Acromio-Clavicularleds Luxation

(AC-separation)

Anatomi

Conoid lig Trapezoid lig

20 deg motion in each plane (AC)

(35 rotation around axis: cc insertion on coracoid – AC (live MRI, Sahara -07)

Anatomi

•  AC-ligaments Yield strength ≈300N

•  CC-ligaments Yield strength ≈600 N

Dawson et al -09, Fukuda -86

SSSC Superior shoulder suspensory complex

Epidemiology

•  10% of shoulder girdle injuries •  40% of shoulder girdle injuries in NFL

Rockwood classification

Stable injuries Conservative treatment (30 % have persistent symptoms)

Mouhsine 03

1 2

Rockwood classification

4 6

Rare injuries Surgical treatment

Rockwood classification

5 3

+ Deltotrapezial fascia rupture

Surgical treatment Treatment?

Diagnosis?

5 3

+ Deltotrapezial

25-100% displacement Shrug test -> reduction

100-300% displacement Shrug test -> no reduction Neck pain

Testing

Also test A-P instability

AC-Separation Conservative treatment or fixation?

Problems?

•  How to select the patient for operation?

•  How to select the method of repair?

Radiology

1.1-1.3 cm

Operative treatment

Acute – repair •  Anatomical reduction

–  Lig healing

•  Fixation/stabilisation –  Until healed

Late – reconstruction •  Reduction •  Ligament substitution •  Protection •  +/- lat clav resection

Endo button fixation

“Tight rope”

Hook plate

Mimics “normal” stability?

Hook plate

Laterala frakturer

Potential problems of Hook Plate

•  Impingement •  Perforation •  Malposition •  Need for removal

Conservative or fixation?

•  Ceccarelli et al 2008 JOT – Meta-analysis – Lack of evidence (5 RCT from >600 articles)

•  Smith et al JOT 2011 – Meta-analysis – Lack of evidence (6 RCT from >700 articles)

•  Cochrane review 2010 – Articles incl April 2009 – No value of surgical intervention

•  Multi centred prospective •  83 patients (Type III, IV, V) •  Acute <28 days •  Randomized

– operative 40 – non-operative 43

•  45% of the 185 eligible patients •  Plate removal >6 months

–  (mean 8.2 months)

Conclusion

•  Hooked plate superior radiologic alignment •  Non operative had better shoulder scores

early (not tell us Type III vs Type IV/V) •  Follow up Op vs Non op

– 6/12 39/40, 38/43 – 1 year 37/40, 32/43 – 2 year 22/40, 20/43

Summary

•  ACJ dislocation; Rockwood 4, 5 and 6

surgery

•  Rockwood 3; asses patient and injury

Några aspekter på rehab

Några aspekter på rehab

•  Icke kirurgisk beh och behandling med primär fix ( endo-button) låta smärtan styra rehab

Några aspekter på rehab

•  Icke kirurgisk beh och behandling med primär fix ( endo-button) låta smärtan styra rehab

•  Hook-plate, ej abduktion ovan axelhöjd 3-4 mån

Några aspekter på rehab

•  Icke kirurgisk beh och behandling med primär fix ( endo-button) låta smärtan styra rehab

•  Hook-plate, ej abduktion ovan axelhöjd 3-4 mån

•  Rekonstruktion med sengraft, passiv och avlastad träning minst 3 mån