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Acromioclavicular Joint Dislocations - my approach and management (2014)
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Lennard Funk
MY EXPERIENCE
2001 2008
REVISIONS !!!
5
PLAN
Indications!
Why Open?!
Why LARS?!
My Technique!
Modifications!
Results
INDICATIONS
• Symptoms • Patient Demands
–Work demands –Society demands
• Overhead Athlete
Review!3 weeks
APPROACHAcute Injury!
< 1 week
Review 3 months Surgery
Coping Not Coping
WHY OPEN?
ACJ STABILISERS
• CC Ligaments – Vertical Stability
• DeltoTrap Fascia – Vertical Stability
• AC Ligaments – Horizontal Stability
Urist, JBJSA, 1946 Debski, JBJSA, 2001
ACJ LIGAMENTS
Two thirds of the superior stability for lesser displacements!
90% the posterior stability
Fukuda et al. JBJSA. 1986
DYNAMIC STABILITY
Delto-trapezial fascia
Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
“Many unsatisfactory results could be due to lack of repair of the trapezius and deltoid.”
Lizaur et al. JBJS. 1994
WHY LARS?(LIGAMENT AUGMENTATION REINFORCEMENT SYSTEM)
SURGICAL PROCEDURES
>100 PUBLISHED!!20% FAILURE RATE
HARRIS ET AL. AJSM 2000
“None of the reconstruction techniques analyzed ... were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”
CORACOCLAVICULAR LIGAMENTS
Strength – 500N (+/- 134)!
Stiffness – 103N/mm (+/- 30)!
Uniaxial Tension 25mm/min
Harris et. al. Am J Sports Med. 2000
FUNCTIONAL ANATOMY
CC LIG POSITIONS
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]
DISCLAIMER:
I have not:!
Received any funding or royalties from LARS /Corin!
Been involved in the development of the LARS
TECHNIQUE
EQUIPMENT
INCISION
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NOTTINGHAM APPROACH
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STANDARD REPAIR
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MODIFICATION 1
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MODIFICATION 2
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CLOSURE
Repair the Superior AC Ligaments!
Repair the Delto-Trapezial Fascia
X-RAYS - DAY 1, 3 WEEKS, 3 MONTHS, 1YR, 2YRS
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Phase 1: (Level 1-2 Exercises)
Core stability & Scapula control!
Proprioceptive exercises (minimal weightbearing below 90 degrees)!
Active ROM as comfortable!
Do not force or stretch
No resistance exercises
Phase 2: (Level 2-3 Exercises)
Progress to light resistance exercises as tolerated!
Sports-specific rehabilitation - Plyometrics and pertubation training!
Phase 3: (Level 3+ Exercises)
Regain scapula & glenohumeral stability working for shoulder joint control rather than range!
Gradually Strengthen
POST-OP
3 WEEKS POST-OP
RESULTS
Three year period !
55 patients !
12 Acute; 43 Chronic!
Mean age of 29 yrs
Nicoletti, Quin & Funk. Presented at SECEC 2008
FU = Minimum 2yrs!
X-Rays at 3 & 24 months!
29 Type III; 5 Type IV; 19 Type V!
12 Revisions
RESULTS
SATISFACTION!
85% Pts Satisfied !
!
PAIN:!
PREOP-OP = 10.43(5-15)!
POST-OP = 1.27(0-6)
RESULTS
REDUCTION
Mean post-op displacement =15%
BA
Displacement = A/B x 100
1 FAILURE:
3 WEEKS POST OP:
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2012 UPDATE
114 Cases over 6 years!
Constant score = 86 (67-100)!
92% returned to previous level sport !
Mean displacement at 28 months = 17%!
Early failures = 2 cases post-trauma!
Late failures = 2 cases post-trauma!
Revisions = 4 cases
SUMMARY
Open - Repair all structures!
LARS - Strongest, Anatomical, Biological!
My Technique - Modified to Patient!
Results
