current concepts in the management of acromioclavicular
TRANSCRIPT
Current Concepts in the Management of Acromioclavicular Injuries
Gregory N. Lervick, MD
CAQ in Orthopaedic Sports Medicine Twin Cities Orthopedics, Edina, MN Team Physician, Minnesota Vikings
Instructor, Shoulder and Elbow Surgery, MOSMI/Fairview Sports Medicine Fellowship Program
Current Concepts in the Management of Acromioclavicular Injuries
The following relationships exist:
1. Royalties and stock options: None
2. Consulting income: – None
3. Research and educational support – Tornier – Smith and Nephew
4. Other support: None
AC Injuries
EPIDEMIOLOGY • Common in hockey, football, wrestling, bicycling
• Majority in 1st 4 decades of life
• 5-10x more common in males
• Majority lower severity grade Fraser-Moodie et al, JBJS-B 2008
Pallis et al, AJSM 2012
AC Injuries
EPIDEMIOLOGY
• Most prevalent shoulder injury at NFL combine – 27% of all athletes – 12% required surgery
Kaplan et al, AJSM 2005
• 2nd only to upper leg contusions in NCAA football Dick et al, J Ath Training 2007
• 45% of all shoulder injuries in NCAA quarterbacks Tummala et al, Orth J Sports Med 2018
AC Injuries
ANATOMY
• Diarthrodial joint
• 6 degrees of freedom
• Hyaline cartilage
• Joint capsule
• Intra-articular disk of varying size/shape
AC Injuries
ANATOMY
• 3D kinematic analysis
• Open vertical MRI
• 14 shoulders – AP translation about 2 mm in
abduction/adduction of shoulder – Slight superior inferior translation with
movement – Scapula rotates through a specific screw axis
passing through insertions of both the AC and CC ligaments
– Average scapular rotation 34.9 deg Sahara et al, J Orth Res 2006
AC Injuries
ANATOMY
• Static stabilizers –AC ligaments –CC ligaments –CA ligament
• Dynamic stabilizers –Deltotrapezial
aponeurosis
Need pic and update references/discussion
AC Injuries
ANATOMY • AC ligaments – Horizontal stability – Posterior and
superior most critical
Klimkiewicz et al, JSES 1999
• CC ligaments – Vertical stability – Particularly true at
higher loads Fukuda et al, JBJS-A 1986
Costic et al, Scand J Med Sci 2004
AC Injuries
MECHANISM
• Direct trauma –Most common –Blow or fall on lateral
acromion with arm neutral or adducted
• Indirect reported – Fall on outstretched
hand
AC Injuries
PRESENTATION
• Ecchymosis
• Abrasion
• Pain
• Swelling
• Prominence of lateral clavicle
• Gross instability
• horizontal
• vertical
AC Injuries
PHYSICAL EXAMINATION • C spine evaluation
• Resting posture
• SC joint
• AC joint – Tenderness – Swelling – Translation/instabili
ty – Cross body
adduction – Always compare!
AC Injuries
PHYSICAL EXAMINATION
• Active range of motion
• Rotator cuff exam – Particularly in older
pts – Concomitant injuries
possible
• Labral pathology – Difficult to
differentiate on exam
• Serial examinations in training room
AC Injuries
IMAGING • Plain radiography – True AP clavicle – Axillary – Zanca Mazzocca et al, AJSM 2008
• Comparison films
• Stress views not necessary
• CT to evaluate fxs
• MRI to rule out associated soft tissue injury
Tischer et al, AJSM 2008
Jensen et al, Int Ortho 2017
AC Injuries
CLASSIFICATION
• Type I: – Sprained AC
ligaments – Intact CC
ligaments
AC Injuries
CLASSIFICATION
• Type II: – Ruptured AC
ligaments – Sprained CC
ligaments – Mild superior
translation of clavicle
AC Injuries
CLASSIFICATION
• Type III:
• Ruptured AC ligaments
• Ruptured CC ligaments
• Clavicle displaced superiorly 100% of diameter
AC Injuries
CLASSIFICATION
• Type IV: – Ruptured AC
ligaments – Ruptured CC
ligaments – Clavicle displaced
posterior relative to acromion
– Herniation of clavicle into or through deltotrapezial fascia
AC Injuries
CLASSIFICATION
• Type V: – Ruptured AC
ligaments – Ruptured CC
ligaments – Deltotrapezial
fascial injury – Clavicle superiorly
displaced 100-300% of its diameter
AC Injuries
CLASSIFICATION
• Type VI: – Clavicle
displaced inferior to coracoid / conjoint tendon
– Case reportable
AC Injuries
TYPE I/II INJURY MANAGEMENT
• Nonsurgical initially – May not be as benign as
once thought – Distal clavicle osteolysis – Mild instability with
subsequent arthrosis – 52% residual symptoms
at 10 yr follow up Mikek, AJSM 2008
– 27% required subsequent surgery at mean 26 mos.
Moushine et al, JSES 2003
AC Injuries
TYPE I/II INJURY MANAGEMENT
• Treatment of residual symptoms controversial – Distal clavicle resection
• Conflicting evidence • Some suggest loss of
strength, poor function • Others demonstrate success
– Ligament reconstruction – Different recovery periods – Implications for athletes
with need for rapid return to play
– No consensus!
AC Injuries
TYPE III INJURY MANAGEMENT • Historically controversial
• Nonsurgical tx still emphasized for acute injuries – 86% in prior survey Nissen / Chatterjee, Am J Ortho 2007
– Recent meta-analysis still argues that nonsurgical appropriate
Tang et al, Medicine 2018
– Canadian randomized control trial: no advantage to early surgery with hook plate
Mah et al, J Orth Trauma 2017
• No conclusive evidence that early surgery is better
AC Injuries
TYPE III INJURY MANAGEMENT
• Residual symptoms – Shoulder fatigue – Weight bearing and
loading complaints – Cosmetic – Pain
AC Injuries
TYPE IV/V INJURY MANAGEMENT
• Surgical
• Little debate
• Early better than delayed
• Skin lesions frequent – Increases infection
risk – Surgery may be
delayed until these resolve
AC Injuries
NONSURGICAL TREATMENT
• Phase I – Rest, ice, prn sling – AAROM rotation, elev/depression – Isometrics at low arm position
• Phase II – Full ROM exercises – Delt,rc, periscapular strengthening – Avoid bench, military presses
• Phase III – Presses – Sport specific
AC Injuries
NONSURGICAL TREATMENT
• Equipment modifications – High density padding – Custom equipment
• Return to play on strength and ROM criteria
• Injection?? – Anesthetic – Corticosteroid – Biologics – Placement in question
(40% accuracy rate) Bisbinas et al, Knee Sports Trauma
Arthr 2006
AC Injuries
SURGICAL INDICATIONS
• Type I/II/III with residual sxs – Arthrosis – Instability
• Type IV-VI acutely
• Numerous techniques
AC Injuries
SURGICAL GOALS: 2018
• Provide a durable reconstruction
• Restore and maintain normal anatomy
• Maximize functional return
• Minimize iatrogenic complications
• AC joint reconstruction: – No consensus on surgical technique •Non-anatomic •WD, modified WD
• Anatomic –MINAR –Dog Bone endobutton –LockDown –+/- graft (auto v. allo)
• Internal fixation • hook plate, Bosworth screw
• Arthroscopic and open approaches Simovitch et al, JAAOS 2009
Beitzel et al, Arthroscopy 2013
AC Injuries
SURGICAL GOALS: 2018
• Nonanatomic procedures – CA ligament transfers
(Weaver-Dunn) JBJS-A 1972
– Modified Weaver-Dunn
• Temporary fixation – Bosworth screw
– Absorbable suture
– CC stabilization
• Largely successful
AC Injuries
SURGICAL TX HISTORY
AC Injuries
SURGICAL OUTCOMES
• Modified Weaver-Dunn – Jiang et al, JBJS-A 2007 – 38 pts – Selected III, IV-V injuries – 89% satisfaction – 84% return to same level sport – 92% return to same level work
AC Injuries
SURGICAL OUTCOMES
• Why not a modified Weaver-Dunn? – Biomechanical concerns – Lee et al, AJSM 2003
• Free grafts stronger than suture or CA ligament • Load to failure for free grafts similar to native CC
ligaments (650 N)
– Mazzocca et al, AJSM 2006 • Anatomic reconstruction has superior mechanical
strength • Less AP clavicle translation
AC Injuries
ANATOMIC RECONSTRUCTION
• Tunnels at conoid and trapezoid ligament origins
• 6mm tunnels
• 5.5mm biotenodesis fixation
• Semitendinosis free graft Mazzocca et al, AJSM 2006
• Graft without augment / support likely inadequate Choi et al, JSES 2017
AC Injuries
ANATOMIC RECONSTRUCTION
• Coracoclavicular ligament reconstruction
• Auto or allograft
• Interference screw fixation?
• Bone tunnels in clavicle
• Anatomy reproduction
AC Injuries
ANATOMIC RECONSTRUCTION
• Coracoid fracture Gerhardt et al, JSES 2011
• Clavicle fracture Turman et al, JBJS-A 2010
• Learning curve
• More complex surgery = more problems?
Milewski et al, AJSM 2012
AC Injuries
ANATOMIC RECONSTRUCTION • Surgical concepts 2018 – Anatomic drill hole
location – SMALL drill holes – Subcoracoid suture
passage – Triple suture
technique – Extracortical graft Clevenger et al, Arthroscopy
2011
– Avoid interference screws
Tashjian et al, JSES 2012
AC Injuries
AFTER SURGERY
• Post-surgical care is important! – Conservative – Shoulder sling x 6 wks – Protected elbow/wrist ROM – Some aerobic activity – Delt isometrics at 4 wks
• Progress to full AROM/gradual strength program at 6 wks
• Full weight program at 10-12 wks
• Full activity 18-20 wks
AC Injuries
SUMMARY
• Common injuries
• Prevalent in collision athletes
• Majority direct trauma
• Majority of lower severity
• Treatment types I-III: generally nonsurgical
• Treatment types IV-VI: surgical
AC Injuries
SUMMARY
• Numerous surgical techniques described
• Trend toward anatomic technique when reconstruction indicated... – Beware of large clavicle bone tunnels – Avoid coracoid tunnels altogether
• Need of well-designed outcome studies
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