Ó 2005 Lippincott Williams & Wilkins, Philadelphia Techniques in Shoulder and Elbow Surgery 6(1):1–7, 2005 O R I G I N A L A R T I C L E Technique of Stabilization in Acromioclavicular Joint Dislocation Philippe Clavert, MD, Pierre Moulinoux, MD, and Jean-Francxois Kempf, MD Orthopaedic Department University Hospital Strasbourg, France n ABSTRACT Acromioclavicular injury is a frequent pathology of collision sports, cycling and motorcycling sports. For stages I and II most of the authors agree that conservative treatment must be the rule; also, for type V and VI lesions, it seems obvious that surgery has to be performed. However, treatment remains controversial for type III separation, between conservative and surgical. The authors suggest a modification of the classic modified Weaver–Dunn technique and a new technique of clavicle stabilization with a screwed anchor in case of acute acromioclavicular dislocation. The main advantage of this technique is that there is no hardware that has to be removed, and there is also no morbidity related to a second incision. Short-term results of surgery usually show excellent functional outcomes without any residual pain. But long terms results of grades I to III are usually associated with arthritis; and for grades IV to VI there is most of the time a decrease of shoulder strength and recurrence of pain in time. toid and trapezius muscles). In 1963 Tossy et al2 suggested a 3 type classification, as did Allman et al3 in 1967 and Juillard in 1976.4 Then, in 1987, Rockwood et al5 improved these classifications and proposed a new one in 6 types, based on a true anterior–posterior radiographic analysis. The first proponent of using the coracoacromial ligament as an autograft to stabilize the joint was Neviaser in 1952.6 The coracoacromial ligament was detached from the coracoid process and sutured to the lateral end of the clavicle. Then Weaver and Dunn in 19727 suggested detaching it from its insertion to the lateral clavicular end. The transferred ligament was secured across the bone marrow to the upper part of the clavicle. As others did, Rockwood8 suggested that a minimum of 2 cm of the lateral end of the clavicle must be taken out. He also proposed to secure the repair by a coracoclavicular screwing to protect the graft in the first 12 weeks postoperatively. n INDICATIONS AND n HISTORICAL PERSPECTIVES CONTRA-INDICATIONS Hippocrates was the first to diagnose this pathologic condition. He also suggested a treatment consisting of bandages. He quoted that that treatment was not as satisfying as for a shoulder dislocation. He also stated that there are no real complications other than ‘‘a tumefaction’’ or ‘‘a deformity.’’1 Since then, more than for any other joint of the body, surgeons have suggested different classifications and treatments. Classifications became more sophisticated in time due to a better understanding of the physiopathology of these lesions. All are based on the damages of the different joint stabilizers, that is, the capsular ligaments (acromioclavicular ligaments), the extra-capsular ligaments (coracoclavicular ligaments), and the musculature (delReprints: Philippe Clavert, MD, Orthopaedic department, CHRU Strasbourg, Avenue Molie`re, 67085 Strasbourg, France. E-mail: [email protected]. Careful preoperative determination of pathology is critical in selecting the best method of treatment. Clinical Evaluation First, an evaluation of the patient’s expectations is necessary. That must include his age, job, and hobbies; his sport and the level of his sporting activities are also important. Then the mechanism of injury has to be analyzed. Most of the time a direct contact to the shoulder with the arm at the side is responsible for the sprain. Rarely, an indirect upward force by the upper extremity or an indirect and downward force leads to an acromioclavicular joint separation. In case of a stage III, IV, or VI acromioclavicular dislocation, visual inspection also reveals a fullness upward displacement of the clavicle relative to the downward Volume 6, Issue 1 1 Clavert et al displaced shoulder (Fig. 1). The physical findings of an acromioclavicular separation are a tenderness over the joint area and an abnormal mobility of that joint. The initial examination also has to look for associated injuries, such as nerve and vascular injuries as well as fractures around the shoulder girdle (coracoid process, acromion, and scapular neck). The motor examination of the deltoid and trapezius must demonstrate normal function of these muscles. Radiographic Evaluation A specific X-Ray examination must be requested not to have overpenetrated films.1 Routine anteroposterior views of the acromioclavicular joint should be taken with the patient standing, the arm unsupported at the side. The X-ray cassette is against the patient’s back. There must be a 10° to 15° of cephalic tilt view to analyze the joint space, that is, not to superimpose the acromion and the distal end of the clavicle. Sometimes a comparative Xray of both sides is necessary. Then a lateral view is necessary to classify the injury. An axillary view will reveal any posterior displacement of the clavicle, as well as associated fractures of the distal part of the clavicle. Finally, even if Bossart et al9 concluded that stress radiographs are not appropriate, these views may help the clinician to diagnose a stage III separation. Of course, in the case of associated lesions of the shoulder, a CT-arthrogram of the shoulder or an MRI may be necessary. From these views the physiopathology of the lesions are inferred and classified. (For this article we will only discuss Rockwood’s classification.) Type I corresponds to a sprain of the acromioclavicular ligament with an AC joint intact; the coracoclavicular ligament remains intact, as well as the deltoid and trapeze muscles. Type II corresponds to a rupture of the acromioclavicular ligament and a sprain of the coracoclavicular ligaments, leading to an increase of the AC joint space, but there is no superior displacement of the clavicle, that is, the coracoclavicular space is fairly increased. In type III, there is a rupture of the acromioclavicular ligaments associated to a coracoclavicular ligament rupture, leading to an AC joint dislocation. The coracoclavicular space increases from 25% to 100%. In this case, the deltoid and the trapeze muscles are deinserted from the end of the clavicle. In type IV, there is a posterior displacement of the clavicle within or through the trapeze muscle, with a deltoid and trapeze muscle deinsertion from the end of the clavicle. The coracoclavicular space looks normal on the X-rays. In type V, more than the rupture of the different ligaments, there a major AC joint dislocation from 100% to 300% in relation to a deinsertion of the muscles from the lateral half of the clavicle. At least, in type VI, there is an inferior AC joint dislocation observed on the plain radiographs, under the acromion or under the coracoid process. In this case the coracoclavicular space is decreased. There is a muscle deinsertion from the end of the clavicle. Contraindication Acromioclavicular joint dislocations may be associated with other trauma of the shoulder, such as fractures of the distal or midshaft clavicle, of the acromion process, or of the coracoid process.10,11 Also, injuries of the respiratory tract may be observed.12,13 Nerve injuries may occur even if this is a rare condition, such as brachial plexus palsy.13 Such injuries are related to a scapulothoracic dissociation (lateral displacement of the scapula associated with an acromioclavicular joint separation and/or bony lesions). Of course, these associated lesions have to be cleared before planning any acromioclavicular surgery. n PREOPERATIVE PLANNING FIGURE 1. Clinical presentation of a type V acromioclavicular separation. Note the upward displacement of the clavicle relative to a downward displacement of the shoulder. 2 Even if it is still controversial14 for types I and II, a conservative treatment must be the rule. We recommend leaving the patient’s arm in a sling; the use of an ice bag and light analgesic are recommended. Patients are suggested to gently maintain their range of motion by pendulums and home program exercises. After pain Techniques in Shoulder and Elbow Surgery Surgery of A/C Joint Dislocation resolution and recovery of full range of motion, patients are allowed to return to a full activity of their upper arm without restriction. Many management options have been proposed for grade III injuries.6–8,15–19 Treatment of these stage III separations has recently tended to nonoperative methods,20–24 with a symptomatic treatment with a limited immobilization. Basically, for most of our patients, a nonoperative treatment is proposed. In the case of a person doing heavy labor and for young and active patients in sports, surgical repairs should be performed. One of the contra-indications for surgical treatment in this case is the young athlete regularly subject to violent and repeated injuries to its acromioclavicular joint, such as a rugby player. For types IV, V, and VI, a surgical treatment is the rule because the distal part of the clavicle is displaced and can penetrate the trapezius. But for inactive and nonlaboring patients, the pros and cons must be discussed with him and sometimes a conservative treatment is proposed. More and more, arthroscopic solutions are developed to treat this condition.25–28 Nevertheless, no large series are already reported. For us, open reduction and internal fixation remains the ‘‘gold-standard.’’ n SURGICAL TECHNIQUES The aims of the surgical treatment are to replace the coracoclavicular ligaments to minimize motion, allow scarring, and increase the subsequent stability of the joint. In this way the different surgical techniques focus to the intrinsic acromioclavicular ligaments, to the coracoclavicular ligaments, and at least to the surrounding muscular structures. Most of the actual techniques combine a restoration of 2 or 3 of these structures even though none of these surgical procedures have the appropriate stiffness to restore the stability of the intact joint before healing.29 The procedure is performed under regional anesthesia associated if necessary with a general anesthesia. We prefer to place the patient in the beach-chair position; the head is slightly deviated toward the controlateral side. The shoulder should be completely free for full rotation with the anterior and posterior shoulder girdle exposed. Prior to beginning surgery it is imperative to document passive motion of the shoulder, as well as the possibility to reduce the dislocation by pushing up the arm while the clavicle is pushed down. Care must be taken during draping to allow access from the top of the shoulder to the base of the neck. A 4 to 6 cm long skin incision is made vertically in Langer’s lines. It begins posterior to the clavicle and then crosses the clavicle medially to the acromioclavicular joint, and then is extended to the tip of the coracoid process. The rupture of the deltotrapezius fascia is visualized and developed if needed, as well as the periosteum over the top of the distal clavicle and the acromion. Most of the time, the anterior part of the deltoid and the trapezius muscles have been stripped off the distal part of the clavicle. If not, we develop this interval so that the distal part of the clavicle can be freely grasped and mobilized. In this way, the torn coracoclavicular ligaments are visualized, as well as the base and the knee of the coracoid process. The acromioclavicular joint is debrided of any loose fragments or intra-articular disk. Acute Acromioclavicular Dislocation: The Screw-In Anchor Technique Recent data show that posttraumatic arthritis develops more frequently by using transarticular fixation techniques.23,24 For this reason we have developed a technique that securely keeps the joint reduced while the ligaments are healing; moreover, there is no hardware that needs to be removed. If possible, acromioclavicular ligaments are repaired by 1 or 2 transosseous sutures. If possible, the torn ends of the coracoclavicular ligaments are tagged with Fiberwire (Arthrex, Naples, FL) loaded on the anchor or with No. 2 Ethibond sutures (Ethicon Products, Johnson & Johnson Company, Westwood, MA) that will be tied at the end of the procedure (Fig. 2). This step is not required for some authors1 because they consider that the scarring tissues will fill the space between the clavicle and the coracoid process and that will secure the repair. With a probe, both sides of the base of the coracoid process as well as its knee are identified. A drill hole is made on the top of the base of the coracoid, perpendicular to its long axis, and a 5.5 mm or two 3.5 Corkscrews anchors (Arthrex, Naples, FL) is screwed in the coracoid FIGURE 2. The torn ends of the coracoclavicular ligaments are tagged with the Fiberwire loaded on the anchor (triangle). Volume 6, Issue 1 3 Clavert et al process; care must be taken not to pass through the deep cortex of the coracoid. The assistant’s role is to maintain the clavicle down while he is pulling-up the arm to reduce the dislocation (Fig. 3). Four bicortical drill holes are made through the clavicle, right above the coracoid process. Four Fiberwire sutures (Arthrex, Naples, FL) are passed through these drill holes. At this time, the 2 sets of the sutures are tied as well as the sutures previously passed through the coracoclavicular ligaments. Then the deltotrapezius muscles fascia interval has to be repaired. They are sutured over the top of the clavicle by a double row of No. 5 Ethibond sutures. A postoperative X-ray is necessary to control the exact positioning of the anchors (Fig. 4). Chronic Acromioclavicular Joint Dislocation: The Modified Weaver–Dunn Technique We think that an isolated excision of the distal end of the clavicle is not the appropriate technique for acromioclavicular dislocation because symptoms are related to the displacement that irritates the surrounding soft tissues and muscles.1,30 That is why the coracoclavicular ligament has to be replaced. We prefer to use the coracoacromial ligament that is already attached to the coracoid and FIGURE 3. The assistant maintains the clavicle down while he is pulling-up the arm to reduce the dislocation. 4 FIGURE 4. X-ray showing 2 anchors screwed in the coracoid process. belongs to the same anatomic layer,18 rather than any other graft, suture, or other synthetic material.8,31–34 But a temporary fixation is necessary to maintain the reduction and then protect the healing of the transferred ligament. This protection is necessary because a graft elongation or insufficiency can occur due to the tension applied to the transferred ligament.1,30,32 Different synthetic materials have been used to avoid removal of metallic hardware.7,33,35,36 We prefer the use of a screwed anchor as described above rather than Kirchner wire, screws,8 or hook plate,37 in order not to have a second surgery to perform and to avoid many hardware complications. Once the distal end of the clavicle is freely mobilized, the 1.5 cm of the distal part of the clavicle is excised, to prevent any postoperative spur formation.1 The medullary canal of the clavicle is curetted to receive the transferred ligament. Using a No. 15 blade, the coracoacromial ligament is harvested from the acomion; most of the time we prefer to keep it attached to a small bone block that is harvested with a quarter inch osteotome (Fig. 5). The clavicle is mobilized to determine if the length of the ligament will fit or not. If not, the anterior part of the ligament can be securely released from the coracoid process.1,17 A No 5 Ethibond suture is passed through the ligament in a Mason and Allen fashion.38 Two small drill holes are placed through the superior cortex of the distal clavicle for the sutures passed through the ligament (Fig. 5), and 4 extra bicortical drill holes, directly above the coracoid process, are needed for the Fiberwire sutures of the Corkscrew. A No. 5.5 or two 3.5 Corkscrew anchor is then screwed in the coracoid process as described above (Fig. 5). The assistant then reduces the acromioclavicular joint as described above (Fig. 3). The 2 ends of the suture are passed into the medullary canal and out the 2 drill Techniques in Shoulder and Elbow Surgery Surgery of A/C Joint Dislocation That last condition may also be observed after surgery.46 Chronic pain may also be related to secondary impingement in relation to a non-rotation of the scapula while the arm is elevated or abducted. At least as for every sprain, climatic pains may be recurrent. Recurrence of a dislocation may also occur. Specific Complications of the Surgical Treatment Recurrence remains the first complication of that surgery. The rate extends from 10 to 15%.30,47 Other complications include infections, hardware complications (fracture, migration), foreign-body reaction to any augmentation material used,48,49 or hypertrophic wounds. More specific complications, such as breakage of the grafts or of the tunnels, or residual deformity, may be encountered. n RESULTS AND PROGNOSIS FIGURE 5. The modified Weaver–Dunn technique—the anchor is screwed in the coracoid process. holes in the superior cortex of the clavicle (Fig. 5); the 4 Fiberwire sutures are also passed through the clavicle. These 2 sets of suture are tied first to maintain the reduction and then the sutures through the coracoacromial ligament are tightened so that the bone block gets into the medullary canal of the clavicle. n POSTOPERATIVE CARE Postoperatively the arm is in a sling for 4 weeks. During this time the patient is allowed to perform some pendulum exercises. After this time, the patient can use his arm for most everyday living activities. Heavy lifting or resisting exercises remain prohibited for the next 6 weeks. In this way no specific rehabilitation is required, but patients are trained to do some home exercises. After recovery of full strength and full range of motion of the shoulder, patients are allowed to practice contact sports. Usually the immediate prognosis of types I and II acromioclavicular dislocation is excellent: patients recover full range of motion with mild or without pain.50 However, acromioclavicular joint arthritis may occur with significant symptoms of pain and loss of strength within the next 5 years.51–53 But referring to Moushine et al,14 the long-term consequences of conservative treatment, even for stages I and II, are underestimated. Main complications are residual symptomatic instability and tenderness over the AC joint in relation to degenerative changes, ossification of the coracoclavicular ligaments or association of both, and distal clavicular osteolysis. For chronic type III injuries, both treatments have shown immediate good results, but long-term results lead to arthritis and loss of strength. That loss of strength may be significantly greater for patients operated on versus patients treated conservatively.53 Patients with acute and chronic types IV, V, and VI lesions require open reduction and fixation. n REFERENCES 1. Rockwood C, Williams G, Young C. Disorders of the acromioclavicular joint. In: Rockwood C, Matsen FI, Wirth M, Lippitt S, eds. The Shoulder. Saunders, Philadelphia; 2004: 521–595. 2. Tossy J, Mead N, Sigmond H. Acromioclavicular separation: useful and practical classification for treatment. Clin Orthop. 1963;28:111–119. n COMPLICATIONS 3. Allaman F. Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg Am. 1967;49:774–784. Most of the time there is a cosmetic complaint due to the extrusion of the end of the clavicle under the skin. But pain in the shoulder area is the consequence of the associated AC joint cartilage injury, osteolysis,1,39–41 or ossification calcification of the acromioclavicular joint.42–45 4. 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