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.