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Acj injury

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Acj injury

  1. 1. Acromioclavicular  Joint  Injury   Jeremy  Granville-­‐Chapman   Upper  Limb  Fellow   Wrigh?ngton  
  2. 2. Learning  Outcomes   •  Understand  anatomy,  epidemiology,   mechanism  of  injury  and  diagnosis  of  ACJ   separa?on   •  Recognize  limita?ons  of  classifica?on  with   respect  to  management   •  Understand  surgical  op?ons  in  ACJ  separa?on,   acute  and  chronic   •  Be  able  to  formulate  a  ra?onal  decision   making  algorithm  for  ACJ  separa?on  
  3. 3. Horizontal     ACJ  Capsule   Superior  56%  stability   Posterior  25%     Ver-cal   CC  ligaments  (Conoid   &Trapezoid)   +   Delto-­‐trapezial  fascia     Distance  1.1-­‐1.3cm  C  to  C   Strength  500±134N   Harris  et  al  Am  J  Sports  Med  2000    
  4. 4. Cadaveric  sec?oning  of  CC  ligaments  
  5. 5. Mechanism  of  Injury   •  Typically  a  direct  blow   to  shoulder   •  indirect  via  fall  onto   elbow   •  Indirect  via  shoulder   ‘whiplash’  
  6. 6. Epidemiology   •  male  athletes  3.5x  >  female  athletes   •  Pro  Rugby  32%  incidence   –   wrestling,  cycling  and  ice  hockey   •  Incidence   –  9  per  1000  pa?ent  years  in  US  Mil  trg  popn   –  14  per  100K  popn  per  year  Grade  III  or  higher   –  Approx  10%  of  trauma?c  shoulder  injuries   •  90%  are  low-­‐grade  sprains   •  Mean  ?me  off  sport  18.4  days     –  10.4  days  for  low-­‐grade  sprains   –  63  days  for  high  grade  injury   Pallis,  M.  et  al.,  2012.  Epidemiology  of  Acromioclavicular  Joint  Injury  in  Young  Athletes.  The   American  Journal  of  Sports  Medicine,  40,  pp.2072–2077.  
  7. 7. Diagnosis   •  Clinical  Examina?on   –  Step  off  and  tenderness  over  ACJ   –  ROM  reduced  eleva?on   –  Scarf  test     –  AP  stability   –  Reducibility     •  Plain  radiograph   –  Zanca  view  (15°  cephalic  ?lt)   –  Axillary  lateral  view  (can  show  AP  instability)   •  US   –  May  demonstrate  subtle  instability   •  MRI   –  Detect  associated  injuries   –  Clarifies  structures  injured  
  8. 8. Associated  intra-­‐ar?cular  injuries   15%  (6/40)  Pauly  et  al  (KSSTA  2009)   18%  (14/77)  Imhoff  et  al  (AJSM  2009)   46%  (45/98)  Arrigoni  P  et  al  (BRASS  group)    >45  yrs  =  67%    <45yrs  =  29%       Should  we  MRI  all  pa?ents?   If  opera?ng,  is  an  arthroscopic  technique  berer?    
  9. 9. Anatomic  Classifica?ons   Rockwood  CA,  Williams  GR,  Youg  DC.    Disorders  of  the  acromioclavicular  joint.    In:  Rockwood   CA.    The  shoulder.    Philadelphia:  Saunders;  1998.  p.  483-­‐553.   Rockwood  on  Zanca  view  has  only  fair  inter-­‐observer  reliability  and  poor  intra-­‐observer   reliability  (CY  Ng,  Funk  L  et  al  Shoulder  and  Elbow  2012)   MRI  diagnosis  differs  in  almost  half  of  cases  (36%  less  severe,  11%,  more  severe  than  XR)   (Nemec  U  et  al.  AJR  2011)  
  10. 10. Natural  History  of  ‘low  grade’  sprains   •  Most  recover  within  7-­‐10  days  and  enjoy   excellent  long  term  outcome     •  BUT  severity  underes?mated..   – Grade  I  -­‐  9%  have  severe  pain,  instability,   diminished  performance  or  cessa?on   – Grade  II  -­‐  42%   – 70%  have  XR  degenera?on  at  f/u   – 33%  develop  persistent  laxity  at  ACJ   Mouhsine  E,  Garofalo  R,  Crevoisier  X,  Farron  A.    Grade  I  and  II  acromioclavicular  disloca?ons:  Results  of   conserva?ve  treatment.    J  Shoulder  Elbow  Surg  November/December  2003;12(6);599-­‐602   Bergfield  JA,  Andrish  JT,  Clancy  WG.    Evalua?on  of  the  acromioclavicular  joint  following  first  and  second-­‐ degree  sprains.    Am  J  Sports  Med  1978;6:153-­‐9  
  11. 11. Higher  Grade  Injuries   •  Grade  III     – 24%  horizontal  abduc?on  weakness   – 87%  achieve  sa?sfactory  outcome  without  surgery   – Increasing  trend  towards  repair  over  conserva?ve   management  –  fashion  or  ra?on?   •  Grade  IV  and  V   – Normally  treated  with  surgery   – Lirle  modern  data  on  conserva?ve  management  
  12. 12. Treatment  Op?ons  –  Acute  (<4  weeks)   •  Conserva?ve  –  early  rehab  to  regain  rhythm   and  strength   •  Acute  surgery     – Hook  plate   – Tightrope   – Grawrope   – Dog  Bone  buron   – LARS  ligament/lockdown  (Surgilig)  
  13. 13. Treatment  Op?ons  -­‐  chronic   •  ACJ  excision  if  stable     •  Reconstruc?on  of  CC  ligs   +  excision  lat  clavicle   –  Weaver  Dunn   –  Surgilig   –  LARS   –  Dog  bone  +  graw  tendon   UTS  (N)   •  CC  Ligament  725N   •  Transferred  CA  ligament    145N   •  Lockdown  Surgilig  1730N   •  LARS  1500N  (30  fibres)   •  Tightrope  675N   •  Dog  Bone  >1000N  
  14. 14. If  grade  marers,  what  to  do  with   Grade  III  ?   •  Older  studies  showed   no  improvement  with   fixa?on  but  higher   complica?ons   •  BUT,  old  techniques     –  Wires/plates/screws   –  Required  r/o  hardware   –  High  complica?ons   •  ?  S?ll  relevant   •  Recent  studies  suggest   berer  outcome  with   surgery   •  Gsterner  et  al  2008     –  88%  vs.  59%  good  or   excellent  results  Hook   plate   •  Fraschini  et  al  2010   –  LARS  (Chronic  pts)   –  93.3%  vs.  0%  non  op  
  15. 15. Modern  techniques  –  Dog  Bone   •  Newest  trans-­‐osseous  design   •  2x  fibretapes  and  2x  dogbones   •  2.4  or  3mm  bone  tunnels   •  Arthroscopic  or  open   •  Lirle  material  on  top  clavicle   •  Augment  with  graw  if  chronic   •  UTS  -­‐  >1200N  (stronger  than   na?ve  CC  ligaments)  
  16. 16. Surgilig  Lockdown   •  Braided  polyester  rope   (Atlan?c  Surgical)   •  UTS  1730N   •  Around  coracoid  base,  behind   and  over  clavicle,  held  with   AP  screw   Wood  TA,  Rosell  PA,  Clasper  JC.  Preliminary  results  of  the  'Surgilig'  synthe?c  ligament  in  the   management  of  chronic  acromioclavicular  joint  disrup?on.   J  R  Army  Med  Corps.  2009  Sep;155(3):191-­‐3.  
  17. 17. LARS  ligament   •  PET  braided  rope  –  extremely   strong  (Corin)   •  Biocompa?ble  –  fibroblas?c   scaffold   •  10M  cycles,  6%  strain   •  Loops  under  coracoid,   through  oblique  clavicle   tunnels    
  18. 18. AC  joint  reconstruc-on  with  an  anatomical  PET  synthe-c  ligament  in  athletes  and   non-­‐athletes.  Clinical  and  radiological  outcomes  at  2-­‐year  minimum  follow-­‐up.   G  M  Marcheggiani  Muccioli*,  C  Manning,  P  Wright,  L  Funk     Athletes  and  non-­‐athletes:  2-­‐year  minimum  follow-­‐up.   43  pts  (age  30  19-­‐54).  21  athletes   Rockwood  III-­‐V   Mean  ?me  to  surgery  3  months  (Athletes)  8  months  (non-­‐athletes)    (range  1   week  to    2  years)   Outcomes:  Constant  scores,  Return  sport,  Zanca  view  displacement     Constant  scores  improved  significantly       Return  to  full  sport  was  4.5  months  (range  3  to  8)   Mean  displacement  was  14%  and  24%  overall  pa?ents  at  3  and  24-­‐month   follow-­‐up  (more  displacement  in  the  non-­‐professional  group).  Displacement  did   not  affect  Constant  scores   Complica?ons:  one  coracoid  fracture  >1yr  and  one  superficial  infec?on  
  19. 19. Decision  Making     •  Classifica?on  alone  unhelpful     •  Sport  and  profession   •  Aim  to  review  at  1-­‐2  weeks  post  injury   – Coping?   •  Chronically  symptoma?c   – Frankly  unstable  or  not?  
  20. 20. Acute   Chronic   Coping   Not  coping   Surgery  Rehab   ACJ  excision   Reconstruc-on   Stable   Unstable   Assessment     DogBone   LARS     LARS     (Surgilig)   DogBone  +   CA  Lig  tx  /  graV   Assessment     ROM   Rhythm   Power   Rehab  

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