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ACJ Injury Rugby
Lennard Funk
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Questions:
What is the Grade? Should we operate?
Why? When? How?
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Rockwood Classification
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What Grade?
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We conclude that the classification of AC joint injuries using a radiograph alone has limited reliability and consistency in clinical practice.
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Indications for Stabilisation Literature = Type 4, 5 & 6
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Treatment?
Operative
Non-operative
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When?
Ceccarelli et al. 2008
“From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, but complications are more evident in the surgery group.
Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation.
More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.”
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Bradley & Elkousy, Clin Sport Med, 2003
“The only advantage to operative intervention consistently borne out in the literature is an increased probability of anatomic reduction.
There is no correlation between reduction and improvement in pain, strength, or motion, however.”
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Athletes Following ACJ Dislocations:
30% of overhead athletes had to reduce sport
9% had to change sport Climbers and patients
performing strength training had to reduce their activities or give up sports
Altered activities in overhead ball sports
Rangger et al. Orthopade 2002 Jun;31(6):587-90
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164 US Naval Cadets
Ongoing symptoms at 6 months: 36% of Grade 1
48% of Grade 2 Major in 13%
Minor in 35%
69% of Grade 3
Cox. Am J Sports Med, 1981
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High Demand
What about rugby? Often able to play Unable to train
Modern day expectations
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Indications
• Symptoms(• Pa+ent(Demands(
– Work(demands(– Society(demands(
• Overhead(Athlete(
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Review 3 weeks
Approach
Acute Injury < 1 week
Review 3 months Surgery
Coping Not Coping
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Surgical procedures
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Coracoclavicular Ligaments
Strength – 500N (+/- 134) Stiffness – 103N/mm (+/-
30) Uniaxial Tension 25mm/min
Harris et. al. Am J Sports Med. 2000
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Harris et al. AJSM 2000
“None of the reconstruction techniques analyzed in the present study were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”
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ACJ Ligaments
Two thirds of the superior stability for lesser displacements
90% the posterior stability
Fukuda et al. JBJSA. 1986
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Dynamic Stability
Delto-trapezial fascia Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
Lizaur et al. JBJS. 1994
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My Experience
2001 2006
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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]
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LARS Ligament
3 weeks post-op
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LARS Ligament Outcomes
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Wright & Funk, 2010. BESS
LARS Ligament Outcomes All patients returned to their previous level of work &
sports post LARS reconstruction in a mean time of 3 months
The mean patient satisfaction score was 93%
In one patient who did not follow the prescribed rehabilitation protocol the reconstruction failed in the early postoperative period.
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LARS Ligament Outcomes The median postoperative residual displacement of the ACJ
was 15%.
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