extend, small
scapula bump along medial scapula border, and head
position extended and rotated away from operative side.
56. ACCR-Steps
• Vertical incision centered on clavicle (starting from
posterior clavicle to just medial of coracoid process
)approx 3.5 cm medial to AC joint.
• Subperiosteal flaps raised to ensure that trapezius and
deltoid attachments are elevated off. Tagging stitches can
be placed to aid in tight closure of this layer during
closure.
57. • Conoid tunnel position marked at least 45 mm from
distal clavicle
• Trapezoid tunnel position marked with at least 25 mm
of bone bridge between tunnels
• Tunnels drilled
58. • Graft passed through
tunnel,beneath coracoid
• Interference fixation with
PEEK screws
(polyetheretherketone)
• Continue brace for 8 weeks
• Strengthening exercises
from 12 weeks
59. • Graft options- semitendinosus allograft/autograft, Anterior tibialis
allograft.
• Semi-tendinosus allograft preferred -simplification of patient
positioning, no donor site morbidity, decreased operative time,
consistency in graft tissue size
• The minimal length needed to ensure graft available for AC ligament
reconstruction approx 110 mm.
62. • Glenohumeral Intra-Articular Pathology Pauly et al. noted a 15%
incidence of intra-articular pathology, SLAP and PASTA(Partial articular
supraspinatus tendon avulsion) lesions, in their series of 40
consecutive patients undergoing arthroscopic-assisted reconstruction
of grade III to V AC joint dislocations
63. Fractures
• lateral clavicle fracture
• base or neck of coracoid process fracture
• concomitant injury to medial clavicular epiphysis (less than 30 years
of age)
• Fracture of midshaft of clavicle with either anterior or posterior
subluxation/dislocation of SC joint (uncommon)
64. Secondary osteoarthritis
• late complication
• usually be managed conservatively,
• If pain is marked, the outer 2 cm of clavicle can be excised.
69. References
• Rockwood and Greens Fractures in Adult, Ninth edition
• Campbell Orthopaedics ,14th edition
• Apley and Solomon’s System of Orthopaedics and Trauma, Tenth
Edition
• https://www.orthobullets.com/shoulder-and-
elbow/3047/acromioclavicular-joint-injury