Complications of Operative and Nonoperative

treatment of AC injuries in 2017

How these influence my decisions

Dr. MingXiang

Department of upper limb of SCOH

Diathroidal joint of variable inclination

Intra-articular disk

Degenerates after 40yrs

Clavicular articular surface smaller

than acromial facet

Anatomy of AC joint

Disk Anatomy

•Articular disk

• Variable and often incomplete or missing

• Effect of disk anatomy on arthritis development

• Unknown

Emura et al(2014) Anatomical observations of the human acromioclavicular joint:

Structure of the Human Acromioclavicular Joint. Clinical Anatomy 27(7)

AC ligament

• AC ligaments prevent horizontal

displacement of the clavicle

Superior AC ligament 56%

Posterior AC ligament 25%

• CA ligament does not play a

significant role in AC stability

Klimkiewicz et al 1999 JSES

Fakuta et al 1986 JBJS

CC Ligaments (coracoclavicular) The trapezoid ligament provides

resistance to acromioclavicular joint

compression

The conoid ligament responsible for

60% of the restraint

to anterior and superior clavicular

displacement and rotation

Trapezoid: 25.4mm(M)，22.9mm（F）Conoid : 47.8mm(M)，42.8mm（F）

Fukuda K, et al. Biomechanical study of the

ligamentous system of the acromioclavicular joint.

J Bone Joint Surg Am. 1986 Mar;68(3):434-40

CC (coracoclavicular) Ligaments

•CC ligaments prevent

vertical displacement

and secondarily prevent

horizontal displacement

Conoid ligament is a posterior structure

Clavicular Rotation

Clavicle rotates 40- 50 degrees on its long axis in

synchrony with scapular motion in arm elevation

Only 5- 8 degrees of motion at A-C joint

Mechanism of Injury

Direct Force: Direct trauma to the shoulder from a fall or in contact sports when the arm is in

an adducted position

Indirect Force：A fall on an outstretched hand or flexed elbow may transmit direct forces

superiorly to the acromioclavicular joint through the humeral head into the acromion

Pathology of AC injuries

Superior or postero-superior migration

of distal clavicle

Changes in the orientation of the scapula

and the rotator cuff

Chronic painful Scapular dyskinesis or

SICK scapula syndrome

Mazzocca AD, Bicos J (2007) Evaluation and treatment of acromioclavicular joint

injuries. Am J Sports Med 35:316–329.

Murena L (2013) Scapular dyskinesis and SICK scapula syndrome following

surgical treatment of type III acute acromioclavicular dislocations. Knee Surg Sports

Traumatol Arthrosc 21:1146–1150

Classification of ACJ dislocation (Rockwood)

Physical Examination

Limited by concomitant problem(RC,SLAP,BT,Labrum,etc)

Most Specific __O’Brien Active Compression Test

Most Sensitive__Cross-Body Adduction Stress Test

Chronopoulos E et al. Diagnostic value of physical tests for

isolated chronic acromioclavicular lesions. Am J Sports Med 2004

Associated glenohumeral lesions （SLAP，RCT）18-30%

Long learning curve

Natera L, Sarasquete Reiriz J, Abat F (2014) Anatomic reconstruction

of chronic coracoclavicular ligament tears: arthroscopic assisted approach

with nonrigid mechanical fixation and graft augmentation. Arthrosc Tech

15;3(5):e583-8.

Pauly S, Kraus N, Greiner S, Scheibel M (2013) Prevalence and pattern

of glenohumeral injuries among acute high-grade acromioclavicular joint

instabilities. J Shoulder Elbow Surg 22:760–766.

Arthroscopic or arthroscopically assisted

reconstruction of ACJ separations

Strongly Consider Diagnostic Shoulder Arthroscopy before AC Repair

Tischer and Imhoff et al 2009 AJSM

Type III AC dislocation

• Patients have changed

– More active

• Surgical techniques have changed

– Arthroscopic or arthroscopically assisted

• Cosmesis

• Modified Rockwood classification

– Grade IIIA ( therapy)

– Grade IIIB (Surgical)Beitzel K et al ISAKOS upper extremity committee consensus

statement on the need for diversification of the Rockwood

classification for acromioclavicular joint injuries. Arthroscopy 2014

Chronic type III AC dislocation

34 patients

24 (70.6%) had scapular dyskinesis with

the arms at rest, and 14 of these (58.3%)

had SICK scapula syndrome

Dyskinesis might be due to loss of the

stable fulcrum of the shoulder girdle

represented by the AC joint and due to

the superior shoulder pain caused by the

dislocation

Gumina S et al. Scapular Dyskinesis and SICK Scapula Syndrome in Patients

With Chronic Type III Acromioclavicular Dislocation. Arthroscopy 2009

CC Repair

• Bosworth Screw

• Good Clinical Results

• Complications

– Screw loosening

– Malpostion

– Screw Breakage

– Destruction of Coracoid

• Bosworth BM Ann Surg 1948

• Ballmer F JBJS B:1991

• Asaghir JM,J Trauma 2011

• Cerclage(Ethibond, PDS, Dacron tape ect)

• Good Clinical Results

• Complications

– Redislocation 44%

– Infection Rate

• Marecchiani GM,KSSTA:2014

• Greiner S,Arch Orthop T Surg:2009

• Stam L,Injury:1991

• Anchors• Good Clinical Results

• Complications– Pull out

• Morrison DS,AJSM:1995

• Choi SW,AJSM:2008

• Buttons(Endobutton,Tight rope,MINAR…)

• Single strand

• Double strand(Anatomical repair)

• Complications– Destroy every ligament remnants

– Coracoid or clavicle fractures – Hardware migration – Tunnel widening

• Cook JB ,JSES:2012• Kany J, Eur J Orthop Surg Traumatol. 2012 • Scheibel M, Am J Sports Med. 2011 • Petersen W,Oper Orth Trauma:2010

• Salzmann M,AJSM:2010

CC Repair

Acute:AC Repair

• Hook Plate• Good Clinical Results

• Complications– 10-22% Vertical loss

– Acromion erosion

– Secondary operation(Removal)

• Eslola A,J Orthop Trauma:1991

• Liam S,Acta Orth Belg:2008

• Kienast B,Eur J Med Res:2011

• Chiang CL,JSES:2010

• Pin/Cerlage Fixation• Good Clinical Results

• Complications– 10-22% Vertical loss

– Pin migration,

– AC joint destruction

– 4%-15%

• Eslola A,J Orthop Trauma:1991

• Leidel BA,J Trauma:2009

12W

AC Dislocation associated with coracoid fracture

CC/AC ligaments may lack healing potential 3 weeks

after the injury

Therapeutic approach for chronic ACJ instability

should be different from that for acute ACJ

instability

Management of chronic ACJ instability must involve

biological augmentation except mechanical fixation

Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU (1995) Surgical treatment of complete

acromioclavicular dislocations. Am J Sports Med 23:324–331.

Natera L, Sarasquete Reiriz J, Abat F (2014) Anatomic reconstruction of chronic coracoclavicular ligament tears:

arthroscopicassisted approach with nonrigid mechanical fixation and graft augmentation. Arthrosc Tech

15;3(5):e583-8.

Chronic AC dislocation

Coracoacromial(CA) ligament transposition

• Classical method

– Original Weaver–Dunn.

– Modified Weaver–Dunn

Boileau P, (2010) All-arthroscopic Weaver–Dunn–Chuinard procedure with double-button fixation for chronic

acromioclavicular joint dislocation. Arthroscopy 26(2):149–160

Weaver JK, Dunn HK (1972) Treatment of acromioclavicular injuries, especially complete acromioclavicular

separation. J Bone Joint Surg Am 54-A:1187–1194.

Chronic AC dislocation

Modified Weaver–Dunn(Dr.Jiang CY)Transposition of lateral part of joint tendon

• Infection rates

– Arthroscopy 3.8%

– Open surgery 5%

– Open tendon grafting 8%

Woodmass JM, (2015) Complications following arthroscopic fixation of

acromioclavicular separations: a systematic review of the literature. Open

Access J Sports Med 6:97–107.

Tauber M, (2009) Semitendinosus tendon graft versus a modified Weaver–

Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a

prospective comparative study. Am J Sports Med 37:181–190.

Modi CS, (2013) Controversies relating to the management of

acromioclavicular joint dislocations. Bone Joint J 95-B(12):1595–1602

Arthroscopy-assisted Vs Open surgery

Anatomical reconstruction

of the CC and AC ligaments

Deshmukh AV (2004) Stability of acromioclavicular joint reconstruction: biomechanical testing of various surgical techniques in a cadaveric

model. Am J Sports Med 32:1492–1498.

Carofino BC, (2010) The anatomic coracoclavicular ligament reconstruction: surgical technique and indications. J Shoulder Elbow Surg 19:37–46.

Yoo YS, (2011) Arthroscopically assisted anatomical coracoclavicular ligament reconstruction using tendon graft. Int Orthop 35(7):1025–1030.

Abat F, (2015)Biomechanical analysis of acromioclavicular joint dislocation repair using coracoclavicular suspension devices in two different

configurations. J Orthop Traumatol 16(3):215–219.

New trends addresses both planes

CCD difference

Horizontal instability

Reduce the lateral as well as

inferior scapular displacement to

provide scapular rotatory stability

Reconstructions

Anatomical Vs non-anatomical

It is currently clear that anatomical procedures are superior

to the classical or modified Weaver–Dunn technique by

taking into consideration the biomechanics and the

resistance of the reconstruction

Michlitsch MG, (2010) Biomechanical comparison of a modified Weaver-Dunn and a free-tissue

graft reconstruction of the acromioclavicular joint complex. Am J Sports Med 38:1196–1203

Grutter PW, (2005) Anatomical acromioclavicular ligament reconstruction: a biomechanical

comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 33:1723–

1728.

Tauber M, (2009) Semitendinosus tendon graft versus a modified Weaver–Dunn procedure for

acromioclavicular joint reconstruction in chronic cases: a prospective comparative study. Am J Sports

Med 37:181–190.

Synthetic Grafts

LARS、Dacron,ect

Many authors reported in their study that they are currently rejecting

the use of synthetic graft, and advising against its use.

The high failure rate of graft tears, clavicular osteolysis, re-dislocations

Fraschini G, (2010)Surgical treatment of chronic acromioclavicular dislocation: comparison between two surgical procedures

for anatomic reconstruction. Injury.

Mares O, (2010) Acute grade III and IV acromioclavicular dislocations: outcomes and pitfalls of reconstruction procedures

using a synthetic ligament. Orthop Traumatol Surg Res.

Marcheggiani Muccioli GM, (2014) Acromioclavicular joint reconstruction with the LARS ligament in professional versus

nonprofessional athletes. Knee Surg Sports Traumatol Arthrosc.

Fauci F, (2013)Surgical treatment of chronic acromioclavicular dislocation with biologic graft vs synthetic ligament: a

prospective randomized comparative study. J Orthop Traumatol .

Autograft or Allograft

• Semitendinosus tendon

• Palmaris longus

Fixation method of the tendinousgraft in the coracoid process

Subcoracoid suture loops

A shear deleterious effect on the bone

Tend to dislocate anteriorly if pass the graft around the caudal portion of the

coracoid

If there is no contact between the cancellous bone and the collagen

of the tendon graft , integration of the graft might not be developed

Natera-Cisneros L, (2015) Treatment of chronic acromioclavicular joint instability. Acta Ortop

Mex 29(3):164–171

Guttmann D, (2000) Complications of treatment of complete acromioclavicular joint dislocations.

Instr Course Lect 49:407–413

Mumford procedure Distal clavicle Resection(DCR)

Degenerative changes in the articular disc and lateral end of the clavicle always

be found during surgery and might be a source of pain in high-grade injuries

Resection of only 5 mm of the distal third of the clavicle to avoid injure the

insertion of trapezoid ligament

The key is adequate resection without creating iatrogenic ACJ instability

Snyder SJ, (1995) The arthroscopic Mumford procedure: an analysis of results.

Arthroscopy 11(2):157–164

Rios CG, (2007) Anatomy of the clavicle and coracoid process for

reconstruction of the coracoclavicular ligaments. Am J Sports Med 35:811–817

Making decisions based on avoiding complication

Conservative treatment

Most TpyeⅠ-Ⅱand stable TpyeⅢ

Surgical treatment

Unstable TpyeⅢ and TpyeⅣ-Ⅵ

Repair CC ligament and/or AC ligament for acute patients

Biological augmentation except mechanical fixation must be

considered for chronic cases

My suggestion

1.Technique: anatomical > non-anatomical.

2.Procedure: arthroscopy-assisted> open.

3.Graft: biological > synthetic.

4.Distal clavicle: resection(<5mm) > remain.