Acromioclavicular Joint Injury Jeremy GranvilleChapman Upper Limb Fellow Wrigh?ngton
Acromioclavicular Joint Injury
Jeremy Granville-‐Chapman Upper Limb Fellow
Wrigh?ngton
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
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
Cadaveric sec?oning of CC ligaments
Mechanism of Injury
• Typically a direct blow to shoulder
• indirect via fall onto elbow
• Indirect via shoulder ‘whiplash’
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.
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
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?
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)
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
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
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)
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
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
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)
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.
LARS ligament • PET braided rope – extremely strong (Corin)
• Biocompa?ble – fibroblas?c scaffold
• 10M cycles, 6% strain • Loops under coracoid, through oblique clavicle tunnels
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
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?
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