Iranian Journal of Orthopaedic Surgery Lahiji, MD; Minaie, MD et al. Vol 15, No 2 (Serial No 57), Spring 2017, p 48-55 Outcome of Acute Acromioclavicular Dislocation Surgery by Modified Weaver-Dunn Technique Abstract Background: Weaver-Dunn technique is one of the common methods for treatment of acute acromioclavicular joint (ACJ) dislocation. Several modifications of this technique have been already described. Because of shortcomings of the previous modifications and due to the importance of keeping coracoacromial ligament (CAL) intact, we report the preliminary results of a new modification to this technique. Methods: Fifteen patients with acute ACJ were enrolled in the current study. In the modified surgical technique, the medial half of CAL was dissected from the bone and passed through a hole made in the clavicle bone and tied on itself. Preoperative CC distance, constant score and UCLA were compared with those of the last visit. Pain intensity was measured using visual analogue scale (VAS). The patients were followed for 4.2±2.6 years. Results: Preoperatively, CC distance of the injured side was significantly greater than the non-injured side (19.5±1.6 mm vs. 7.1±0.5 mm; p<0.001). At the last visit, CC distance of the operated side was insignificantly greater than the healthy side (8.2±0.9 mm vs 7.1±0.5 mm; p=0.318). Mean constant score was 93.3±13.2 and 95.1±10.8 in operated and healthy shoulders, respecvely (p=0.118). UCLA averaged 32.6±3.3 and pain intensity 1.4±0.8. Conclusion: Treatment of acute ACJ dislocations using the proposed modified Weaver-Dunn technique is associated with favorable outcomes, while it preserves joint stability and function. Keywords: acromioclavicular joint, dislocation, coracoacromial ligament, Weaver-Dunn technique Received: 9 months before printing; Accepted: 5 month before printing *Farivar Lahiji, MD; *Reza Minaie, MD; ***Shahin Talebi, MD; **Seyed Rouhollah Mousavi, MD, ****Farshad Safdari, MSc *Orthopedic surgeon, Introduction Akhtar hospital, Shahid Beheshti University of Acute acromioclavicular joint (ACJ) injuries are common problem that involves medical sciences, Tehran, more than 12% of shoulder injuries(1,2). ACJ injuries can range from a simple Iran ***Resident of sprain with very mild to severe dislocation and facial rupture, rupture of the orthopedic surgery, coracoacromial ligament (CC) or ACJ, and consequent severe shoulder Akhtar hospital, Shahid dysfunction(3). In recent years, various causes have led to significant increase Beheshti University of in the prevalence of these injuries. The most common mechanism of ACJ medical sciences, Tehran, injury is falling on the shoulder with the arm in adduction(4). Iran **Orthopedic surgeon, The purpose of ACJ dislocation treatment is returning the patient’s activity Qom University of level to pre-injury level with a strong, painless, and mobile shoulder joint; medical sciences, Qom, joint reduction and restoration or CC ligament restoration is part of the Iran treatment(4,5). In type I and II injuries, non-surgical treatments and in type IV- ****Orthotist and VI injuries, surgical treatment is used. This is while the appropriate treatment prosthetist, Bone Joint (6) and Related Tissues for type III injuries is controversial . In a study in 2013, Beitzel and colleagues Research Center, Shahid stated that more than 150 different surgical techniques have been introduced Beheshti University of for treatment of ACJ injuries(7). Despite all studies addressing ACJ injuries medical sciences, Tehran, treatment, the ideal treatment approach is still controversial(4). Iran One of the commonly-used techniques with favorable outcomes is the one introduced by Weaver and Dunn in 1972, which includes removal of distal Email: (8) [email protected] clavicle and coracoacromial ligament displacement . 48 Iranian Journal of Orthopaedic Surgery Vol 15, No 2 (Serial No 57), Spring 2017, p 48-55 Outcome of Acute Acromioclavicular … One of the commonly-used techniques with ACJ for a stress-induced radiograph in bilateral favorable outcomes is the one introduced by anteroposterior view. In these images, the Weaver and Dunn in 1972, which includes distance between the tip of coracoid to the removal of distal clavicle and coracoacromial lower surface of clavicle bone was measured ligament displacement(8). Since the (CC distant). Then the patients underwent introduction of Weaver-Dunn technique, surgery. several modifications have been suggested to this technique, each with its own advantages The modified Weaver-Dunn surgical technique and disadvantages that usually involve using First, a C-shape cut was created (transverse, (1,9,10) coracoclavicular stabilizer . Although these skin, or rotation toward the coracoid). This cut methods are associated with favorable results, began a bit outside acromioclavicular joint and various studies have shown very low efficacy extended to the lateral one-third of clavicle of Weaver-Dunn technique compared to bone. Then, the cut was continued in a curve healthy CCL, with various problems such as shape up to coracoid (Robert approach). A (11-16) laxity, especially in the sagittal plane . In small part of the anterior deltoid was the present study, we will introduce a new separated from the clavicle and the ruptured modification to this technique, in which part of coracoclavicular ligament and healthy these ligaments remain intact, and we assume coracoacromial ligament is exposed. Of course, that this method will improve joint stability in ACJ type 5, CAL may also be torn. Then half and patients’ function. In addition, we of the medial CAL segment of the acromion examined the short term treatment results of was removed, while care must be taken not to patients with ACJ dislocation by this method. damage the coracoid adhesion. The separated ligament was made cylindrical Methods by Krakow method with fiber suture thread No. 2 (2 mm fiber suture). Subsequently, a 3.2 In this case series, all type III and V patients in mm drill head was used to create a hole on senior surgery service (FL) with acute ACJ superior clavicle towards inferior, lateral to dislocaon during 2007 to 2013 at Akhtar CAL attachment site, and then enlarged with a Hospital treated with this technique were 4.5 mm drill head. Threads were passed from investigated, if they had the eligibility criteria the created hole from inferior to superior. of the study and signed the written informed Clavicle and CAL were mounted and fixed with consent. In this study, simple and non-random two 2 mm K-wire pins. The fiber thread was sampling method was used and according to pulled so that the ligament entered the hole the new surgical method, the sample size was and was knotted on it. Then, deltoid and ACJ considered at 15 paents. It is noteworthy that joint capsule were restored. The skin and the none of the patients suffered from coinciding underlying skin are sewn. The limb was placed damages, such as humerus fracture. pendant for 4 weeks. Then pendulum and Initially, patients with ACJ injuries following circulatory movements began on the pendant, trauma were explained about the study aer 6 weeks pins were pulled out at objectives and implementation. Those who outpatient clinic, and physiotherapy was were willing to participate in the study were started. asked to sign a written informed consent form. After surgery, standard rehabilitation was Patients underwent physical examination and performed for the patients. Patients referred their demographic information such as age, to the hospital three months later for final sex, and mechanism of injury were recorded. evaluations. At this stage, the constant and Then radiographic evaluations were done. To do this, using weight, stress was induced to 49 Iranian Journal of Orthopaedic Surgery Lahiji, MD; Minaie, MD et al. Vol 15, No 2 (Serial No 57), Spring 2017, p 48-55 1-a. 1-b. 1-c. 1-d. Figure 1. Figure 1-a. One of the patients before surgery Figure 1-b. One of the paents, aged 28 years, after surgery Figure 1-c. One of the paents, aged 30 years, three years after surgery Figure 1-d. In abduction Figure 1-e. Radiographic image of the same patient 1-e. UCLA questionnaires were completed for all position in radiography. Finally, the data were patients to evaluate the functional treatment analyzed statistically. outcome. Patients were asked to express their Quantitative data were presented as mean ± pain intensity and satisfaction with the results SD and qualitative data were presented by of the treatment using visual analogue scale numbers and percentages. To compare the (VAS). In addition, stress-induced radiography data before and after treatment, paired t-test was performed to measure CC distant. It is or Wilcoxon tests were used. McNemar test noteworthy that CC distant was calculated was used to compare qualitative data before proportional to the healthy side to give a more and after treatment. All analyses were realistic view towards ACJ position. Also in the performed using SPSS ver.16 stascal final visit, the joint was evaluated in reduction soware. In this study, p<0.05 was considered as the significant level. 50 Iranian Journal of Orthopaedic Surgery Vol 15, No 2 (Serial No 57), Spring 2017, p 48-55 Outcome of Acute Acromioclavicular … Results Table 1. Comparison of the results of CC distance before surgery, immediately after surgery and at final In this study, a total of 15 paents with acute visit Ratio of ACJ dislocation were investigated. The mean CC age of the paents was 34.6±10.2 years and all distance of the patients were male. Of these, the injury was Measure Healthy Injured P- injured grade III in 2, and grade V in the rest. It should ment time side side value be noted that two patients who suffered from side to the grade III injury were professional athletes.