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Type III Acromioclavicular Separation: Rationale for Anatomical Reconstruction

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Type III Acromioclavicular Separation: Rationale for Anatomical Reconstruction A Review Paper Type III Acromioclavicular Separation: Rationale for Anatomical Reconstruction Adam J. Farber, MD, Brett M. Cascio, MD, and John H. Wilckens, MD merge with the parallel fibers of the superior AC liga- ABSTRACT ment, making it the strongest and most biomechanically Treatment of acute type III acromioclavicular separa- important of the AC ligaments.5,9 Urist10 showed that tion is controversial. In some patients, nonoperative AC ligaments are the primary restraint to anterior and treatment is associated with pain, weakness, and stiff- posterior displacement, providing horizontal AC joint ness. Many acromioclavicular joint reconstructions are stability. Fukuda and colleagues11 confirmed the impor- associated with complications and results not sub- tance of AC ligaments in providing horizontal stability stantially better than those of nonoperative treatment. Use of autogenous free tendon graft to anatomically with small (physiological, eg, daily activities) and large reconstruct the acromioclavicular and coracoclavicular (pathologic, eg, injuries) loads, suggesting that AC liga- ligaments offers several advantages over other surgi- ments provide a substantial amount of vertical AC joint cal techniques. These advantages include improved stability at small loads. biomechanical properties, no foreign body implanta- The coracoclavicular (CC) ligament, a strong ligament tion, biological fixation, anatomical reconstruction, and that runs from the outer inferior surface of the clavicle early rehabilitation. to the base of the coracoid process of the scapula, has njuries to the acromioclavicular (AC) joint are com- “Reconstruction gives patient mon, and there is general agreement regarding treat- ment for all injury types1-3 except acute type III AC and surgeon more flexibility, dislocation. In this article, we review the pertinent because the decision to operate Ianatomy of the AC joint and its stabilizing structures; the epidemiology, mechanism of injury, physical examination is based on symptoms, not injury findings, and radiographic workup of AC separations; the acuteness or patient demands.” nonoperative and surgical treatment options, emphasizing their limitations and complications; and the rationale and 2 components: the conoid and trapezoid ligaments. The technique for using autogenous free tendon graft to treat conoid ligament attaches to the posteromedial side of acute type III AC dislocations. the base of the coracoid process5 and to the posterior undersurface of the clavicle at the junction of the middle ACROMIOCLAVICULAR and lateral thirds of the clavicle.5 The trapezoid ligament JOINT STABILITY arises from the base of the coracoid process, anterior Contact between the clavicle and the acromion provides and lateral to the attachment of the conoid ligament, and the bony contribution to AC joint stability.2,4-8 The AC extends superiorly to the undersurface of the clavicle, joint is surrounded by a thin capsule that is reinforced where it inserts anteriorly and laterally to the conoid liga- by the superior, inferior, anterior, and posterior AC liga- ment along the trapezoid ridge on the clavicle.5 Strength ments. The aponeurosis of the trapezius and the deltoid of the intact CC ligament ranges from 500±134 N to 725±231 N, and stiffness ranges from 103±30 N/mm to 116±36 N/mm.12,13 At the time of the study, Dr. Farber was a Chief Resident, Dr. Although the AC ligaments provide more constraint Cascio was a Chief Resident, and Dr. Wilckens was Chairman at small physiologic loads, at larger loads the CC liga- at JHBMC, Department of Orthopaedic Surgery, Johns Hopkins ment provides more vertical stability than the AC liga- University/Johns Hopkins Bayview Medical Center, Baltimore, ments do.11 Fukuda and colleagues11 showed that the Maryland. conoid ligament is primarily responsible for this verti- Address correspondence to: John H. Wilckens, MD, c/o Elaine cal stability, that it also provides substantial anterior P. Henze, BJ, ELS, Department of Orthopaedic Surgery, Johns stability, and that the trapezoid ligament provides sta- Hopkins Bayview Medical Center, 4940 Eastern Ave, #A672, bility during axial compression. Debski and colleagues9 Baltimore, MD 21224-2780 (tel, 410-550-5400; fax, 410-550- showed biomechanically that the trapezoid and conoid 2899; e-mail, [email protected]). ligaments act separately but synergistically in restrain- Am J Orthop. 2008;37(7):349-355. Copyright Quadrant HealthCom ing superior-, anterior-, and posterior-directed loads to Inc. 2008. All rights reserved. the AC joint. July 2008 349 Type III Acromioclavicular Separation Nonoperative Intervention Many authors have reported good results with nonopera- tive treatment.15,24,28,29 As there seems to be little difference in functional results among nonoperative regimens, most authors currently recommend short-term use of a simple sling followed by early motion.15,17,21,24,27,29,30 Studies have found that nonoperative outcomes equaled or exceeded surgical outcomes and without the risk for surgical complications.19,21,26,30-32 Some authors have reported that patients treated nonoperatively returned to sports and work sooner and regained motion faster.26,30 Complete reduction is unnecessary for good results.15,19,21 However, there is a 10% to 20% rate of unsatisfactory results with nonoperative treat- ment, primarily because of persistent pain, limited motion, and instability.10,16,28 Devices used to maintain reduction Figure 1. Classification of acromioclavicular joint injuries. (eg, harnesses, casts, braces) are associated with the risk for Copyright 1997 American Academy of Orthopaedic Surgeons. skin irritation and ulceration and the need for frequent reduc- Reprinted from the Journal of the American Academy of tion assessments and device adjustments.19,28,33,34 Orthopaedic Surgeons, Volume 5(1), pp 11-18 with permission. Surgical Intervention ACROMIOCLAVICULAR Surgical treatment is absolutely indicated for open injuries JOINT SEPARATION and severe brachial plexus injuries. It is relatively indicated There are 6 types of AC joint separations (Figure 1).1,3 Type for heavy laborers, high-level overhead athletes, and patients III separations represent a complete dislocation of the AC with severe displacement (>2 cm).14,17,19,25,26,30,35-38 joint, with disruption of the AC and CC ligaments and attenu- More than 100 surgical procedures for treating AC joint ation of the deltotrapezial attachment.3 instability have been described in the literature—an indica- The most common cause of injury is a direct force, pro- tion that none is ideal.2 The main surgical treatments are duced by a fall onto the point of the shoulder with the arm primary AC joint fixation, dynamic muscle transfer, CC adducted,3,14-20 that drives the acromion downward and stabilization, distal clavicle excision, and CC ligament medially. The force magnitude determines the severity of reconstruction; free graft anatomical reconstruction is the injury and the structures involved. another choice. Patients with type III AC separations typically present Primary Acromioclavicular Joint Fixation. This pro- with shoulder pain, local tenderness, and visual and pal- cedure, involving Kirschner wires, Steinmann pins, screws, pable displacement of the AC joint.14,21 The AC joint is suture wires, or plates,19,32,39 attempts to hold the acromion– best visualized with dedicated anteroposterior radiographs clavicle–coracoid triad in a reduced position long enough to of the affected and contralateral AC joints and an axillary allow healing of the ruptured CC and AC ligaments. This tech- radiograph of the shoulder, which is useful for evaluating nique often is used to supplement a CC and/or AC ligament the position of the distal clavicle with respect to the acro- repair or reconstruction.6,8,32,38,40 mion in the anteroposterior plane. A 15° cephalic-tilt radio- Primary AC joint fixation is complicated by loss of reduc- graph (Zanca view) precludes the superimposed acromion tion (5%), persistent instability,6,30,40 and superficial infec- obscuring the AC joint.22 Stress or weighted radiographs tions.6,25,30,32,41 In addition, transarticular fixation devices are not recommended because of patient discomfort, inef- can damage the AC joint’s meniscus and articular cartilage, fectiveness, added cost, and additional radiation expo- which may lead to early degenerative changes.6,19,40,41 Pin sure.23 In type III injuries, the lateral end of the clavicle is fixation is complicated by risk for pin breakage and migra- displaced 100% above the superior border of the acromion, tion.6,19,30,32,38,40-45 Pins have migrated into the spinal canal, and the CC interspace is markedly larger than that on the eye, lung, neck, heart, great vessels, and abdomen, occasionally contralateral side. resulting in death.2,30,42-46 To avoid such risks, most surgeons remove pins 4 to 16 weeks after surgery.6,19,30,32,38,40-42,44 TREATMENT OF ACUTE TYPE III Sim and colleagues39 used a hook plate to try to immo- ACROMIOCLAVICULAR INJURIES bilize the AC joint while avoiding injury to the articular Most clinicians recommend nonoperative treatment for surfaces and possibly avoiding early degenerative arthrosis. type I and type II injuries and operative treatment for Although 94% of their patients had good to excellent results, types IV, V, and VI.2,10,17,20,24,25 However, treatment for the technical difficulty and complications of this technique acute type III injuries is controversial. Recommendations limited its use. The complications
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