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SUKESH .A N
JUNIOR RESIDENT ORTHOPAEDICS
TDMC ALAPUZHA
case
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
MATHEW
Preop x ray
STRAP INCISION
JOINT DISLOCATION
JOINT REDUCTION
CLAVICLE TO BASE OF
CORACOID
K WIRE FIXATION
Post op xray
Acromioclavicular Joint
update
9% of shoulder girdle injuries
Generally occurs in males age 20-
30
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.
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
PHYSICAL FINDINGS
Pain over lateral clavicle / AC joint
Prominent distal clavicle
May have skin abrasions
Unable to lift arm.
A mobile distal clavicle
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)
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.
Type I
Sprain of acromioclavicularligament
AC joint intact
Coracoclavicularligaments intact
Deltoid and trapeziusmuscles intact
AC joint disrupted
< 50% Vertical
displacement
Sprain of the
coracoclavicular
ligaments
CC ligaments intact
Deltoid and trapezius
muscles intact
Type II
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
Type III Variants
“Pseudo-dislocation” through an intact
periosteal sleeve
Physeal injury
Coracoid process fracture
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
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
Type VI
AC joint dislocated and clavicle displaced inferior to the acromionor the coracoid process
AC and CC ligaments disrupted
Deltoid and trapeziusmuscles detached from the distal clavicle
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
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
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.
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.
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 3029
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
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
BOSWORTH TECHNIQUE
CLAVICULAR HOOK PLATE
REPAIR & TIGHT ROPE AUGMENTATION
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
SURGILIG RECONSTRUCTION
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
Other neo ligaments
ROTA LOK system
KEIO LEEDS system
All are poly ester artificial ligaments
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)
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 coracoclavicularscrew or suture.
Repair of deltotrapezialfascia
Young patients,elderly with painful, disabled,degenerative ac
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)
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
Complications of AC Joint
dislocations
AC joint Arthritis
Cosmetic
Scapular Dyskinesia
SICK scapula syndrome
# Clavicle ,# Coracoid
Implant Failure
Infection
Shoulder stiffness
Rotator cuff problems
SICK Scapula syndrome
SICK Scapula syndrome
S- Scapular malposition
I-I nferomedial prominence of Scapula
C- Coracoid pain
K- Kinesial abnormalities of scapula
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.
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 nonoperativetreatment 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
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.
THANK YOU