Acromio-Clavicularleds Luxation (AC-separation)
Transcript of Acromio-Clavicularleds Luxation (AC-separation)
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