acj injury myths debunked

Lennard Funk

Three Myths Debunked!

lenfunk@shoulderdoc.co.uk

@theshoulderdoc

AC Joint Injuries

Type 1 Type 2 Type 3

Type 4 Type 5 Type 6

Normal

Rockwood ClassificationFractures in Adults, 1991

“there is a general consensus for nonoperative treatment of Rockwood type I and type II lesions, initial nonsurgical treatment of type III lesions, and operative intervention for Rockwood type IV to VI lesions”

Arthroscopy. Feb, 2013.

Case 1: Would you Fix this?A. Yes

B. No

C. Abstain

Case 2: Would you Fix this?A. Yes

B. No

C. Abstain

“The extent to which beliefs are based on evidence is very much less than believers suppose”

Bertrand Russell The Skeptical Essays, 1928

Myth 1. “Treat according to Grade”

The Grade does not matter

Indications for StabilisationLiterature = Type 4, 5 & 6

The classification of AC joint injuries using radiographs alone has limited reliability and consistency in clinical practice.

Inter-Observer Reliability: • Rockwood classification

–Mean inter-observer agreement = 64.6%–Weighted kappa = 0.258

• Tossy and Allman classification–Mean inter-observer agreement = 68.1%–Weighted kappa = 0.309

Intra-Observer Reliability: • Rockwood classification

–Mean inter-observer agreement = 59.4%–Weighted kappa = 0.150

• Tossy and Allman classification–Mean inter-observer agreement = 67.4%–Weighted kappa = 0.113

“The Rockwood classification system has limited interobserver and intraobserver reliability, even with the help of 3D CT.

Inconsistent agreement with use of this system limits its role in clinical decision-making.”

2014 23:665-70

Clinical Grade?

Clinical Grade?

Instability?

3 months Pain free FROM

Case 1

Case 2

3 months Painful ++

Myth 2. “The clavicle is displaced”

It is a Scapula Injury

‘SICK’ Scapula

Scapular malposition Inferior medial border prominence Coracoid pain & malposition dysKinesis of scapular

Gumina et al. Arthroscopy. 2009

70.6% of patients exhibited scapular dyskinesis 58.3% met criteria for SICK scapular syndrome Patients with dyskinesis = lower Constant & Simple Shoulder Scores

‘Locked Scapula’ (stable)

‘Shocked Scapula’ (unstable)

Myth 3. “Reconstruct the CC Ligaments”

It’s not just about the Coracoclavicular Ligaments

Coracoclavicular Ligaments

Strength – 500N (+/- 134)

Stiffness – 103N/mm (+/- 30)

Uniaxial Tension 25mm/min

Harris et. al. Am J Sports Med. 2000

ACJ Ligaments Two thirds of the superior stability for lesser displacements

90% the posterior stability

Fukuda et al. JBJSA. 1986

Dynamic StabilityDelto-trapezial fascia

Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.

“Many unsatisfactory results could be due to lack of repair of the trapezius and deltoid.

Lizaur et al. JBJS. 1994

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”

My Approach:Scapula Injury:

Separation of the Axial And Appendicular segments

Look for:

Locked Scapula

Shocked Scapula Don’t make decisions on X-Rays or scans

Don’t be hasty to operate

Review:

Coper

Non-coper

My indicationsPatient Demands

Work demands

Society demands

Overhead Athlete

Review 3 weeks

ManagementAcute Injury < 1 week

Review3 months Surgery

Coping Not Coping

Scapula Rehab

Scapula Rehab

Nottingham Approach

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Standard repair

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Modification 1 (2008)

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Modification 2

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ClosureRepair the Superior AC Ligaments

Repair the Delto-Trapezial Fascia

KSSTA, 2014

KSSTA, 2014

THANK YOU

lenfunk@shoulderdoc.co.uk

“The extent to which beliefs are based on evidence is very much less than believers suppose”

Bertrand Russell

@theshoulderdoc