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Ac dislocation

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ac joint dislocation

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Ac dislocation

  1. 1. SUKESH .A N JUNIOR RESIDENT ORTHOPAEDICS TDMC ALAPUZHA case
  2. 2.  Mathew 55 yrs  h/0 RTA 1 week  c/o pain & swelling left shoulder  Bony prominence over lateral end of left clavicle  Difficulty in raising left arm  ACROMIO-CLAVICULAR JOINT DISLOCATION
  3. 3. MATHEW
  4. 4. Preop x ray
  5. 5. STRAP INCISION
  6. 6. JOINT DISLOCATION
  7. 7. JOINT REDUCTION
  8. 8. CLAVICLE TO BASE OF CORACOID
  9. 9. K WIRE FIXATION
  10. 10. Post op xray
  11. 11. Acromioclavicular Joint update
  12. 12.  9% of shoulder girdle injuries  Generally occurs in males age 20- 30
  13. 13. ANATOMY  The AC joint is a diarthrodial joint.  Located between the lateral end of the clavicle and the medial acromion.  The AC ligaments (anterior, posterior, superior, inferior) strengthen the thin capsule  Fibers of the deltoid and trapezius muscles blend with the superior AC ligament to strengthen the joint  The horizontal stability of the AC joint - by the AC ligaments.  The vertical stability - by the CC /coracoclavicular ligaments.
  14. 14. MECHANISM OF INJURY  Direct: This is the most common mechanism, resulting from a fall onto the shoulder with the arm adducted.  Indirect: A fall onto an outstretched hand with force transmission through the humeral head and into the AC articulation
  15. 15. PHYSICAL FINDINGS  Pain over lateral clavicle / AC joint  Prominent distal clavicle  May have skin abrasions  Unable to lift arm.  A mobile distal clavicle
  16. 16. Radiographic Evaluation of the Acromioclavicular Joint  Anteroposterior view  Stress veiw (3-4kg weight tied to wrist for complete muscle relaxation )  Zanca view (15 degree cephalic tilt)
  17. 17. CLASSIFICATION  Initially classified by both Allman and Tossy et al. into three types (I, II, and III).  Rockwood added types IV, V, and VI, so that now six types are recognized.  Classified depending on the degree and direction of displacement of the distal clavicle.
  18. 18. Type I  Sprain of acromioclavicular ligament  AC joint intact  Coracoclavicular ligaments intact  Deltoid and trapezius muscles intact
  19. 19.  AC joint disrupted  < 50% Vertical displacement  Sprain of the coracoclavicular ligaments  CC ligaments intact  Deltoid and trapezius muscles intact Type II
  20. 20. Type III  AC ligaments and CC ligaments all disrupted  AC joint dislocated and the shoulder complex displaced inferiorly  CC interspace greater than the normal shoulder(25-100%)  Deltoid and trapezius muscles usually detached from the distal clavicle
  21. 21. Type III Variants  “Pseudo-dislocation” through an intact periosteal sleeve  Physeal injury  Coracoid process fracture
  22. 22. Type IV  AC and CC ligaments disrupted  AC joint dislocated and clavicle displaced posteriorly into or through the trapezius muscle  Deltoid and trapezius muscles detached from the distal clavicle
  23. 23. Type V  AC ligaments disrupted  CC ligaments disrupted  AC joint dislocated and gross disparity between the clavicle and the scapula (100- 300%)  Deltoid and trapezius muscles detached from the distal half of clavicle
  24. 24. Type VI  AC joint dislocated and clavicle displaced inferior to the acromion or the coracoid process  AC and CC ligaments disrupted  Deltoid and trapezius muscles detached from the distal clavicle
  25. 25. TREATMENT  Type I: Rest for 7 to 10 days, ice packs, sling. Refrain from full activity until painless, full range of motion (2 weeks).  Type II: Sling for 1 to 2 weeks, gentle range of motion as soon as possible. Refrain from heavy activity for 6 weeks
  26. 26.  Type III:  For inactive, nonlaboring patients nonoperative treatment is indicated:  Younger, more active patients with more severe degrees of displacement and laborers who use their upper extremity above the horizontal plane may benefit from operative stabilization.  Type IV, V,& IV:  Open reduction and surgical repair of the coracoclavicular ligaments are performed for vertical stability
  27. 27.  Type III Injuries: Need for acute surgical treatment remains controversial.  Most surgeons recommend conservative treatment except in the throwing athlete or overhead worker.  Repair generally avoided in contact athletes because of the risk of reinjury.
  28. 28. Literature unable to support operative or nonoperative treatment as superior  Functional outcomes appear similar.  Cosmesis not different (scar vs bump)  Only 50% of surgical cases reduced at follow-up.  10% complications after surgery. Ceccarelli et al. J Orthopaed Traumatol 2008;9:105-108.
  29. 29. SURGICAL MANAGEMENT  Should fulfill 3 requirements:  1. ac joint must be exposed & debrided  2.coracoclavicular & acromioclavicular ligaments must be repaired or reconstructed  3.stable reduction of ac joint Campell 12th edition chapter 60 page 30
  30. 30. MANAGEMENT  5 major categories: 1.Ac reduction & fixation 2.Ac reduction,cc ligament repair & cc fixation 3.Combination of 1 & 2 4.Distal clavicle excision 5.Muscle transfers Campell 12th edition chapter 60 page 3029
  31. 31.  Campell describe,  MAZZOCCA TECHNIQUE -anatomic reconstruction of conoid & trapezoid ligaments -autologous semitendinosus graft preferred,reconstruction with suture tape -biomechanical studies by mazzoca demonstrated superior fixation compared with pin fixation or repair
  32. 32. BOSWORTH TECHNIQUE
  33. 33. CLAVICULAR HOOK PLATE
  34. 34. REPAIR & TIGHT ROPE AUGMENTATION
  35. 35. LARS LIGAMENT  Synthetic Ligament  Made of polyethylene terephthalate  Longitudinal-running fibres that match the structure of native human tissue.  LARS ligament reproduces the anatomy and mechanics of the torn coracoclavicular ligament
  36. 36. SURGILIG RECONSTRUCTION
  37. 37. SURGILIG RECONSTRUCTION  Surgilig is an artificial ligament  It is made of double braided polyester with a patented weave design which acts as a scaffold encouraging tissue in-growth
  38. 38. Other neo ligaments  ROTA LOK system  KEIO LEEDS system  All are poly ester artificial ligaments
  39. 39. Techniques for Late Surgical Treatment of Acromioclavicular Injuries  Reduction of AC joint and repair of AC and CC ligaments  Resection of distal clavicle and reconstruction of CC ligaments (Weaver-Dunn Procedure)
  40. 40. WEAVER-DUNN PROCEDURE  The distal clavicle is excised.  The CA ligament is transferred to the distal clavicle.  The CC ligaments are repaired and/or augmented with a coracoclavicular screw or suture.  Repair of deltotrapezial fascia  Young patients,elderly with
  41. 41. Surgery versus Sling for AC Joint Dislocations  Study finds hook plate fixation is not superior to nonsurgical treatment for acute injuries (AAOS Now December 2012 .Maureen Leahy)
  42. 42. Reconstruction for neglected cases  Grafts used  Semitendinosis  Gracilis  Allografts • Used as a single or double bundle to reconstruct the coracoclavicular ligament. • Synthetic ligaments like LARS or Surgilig can be used for reconstruction
  43. 43. Complications of AC Joint dislocations  AC joint Arthritis  Cosmetic  Scapular Dyskinesia  SICK scapula syndrome  # Clavicle ,# Coracoid  Implant Failure  Infection  Shoulder stiffness  Rotator cuff problems
  44. 44. SICK Scapula syndrome  SICK Scapula syndrome  S- Scapular malposition  I-I nferomedial prominence of Scapula  C- Coracoid pain  K- Kinesial abnormalities of scapula
  45. 45. Arch Orthop Trauma Surg. 2013 Jul;133(7):  In addition to the correct type of injury therapy strategies should be adapted to patient's demands and compliance.  A certain debate is still ongoing regarding type III injuries  non-operative treatment of type III injuries results to provide equal functional outcomes as compared to surgical treatment associated with less complications  If surgical treatment is indicated, open surgical procedures using pins, PDS-slings or hook plates are still widely used concurring with recent minimally invasive, arthroscopic techniques using new implants designed to remain in situ.
  46. 46. 2013 Arthroscopy Association of North America. Published by Elsevier Inc  3 considerations in determining treatment options for patients with acromioclavicular (AC) joint dislocations:  (1) operative versus nonoperative management,  (2) early versus delayed surgical intervention, and  (3) anatomic versus non anatomic techniques -There is a lack of evidence to support treatment options for patients with AC joint dislocations. - Although there is a general consensus for nonoperative treatment of Rockwood type I and II lesions, -initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions, -further research is needed to determine if differences exist regarding early versus delayed surgical intervention and anatomic vs nonanatomic surgical techniques
  47. 47. Journal of Orthopaedic Surgery and Research 2015  Treatment options should be thoroughly discussed with patients, weighing all subjective, objective and radiographic outcomes and the relative advantages of each option.
  48. 48. THANK YOU

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