Anatomic-Biological Reconstruction

of Acromio-clavicular Joint Injuries

Dr Utsav AgrawalDr Vikram Sapre

Dr Samir Dwidmuthe

Department of OrthopaedicsLata Mangeshkar Hospital

Nagpur

INTRODUCTION Analysis of shoulder function in 11 patients with chronic

(>6weeks) acromio-clavicular joint injuries managed by

ANATOMIC-BIOLOGIC

ACROMIO-CLAVICULAR JOINT RECONSTRUCTION

• > Grade III injuries

• A Retrospective case series

• Study period of 2 years with a minimum follow-up of

6 months

• All patients were evaluated by questionnare based on Constant score and ASES score (Association of shoulder and elbow surgeons) for shoulder function.

Cause

Direct injury

Fall on lateral aspect of shoulder

on an adducted arm

• Lead to chronic shoulder pain

and instability

• Should thus be managed

actively, especially in arm

dominant individuals

Stabilizers of AC joint

AC Ligament

Trapezoid and Conoidpart of CC ligment

Classification

Management Options

Conservative

Intra-articular fixation

Extra-articular fixation

Acromio-clavicular joint reconstruction

Bosworth Screw Weaver-Dunn Procedure

Sood A, Wallwork N, Bain GI.

Int J Shoulder Surg. 2008 Jan;2(1):13-21.

The traditional surgeries for acromioclavicular joint disruptions like Bosworth’s Screw , Modified Weaver-Dunn procedure, has been

associated with high rate of recurrence of deformity and complications

Thomas K, Litsky A, Jones G, Bishop JY. Am J Sports Med. 2011 Apr;39(4):804-10

Compared five different techniques for reconstruction of AC joint and concluded :

Anatomic AC joint techniques gives biomechanically more stringer construct when compared to traditional

techniques.

Lee SJ, Keefer EP, McHugh HP, et al. Am J Sports Med. 2008;36:1990.Cadaver study

All of the un-augmented Weaver-Dunn reconstructions failed with low loading. None of the augmented (with ethibond #5) Weaver Dunn reconstructions failed at low load while all failed under high load.

The semitendinosus graft reconstructions did not fail under the low- or high-load conditions.

27 cases of anatomic ACJ reconstruction - 10 cases with coracoid tunnel and 17 cases of coracoid sling. They found high incidence of complication with coracoid tunnel(80%) as compared to sling technique(35%).They concluded that newer techniques have high complication rates more in

coracoid tunnel technique. They emphasized the real danger of clavicle fracture while drilling two tunnels in clavicle.

Milewski MD, et alAm J Sports Med. 2012 Jul;40(7):1628-34.

Anatomic-Biologic Acromio-clavicular Joint reconstruction

Open reconstruction of coracoclavicular ligament (both conoid and trapezoid part) and acromioclavicular ligament with semi-tendinosus graft

2 tunnels in clavicle and looping semi-tendinosus from under coracoid

• 40 years, Male patient

• Pain in right shoulder

• History of Road traffic accident

Deformity at right shoulder

Radiography

Semitendinosus Harvested from Ipsilateral Knee

Marking anatomical landmarks

Vertical incision from ACJ to coracoid

Osteotomyat Lateral end of Clavicle

8-10 mm of lateral end clavicle excised

Tunnels created for graft placementMazzocca et al. The anatomic coracoclavicular ligament reconstruction.

Op Tech in Sports Med, Vol12, No1 (Jan), 2004: 56-61

2 Tunnels created in clavicle for conoidand trapezoid part of CC ligament

Looping the graft and

2 strands of ethibond No.5

Stetnsky clamp

Graft hooked from under coracoid and fixed over clavicle with endo-button

Final Reconstruction

PRE-OP Immediate POST-OP

AT 1 year

Constant score Pain 15

Activities of Daily living 20

ROM 40

Power 25

Total Score 100

ASES

Valuation Score

Excellent 91-100

Good 81-90

Satisfactory 71-80

Adequate 61-70

Poor <60

10 RG4 42 Male Aug’13 No loss of reduction 96.66 14 19 38 22 93 Excellent

11 NOC 2 44 Male Jan ’14 Satisfactory reduction 91.22 13 20 36 21 90 Excellent

Sr.

No

Patien

t Age Sex

D.O.S

x Post op xrays

ASES

score pain /15 ADL/20 ROM/40

Power

/25

Total

Scor

e Result

1 LMH 1 45 male Oct-11

Reduction

maintained,no osteolysis 96.66 15 20 40 22 97 Excellent

2

LMH

2 55 male

Mar-

12

Reduction Maintained,

Superficial Infection 89.99 10 18 40 24 92 Excellent

3 NOC 25 male Apr-12 reduced 89.97 15 14 40 20 89 Excellent

4 NOC 1 34 male

Nov-

12

min loss of reduction

<5mm 89.99 15 16 40 18 89 Good

5 MT 1 46 male Jan-13 Reduction maintained 88.32 10 18 40 22 90 Good

6 MT2 54 male Jan-13 Reduction maintained 96.66 15 18 40 24 97 Excellent

7 RG 1 49 male Feb-13 Reduction maintained 93.32 15 16 40 22 93 Excellent

8 RG 2 52 male

May-

13 Reduction maintained 86.66 10 16 40 20 86 Excellent

9 RG3 47 male Jun-13 Reduction maintained 69.99 10 12 40 13 75 Satisfactory

RESULTS

Out of 11 patients

8 had excellent outcome

2 good outcome

and

1 satisfactory outcome

Complications Minimal loss of reduction in one patient (<5mm)

Wound edge necrosis in 1 patient

No clavicle fracture/osteolysis

Conclusion The anatomic coracoclavicular joint reconstruction

technique is designed to place tendon grafts in the exact anatomic location

Also attempts to reproduce AC ligament

Use of internal splint with ethibond helps to keep joint reduced till ligamentization occurs

Endobutton helps preventing cut through of tunnels

Looping of graft from under coracoid avoids chances of fracture

Use of minimal and cheaper implants

Drawbacks of study and technique Less no. patients studied

More biomechanical studies are required to validate the procedure

Need long term evaluation to know specific complications of the procedure

Dr Utsav Agrawal

N.K.P. Salve Institute of Medical sciences

Nagpur