June 11, 2013. Joseph C McCormick III, MD Orthopaedic Surgeon Affinity Medical Group.
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Transcript of June 11, 2013. Joseph C McCormick III, MD Orthopaedic Surgeon Affinity Medical Group.
June 11, 2013
Joseph C McCormick III, MD
Orthopaedic Surgeon
Affinity Medical Group
Disclosure Slide
• Nothing to disclose in terms of financial or industry relationship.
Goals
• Review anatomy of acromioclavicular joint
• Mechanism of injury
• Classification of acromioclavicular injuries
• Define treatment based on grade
• Review of clinical outcomes and biomechanical literature regarding AC Injury
History
• Hippocrates first to distinguish AC injuries from GH joint injuries and to delineate the mechanism of injury
– “Physicians are particularly liable to be deceived in this accident, so that they may prepare as if for dislocation of the shoulder;…”
History• Galen diagnosed his own AC dislocation sustained while wrestling
• Treated himself as Hippocrates suggested with tight bandages to hold clavicle down with arm elevated
• Abandoned this treatment after a few days because it was so uncomfortable
• Hippocrates felt that no “impediment, great or small will result from such an injury”
• Furthermore he stated the deformity cannot be restored to its “natural situation”
• This statement has been received by the ortho community over the years as a challenge.
• First reported surgical procedure for AC dislocation by Cooper in 1861
AnatomyDiarthrodial joint
Has fibrocartilaginous disk
Clavicle rotates with external rot and abduction
AC ligaments stabilize in AP direction, insert on clavicle 1.5 cm from joint – superior and posterior fibers most robust
CC ligaments – predominant restraint to vertical translation
Anatomy
Coraco-clavicular Interval: average 1.1 - 1.3 cm
Trapezoid: attaches anterior and lateral on clavicle Average distance distal clavicle to center 2.54 cm males/ 2.29 cm
females
Conoid: attaches posterior and medial on clavicle Larger of the 2 CC ligmaments Next ligament to fail after AC ligament disruption Ave distance distal clavicle to medial aspect of conoid tuberosity 4.72 cm
males/ 4.28 cm females OKU 4 Sports Medicine
Dynamic stabilizers
Muscles that cross joint important to stability
Anterior deltoid helps to suspend arm from clavicle attachment
Trapezius has confluent fascial attachment over dorsum of acromion
Importance noted in the higher grades of injury, i.e.. Type V
Mechanism
Direct vs. IndirectDirect by far most common
Direct force to acromion with the shoulder adducted, usually result of fall
Acromion moves inferiorly and medially while clavicle is stabilized by the SC joint ligaments
Force results in systematic failure of stabilizing structures as it propagates
AC ligaments/capsule CC ligaments deltotrapezial fascia
Indirect is more rare results from fall onto outstretched
hand/arm with superiorly directed force typically affect AC ligaments only
DiagnosisDuring exam should be sitting or standing w/o support for the injured arm
Check for tenderness to palpation at the AC joint and the CC interspace
If patient can tolerate check joint for stability
Check to see if reducible
Examine SC joint as well
Neurologic exam to r/o brachial plexus injury
Radiographs
AP, axillary lateral and Zanca views can be taken to best assess the joint
Should be taken with the patient upright and no support of injured arm
Stress views ??
Stress Radiographs ?
ASES Survey
81% Not in ER91% No change in
Treatment
Stress views are costly, painful, and don’t often provide new info, so aren’t routinely used anymore
Radiographs
Zanca View Underpenetrated
view 10-15 degree
cephalic tilt
Axillary View Assess horizontal
displacement
Biplanar Instability/Displacement
Vertical Horizontal
Dynamic Axillary View Tauber et al AJSM 2010
Gleno-acromio-clavicular angle
May help detect previously missed horizontally unstable injuries.
Classification
Originally described by Tossy and Allman in the 1960’s
Included types I,II, and III
In 1984, classification modified by Rockwood
Now types IV, V, and VI added, better predictor of prognosis, need for surgical intervention
Type I
No visible deformity
Swelling/pain over AC joint
No pain over CC interspace
Radiographs appear normal
Type II
AC ligaments disrupted
Horizontally unstable
Absent or very minimal vertical instability
Tenderness over CC interspace
Abnormal radiographs
Type III
Horizontal and vertical instability
Radiographically AC joint is dislocated
Pain in CC interspace
Typically pain is greater with Type III and higher injury
Historically more debate with choice of treatment
Type IV
AC joint dislocation
Clavicle displaced posteriorly
AC joint irreducible on exam
Occasionally associated with SC dislocation
Type IV
Type V
All stabilizing ligaments disrupted
Deltoid and trapezius muscles and fascia at least partially detached from clavicle
AC joint irreducible
May develop symptoms due to brachial plexus traction
Type V
Type VI
High energy variant
Result of hyperabduction and external rotation
Distal clavicle comes to rest in subcoracoid position
Summary
Treatment I and IINonsurgical management is uniformly recommended for type I and II injuries
A period of immobilization in a sling for comfort until pain subsides
Usually 7-10 days for type I, up to 2 weeks for type II
Possible anesthetic injection for return to high level play
Unloading foam padding
Once acute pain has subsided rehabilitation program is instituted
Not So Benign?Mouhsine et al JSES 2003
33 patients Grade I and II injuries treated conservatively
27% required surgery within 36 months (6 distal clavicle excision, 3 Weaver-Dunn)
24 pts remaining assessed 6 yrs post injury both clinically and radiographically
Only 16% patients with no radiographic degenerative changes or osteolysis evident
Not So Benign?
Mikek AJSM 2008
23 patients with Type I and II AC Disruption with 10 year Follow-up
52% reported occasional symptoms Constant score 70.5 injured vs 86.8 (P < .001) UCLA score 24.1 vs 29.2 (P < .001) Simple Shoulder Test 9.7 vs 10.9 (P < .002)
RehabilitationEarly focus is on passive and active ROM
Once symmetric and painless ROM achieved then progress to isometric shoulder strengthening
Isotonic strengthening is next with gradual escalation of strength and endurance with return to sport in mind
Return to sport is not allowed until painless/full ROM is achieved and strength has returned.
This may take longer for type II injuries, and some recommend contact sports/heavy lifting should be avoided for 2-3 months
Type III injuries
In 1974 Powers and Bach reported that 92% of 116 type III injuries were treated operatively
Of 163 ortho residency program chairmen surveyed at that time 91.5% advocated surgical treatment
In 1992 Cox surveyed 231 chairmen and 62 orthopedists participating in care of athletes
72% of chairmen favored non-op management 86% of team orthopedists favored no-op management
trend toward non-surgical management is well supported in the literature
Natural History of Type III
Schlegel et al AJSM 2001 Prospective study non-operative treatment of
20 patients with Type III AC injuries assessed strength, ROM, subjective questionnaire
Ave Sling use: 8 days (2-25) Ave return to work: 9 days (1-24)
7 professionals, 8 laborers, 2 students, 3 unemployed/retired
Analgesic discontinued: 1 wk (15); 2 wk (5)
Natural History of Type IIISchlegel et al 1 year resultsAll had full, pain free, symmetric ROM
No statistical difference in dynamometer strength
A statistically significant 17% decrease in bench press strength on injured side was noted
80% favorable subjective results
20% unfavorable 3 of 4 secondary gain bias Only 1 of 4 elected to
undergo surgical intervention
Non-op managementGalpin et al 1984, retrospective review comparing outcome in type III injuries, 21 treated non-op, 16 with surgery (Bosworth screw and ligament repair) avg 3 yr f/u
Showed overall chances of late pain or altered function were not statistically different
Surgical patients took longer to become pain free, and longer to return to work2.8 vs. 4.5 months, and 2.6 vs. 6.8 weeks, respectively
Numbers were limited to correlate treatment with patient demands
Glick et al 1977, retrospective review of 35 AC dislocations treated non-operatively. 29/35 had no pain, none had disabling pain, 31/35 had no weakness, none had disabling
weakness
None of the patients who had supervised rehabilitation complained
8/10 throwers were not affected while throwing, two were professional quarterbacks and one a collegiate javelin thrower
Concluded that complete reduction not necessary for satisfactory function
Randomized prospective trialBannister et al 1989 – 60 patients with acute AC dislocations random number drawn to allocate operative vs. no-op treatment
Faster return to work for manual and clerical workers treated non-operatively
After 4 years of f/u no real difference between the two groups in terms of pain/function with one exception
In the 12 dislocations with more severe dislocation, i.e.. Type V, surgery gave better results
Concluded that younger patients with severe displacement are more likely to achieve an excellent result if stabilized early
Felt that surgical treatment created greater morbidity in the lesser grades of injury
Slight strength loss?Wojtys et al, 1989, retrospective review of 22 patients with type III treated non-operatively
Showed that laborers and athletes can recover strength and endurance, return to pre-injury level of activity without surgery
Strength testing showed some statistically insignificant strength loss, indicating that the strength and endurance advantage one might expect of the dominant arm may be lessened or lost
May be a factor to consider for those requiring high levels of shoulder strength for work/athletics, or those involved in highly repetitious endurance activities such as swimming/pitching
Rarity of type III AC separation precludes study of significant numbers with controls to determine treatment that is best for athletes who rely on their elite throwing ability
McFarland MLB Survey Study 1997
American Journal of Orthopedics, Nov 1997
Phillips et. al CORR 1998 Meta-analysis Type III AC Injury
OP vs NON-OP
Pain absent or minimal 93% 95%
ROM normal/near normal 86% 95%
Strength normal /near normal 87% 91%
Subsequent surgery 59% 6%
Operative results and Timing
Weinstein et al AJSM 1995 44 patients Type III Injury
27 acute, 17 late repairs
CC nonabsorbable suture repair/recon
15/27 and 17/17 CA transfer
89% satisfactory results, 93% return to sports Timing Acute (<3 wk) vs Late (> 3wk)
Satisfactory results 96% vs 77%
Loss of reduction 15% vs 29%
Types IV, V, IV
All require operative intervention
All stabilizers, static and dynamic are injured
Treatment Old School
Not well tolerated, Dermal Complications
Surgical management
Fixation across AC joint
Fixation between coracoid and clavicle
Ligament reconstruction
Distal clavicle excision
Acromioclavicular Fixation
Pin fixation
Has been abandoned since reports of rare pin migration Heart, Lung,
Great vessels
Acromioclavicular fixation
Hook Plate
Only used for acute injury
Requires subsequent surgery for removal
Fixation between coracoid and clavicle
Bosworth popularized the use of a screw for fixation of the clavicle to the coracoid
This technique initially did not include recommendation for repair or reconstruction of the CC ligaments
Today the use of screws and suture loops has been described alone and in combo with ligament reconstruction
Placement of synthetic loops between the coracoid and clavicle can be done arthroscopically, main advantage: doesn’t require staged screw removal
Ligament reconstructionWeaver and Dunn were the 1st to describe transfer for the native CA ligament to reestablish AC joint stability
Their technique described excision of the distal clavicle with this ligament transfer
Construct can be augmented with a suture loop for protection until the transferred ligament heals
Ligament Reconstruction
Open and Arthroscopic techniques
Restore Anatomy
orthoillustrated.com
Anatomic Ligament Reconstruction
Alternative technique is use of semitendinosus autograft for reconstruction
Loop around or fix into coracoid, then fix through two separate clavicle bone tunnels to approximate normal anatomic location of CC ligaments
Recent biomechanical studies have demonstrated the superiority of this construct
Biomechanical studies Lee et al., 2003 – 11 cadaveric shoulders tensile tested to failure comparing suture loop, CA transfer, and free tendon recon
Reconstructions found to have failure strengths as strong as those of native CC ligaments
CA transfer was the weakest construct, and shows that greatest elongation at failure
Concluded tendon graft reconstruction to be an alternative to CA lig transfer possibly providing a permanent biologic reconstruction
Given its biomechanical properties similar to native CC ligaments, reconstruction with tendon graft may allow for shorter post op immobilization and accelerated rehab program
Biomechanical studies
Mazzocca et al, 2006, studied 42 cadaveric specimens comparing stability of 3 AC joint reconstruction techniques
Anatomic CC reconstruction with tendon graft provided ant, post, and superior stability similar to intact state
Modified Weaver-Dunn had significantly greater laxity compared to anatomic CC recon and arthroscopic reconstruction
Concluded that anatomic reconstruction with free tendon graft may provide stronger, more permanent biologic solution for AC joint dislocation
Newer proposed techniquesGrutter and Petersen 2005 AJSM (Cadaveric study)
Anatomic Reconstruction using FCR graft to reconstruct CC and superior AC ligament
Similar strength as native AC joint in coronal plane
Newer Proposed TechniquesFreedman et al AJSM 2010 (Cadaveric study)
Intramedullary AC reconstruction with 5 cm semitendinosus graft and fibertape
AP translation Intact: 2.34 - 7.86 mm Recon: 1.20 - 2.95 mm
Superior/Inferior translation Intact: 2.56 - 6.16 mm Recon: 2.42 - 4.57 mm
Did not reproduce similar stiffness, load to failure, and energy absorption as intact AC complex
Newer proposed techniques
Improved horizontal stability with addition of intramedullary AC ligament reconstruction. -50% less AP translation
No difference in: - Superior/inferior translation - Load to failure
AJSM 2010
ComplicationsNon operative Pain Post traumatic arthritis/osteolysis Possible neurologic injury Possible strength deficit
Surgical Same as above plus… Clavicle or coracoid fracture Loss of reduction Pneumothorax Neurovascular injury
SummaryType I, II
restricted activity initially Analgesic, Injection Rehabilitation
Type III Controversial- trends toward initial non-operative
management Late reconstruction if symptomatic Optimal strategy has changed and alternated over
time
Type IV,V, VI Repair/reconstruction
Case
HPI: 21 yo R HD male college student presents to clinic after fell off bike over the handle bars onto his R shoulder
Exam: Ecchymosis, Gross deformity R AC joint TTP distal clavicle and CC interspace Distally NVI R upper extremity
Radiographs
Post op
Acute CC repair with Fiberwire Suture Loops
References• Bannister, G, Wallace, W, Stableforth, P.G.: The Management f Acute Acromioclavicular Dislocation. JBJS(Br) 1989; 71-B:848 -50
• Galpin, R, Hawkins, R, Grainger, R: A Comparative Analysis of Operative Versus Nonoperative Treatment of Grade III Acromioclavicular Separations. CORR 1985;193:150-155
• Glick, J, Milburn, L, Haggerty, J, et al: Dislocated acromioclavicular joint. Follow-up study of 35 unreduced acromioclavicular dislocations. Am J Sports Med 1977;5: 264-270
• Lemos, M: The Evaluation and Treatment of the Injured Acromioclavicular Joint in Athletes. Am J Sports Med 1998;26:137-144
• Lee, S, Nicholas, S, Akizui, K, et al: Reconstruction of the Coracoclavicular Ligaments with Tendon Grafts. Am J Sports Med 2003;31:648-654
• Mazzocca, A, Santangelo, S, Johnson, S, et al: A Biomechanical Evaluation of an Anatomical Coracoclavicular Ligament Reconstruction. Am J Sports Med 2006;34:236-246
• McFarland, EG, Blivin, SJ, Doehring, CB, et al: Treatment of Grade III Acromioclavicular Separations in Professional Throwing Athletes. Am J Orthop 1997;11:771-774
• Simovitch, R, Sander, B, Lavery, K, et al: Acromioclavicular Joint Injuries: Diagnosis and Management. JAAOS 2009;17:207-219
• Wojtys, E, Nelson, G: Conservative Treatment of Grade III Acromioclavicular Dislocations. CORR 1991;268:112-119
• Galatz, L, Williams, G: Acromioclavicular Joint Injuries. Rockwood and Green’s Fractures in Adults, 5 th ed. 2002;1210-1244
• Mazzocca, A. Arciero , R . Evaluation and Treatment of Acromioclavicular Joint Injuries. Am J Sports Med 2007 35: 316
• Grutter, P. Petersen, S. Anatomical Acromioclavicular Ligament Reconstruction. Am J Sports Med 2005 33: 1723
• Mikek, M. Long-Term Shoulder Function After Type I and II Acromioclavicular Joint Disruption. Am J Sports Med 2008 36: 2147
• Schlegel, T et al. A Prospective Evaluation of Untreated Acute Grade III Acromioclavicular Separations. Am J Sports Med 2001 29: 699
• Gonzalez-Lomas, G et al. Intramedullary Acromioclavicular Ligament Reconstruction Strengthens Isolated Coracoclavicular Ligament Reconstruction in Acromioclavicular Dislocations. Am J Sports Med 2010 38: 2113
• Tauber, M, et al. Dynamic Radiologic Evaluation of Horizontal Instability in Acute Acromioclavicular Joint Dislocations. Am J Sports Med 2010 38: 1188
• Mouhsine E, Garofalo R, Crevoisier X, Farron A. Grade I and II acromioclavicular dislocations: results of conservative treatment. J Shoulder Elbow Surg. 2003;12:599-602
• Phillips A, Smart C, Groom A. Acromioclavicular dislocation. Clin Orthop Relat Res. 1998;353:10-17
• Weinstein, D et al Surgical Treatment of complete acromioclavicular dislocations. AJSM 1995 23: 324-330
• Kibler, B. AAOS OKU Sports Medicine 4 2009• Google Images
Thank You
• Questions?