1. Acromioclavicular
Joint
Injury
Jeremy
Granville-­‐Chapman
Upper
Limb
Fellow
Wrigh?ngton

2. Learning
Outcomes
• Understand
anatomy,
epidemiology,
mechanism
of
injury
and
diagnosis
of
ACJ
separa?on
• Recognize
limita?ons
of
classifica?on
with
respect
to
management
• Understand
surgical
op?ons
in
ACJ
separa?on,
acute
and
chronic
• Be
able
to
formulate
a
ra?onal
decision
making
algorithm
for
ACJ
separa?on

3. Horizontal
ACJ
Capsule
Superior
56%
stability
Posterior
25%
Ver-cal
CC
ligaments
(Conoid
&Trapezoid)
+
Delto-­‐trapezial
fascia
Distance
1.1-­‐1.3cm
C
to
C
Strength
500±134N
Harris
et
al
Am
J
Sports
Med
2000

4. Cadaveric
sec?oning
of
CC
ligaments

5. Mechanism
of
Injury
• Typically
a
direct
blow
to
shoulder
• indirect
via
fall
onto
elbow
• Indirect
via
shoulder
‘whiplash’

6. Epidemiology
• male
athletes
3.5x
>
female
athletes
• Pro
Rugby
32%
incidence
–
wrestling,
cycling
and
ice
hockey
• Incidence
– 9
per
1000
pa?ent
years
in
US
Mil
trg
popn
– 14
per
100K
popn
per
year
Grade
III
or
higher
– Approx
10%
of
trauma?c
shoulder
injuries
• 90%
are
low-­‐grade
sprains
• Mean
?me
off
sport
18.4
days
– 10.4
days
for
low-­‐grade
sprains
– 63
days
for
high
grade
injury
Pallis,
M.
et
al.,
2012.
Epidemiology
of
Acromioclavicular
Joint
Injury
in
Young
Athletes.
The
American
Journal
of
Sports
Medicine,
40,
pp.2072–2077.

7. Diagnosis
• Clinical
Examina?on
– Step
off
and
tenderness
over
ACJ
– ROM
reduced
eleva?on
– Scarf
test
– AP
stability
– Reducibility
• Plain
radiograph
– Zanca
view
(15°
cephalic
?lt)
– Axillary
lateral
view
(can
show
AP
instability)
• US
– May
demonstrate
subtle
instability
• MRI
– Detect
associated
injuries
– Clarifies
structures
injured

8. Associated
intra-­‐ar?cular
injuries
15%
(6/40)
Pauly
et
al
(KSSTA
2009)
18%
(14/77)
Imhoff
et
al
(AJSM
2009)
46%
(45/98)
Arrigoni
P
et
al
(BRASS
group)
>45
yrs
=
67%
<45yrs
=
29%
Should
we
MRI
all
pa?ents?
If
opera?ng,
is
an
arthroscopic
technique
berer?

9. Anatomic
Classifica?ons
Rockwood
CA,
Williams
GR,
Youg
DC.
Disorders
of
the
acromioclavicular
joint.
In:
Rockwood
CA.
The
shoulder.
Philadelphia:
Saunders;
1998.
p.
483-­‐553.
Rockwood
on
Zanca
view
has
only
fair
inter-­‐observer
reliability
and
poor
intra-­‐observer
reliability
(CY
Ng,
Funk
L
et
al
Shoulder
and
Elbow
2012)
MRI
diagnosis
differs
in
almost
half
of
cases
(36%
less
severe,
11%,
more
severe
than
XR)
(Nemec
U
et
al.
AJR
2011)

10. Natural
History
of
‘low
grade’
sprains
• Most
recover
within
7-­‐10
days
and
enjoy
excellent
long
term
outcome
• BUT
severity
underes?mated..
– Grade
I
-­‐
9%
have
severe
pain,
instability,
diminished
performance
or
cessa?on
– Grade
II
-­‐
42%
– 70%
have
XR
degenera?on
at
f/u
– 33%
develop
persistent
laxity
at
ACJ
Mouhsine
E,
Garofalo
R,
Crevoisier
X,
Farron
A.
Grade
I
and
II
acromioclavicular
disloca?ons:
Results
of
conserva?ve
treatment.
J
Shoulder
Elbow
Surg
November/December
2003;12(6);599-­‐602
Bergfield
JA,
Andrish
JT,
Clancy
WG.
Evalua?on
of
the
acromioclavicular
joint
following
first
and
second-­‐
degree
sprains.
Am
J
Sports
Med
1978;6:153-­‐9

11. Higher
Grade
Injuries
• Grade
III
– 24%
horizontal
abduc?on
weakness
– 87%
achieve
sa?sfactory
outcome
without
surgery
– Increasing
trend
towards
repair
over
conserva?ve
management
–
fashion
or
ra?on?
• Grade
IV
and
V
– Normally
treated
with
surgery
– Lirle
modern
data
on
conserva?ve
management

12. Treatment
Op?ons
–
Acute
(<4
weeks)
• Conserva?ve
–
early
rehab
to
regain
rhythm
and
strength
• Acute
surgery
– Hook
plate
– Tightrope
– Grawrope
– Dog
Bone
buron
– LARS
ligament/lockdown
(Surgilig)

13. Treatment
Op?ons
-­‐
chronic
• ACJ
excision
if
stable
• Reconstruc?on
of
CC
ligs
+
excision
lat
clavicle
– Weaver
Dunn
– Surgilig
– LARS
– Dog
bone
+
graw
tendon
UTS
(N)
• CC
Ligament
725N
• Transferred
CA
ligament
145N
• Lockdown
Surgilig
1730N
• LARS
1500N
(30
fibres)
• Tightrope
675N
• Dog
Bone
>1000N

14. If
grade
marers,
what
to
do
with
Grade
III
?
• Older
studies
showed
no
improvement
with
fixa?on
but
higher
complica?ons
• BUT,
old
techniques
– Wires/plates/screws
– Required
r/o
hardware
– High
complica?ons
• ?
S?ll
relevant
• Recent
studies
suggest
berer
outcome
with
surgery
• Gsterner
et
al
2008
– 88%
vs.
59%
good
or
excellent
results
Hook
plate
• Fraschini
et
al
2010
– LARS
(Chronic
pts)
– 93.3%
vs.
0%
non
op

16. Modern
techniques
–
Dog
Bone
• Newest
trans-­‐osseous
design
• 2x
fibretapes
and
2x
dogbones
• 2.4
or
3mm
bone
tunnels
• Arthroscopic
or
open
• Lirle
material
on
top
clavicle
• Augment
with
graw
if
chronic
• UTS
-­‐
>1200N
(stronger
than
na?ve
CC
ligaments)

17. Surgilig
Lockdown
• Braided
polyester
rope
(Atlan?c
Surgical)
• UTS
1730N
• Around
coracoid
base,
behind
and
over
clavicle,
held
with
AP
screw
Wood
TA,
Rosell
PA,
Clasper
JC.
Preliminary
results
of
the
'Surgilig'
synthe?c
ligament
in
the
management
of
chronic
acromioclavicular
joint
disrup?on.
J
R
Army
Med
Corps.
2009
Sep;155(3):191-­‐3.

18. LARS
ligament
• PET
braided
rope
–
extremely
strong
(Corin)
• Biocompa?ble
–
fibroblas?c
scaffold
• 10M
cycles,
6%
strain
• Loops
under
coracoid,
through
oblique
clavicle
tunnels

19. AC
joint
reconstruc-on
with
an
anatomical
PET
synthe-c
ligament
in
athletes
and
non-­‐athletes.
Clinical
and
radiological
outcomes
at
2-­‐year
minimum
follow-­‐up.
G
M
Marcheggiani
Muccioli*,
C
Manning,
P
Wright,
L
Funk
Athletes
and
non-­‐athletes:
2-­‐year
minimum
follow-­‐up.
43
pts
(age
30
19-­‐54).
21
athletes
Rockwood
III-­‐V
Mean
?me
to
surgery
3
months
(Athletes)
8
months
(non-­‐athletes)
(range
1
week
to
2
years)
Outcomes:
Constant
scores,
Return
sport,
Zanca
view
displacement
Constant
scores
improved
significantly
Return
to
full
sport
was
4.5
months
(range
3
to
8)
Mean
displacement
was
14%
and
24%
overall
pa?ents
at
3
and
24-­‐month
follow-­‐up
(more
displacement
in
the
non-­‐professional
group).
Displacement
did
not
affect
Constant
scores
Complica?ons:
one
coracoid
fracture
>1yr
and
one
superficial
infec?on

20. Decision
Making
• Classifica?on
alone
unhelpful
• Sport
and
profession
• Aim
to
review
at
1-­‐2
weeks
post
injury
– Coping?
• Chronically
symptoma?c
– Frankly
unstable
or
not?

21. Acute
Chronic
Coping
Not
coping
Surgery
Rehab
ACJ
excision
Reconstruc-on
Stable
Unstable
Assessment
DogBone
LARS
LARS
(Surgilig)
DogBone
+
CA
Lig
tx
/
graV
Assessment
ROM
Rhythm
Power
Rehab