Injuries to the acromioclavicular joint of the shoulder represent

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1 Treatment of acromioclavicular separations A retrospective study* JOHN P. PARK, M.D., JAMES A. ARNOLD, M.D., TOM P. COKER, M.D., WALTER DUKE HARRIS, M.D., AND DAVID A. BECKER, Ph.D., Fayetteville, Arkansas From the Division of Sports Medicine, University of Arkansas, Fayetteville, Arkansas ABSTRACT A retrospective study of 134 patients with Types I, II, and III acromioclavicular separations was carried out. The average followup was 6.3 years, with the longest being 19 years, and the shortest being 1 year. The mechanism of injury was a direct blow in 92% of the patients. The average age of the patients was 30.1 years, with a range from 13 to 68 years. All patients were evaluated using a standard rating system for the shoulder and humerus, the total for perfect recovery being 100. Twentyfour patients with Type I separations were immobilized 19.5 days, with a disability period of 6 weeks, and rated 94 points. Twenty-five patients with Type II separations were immobilized 27 days for the conservative groups, had a disability period of 6 weeks, and rated 90 points. Eighty-five patients with Type III acromioclavicular separations were followed. Seven patients had conservative treatment, were immobilized an average of 22 days, with a disability period of 13 weeks, and rated 82. Of those patients who underwent surgical repair, excluding Dacron graft substitution, the immobilization period was 6 weeks, with a disability period of 12 weeks, and a rating of 80. Fifty-eight patients underwent repair with double velour Dacron prosthetic substitution for the coracoclavicular ligaments, combined with distal clavicular resection in all but two patients. The average immobilization period was 1 week, with the average disability period being 3 weeks. The average rating was 96, with 24 patients rating 100. The major cause for a rating less than 100 was light to moderate pain that persisted in a few cases, which was only occasional and associated with a particular activity. One infection occurred requiring graft removal 5 months after surgery. Calcification in the area of the coracoclavicular ligaments did not affect the final rating and recurrence of deformity was not noted. *Presented at the American Orthopaedic Society Sports Medicine Meeting, Innisbrook, Florida, July 8 to 12, t Address correspondence to: John P. Park, M.D., Division of Sports Medicine, P.O. Drawer 1608, Fayetteville, Arkansas Injuries to the acromioclavicular joint of the shoulder represent a potentially disabling malady, especially to the athlete, wage earner, or other active person who places physical demands on his shoulder. The purpose of this paper is to assess or III the treatment results in 134 patients with Types I, II, acromioclavicular separations. Emphasis will be placed on Type III injuries and the form of treatment we have found most successful in restoring an athlete to his preinjury level performance. The literature is replete with articles on the treatment of acromioclavicular separations. Most authors have recommended conservative nonsurgical treatment for Types I or II acromioclavicular separations.1-8 Treatment modalities have included &dquo;skillful neglect,&dquo; varieties of slings or harnesses, or even casting as recommended by Urist. Published reports have substantiated this approach to treatment with good to excellent results obtained in most patients. However, a revealing study by Bergfeld et al.l evaluating Types I and II sprains in midshipmen at the United States Naval Academy concluded that 9% of Type I and 23% of Type II sprains became significantly symptomatic after injury. Failures of later treatment have usually resulted from degenerative changes occurring in 9 12> 13 the acromioclavicular joint. Brosgolll and others~~ have recommended surgical excision of the distal end of the clavicle to alleviate complaints in the symptomatic patient. The greatest controversy exists in the treatment of Type III acromioclavicular separations, specifically whether or not surgical treatment is preferable to closed methods of management. Closed treatment has been recommended by numerous authors.9, Glick et al.18 after following 35 acromioclavicular dislocations in athletes, concluded that complete reduction was not necessary for satisfactory function. He recommended supportive therapy during the acute phase of injury, followed by continuous strengthening exercises as an effective method of treatment in Type III injuries. For numerous reasons we have seen more failures of treatment with conservative methods 251

2 including (1) failure of patients to return for frequent adjustments in supporting apparatus; (2) removal of the apparatus because of discomfort in wearing; (3) skin maceration, tape irritation, or pressure sore; (4) joint stiffness, a frequent postimmobilization problem, especially in the older patient; (5) prolonged immobilization; and (6) residual deformity even after an adequate period of immobilization. Advocates of surgical treatment have noted similar problems with attempts at conservative management of these injuries. More than 30 operative procedures have been described for Type III acromioclavicular separations.1-8, 10-14, 16, Basically, there are two types of fixation utilized in the surgical treatment of Type III acromioclavicular separations: (1) involving fixation of the distal clavicle and acromion process through the acromioclavicular joint, and (2) fixation of the clavicle to the coracoid process, thus relocating the acromioclavicular joint. Bargren et a1.2 has demonstrated the biomechanical validity of coracoclavicular approaches to fucation in deference to acromioclavicular techniques. There are many difficulties associated with surgical treatment of the acromioclavicular joint. These have one or more used for of the following disadvantages: (1) migration of pins fixation (2) erosion of bone by fixation devices; (3) failure of metallic fixation devices; (4) recurrence of deformity; (5) late development of acromioclavicular arthralgia; (6) a second operation being necessary to remove many fixation devices; and (7) the ordinary risks of surgery, including scar formation, infection, hematoma, and so forth. The ideal operative procedure should eliminate the possibility of migration of fixation devices or failure of acromioclavicular reduction. Late degenerative changes in the acromioclavicular joint should not be seen and any further operative procedure should be unnecessary. In addition, the result should be cosmetically acceptable and should allow the patient to have a fully functional shoulder in a short period of time. In this paper we are reporting our analysis of the treatment for acromioclavicular separations in 134 patients, 85 of whom sustained Type III separations. In particular, we describe our technique of using a Dacron prosthetic substitute in 58 of 78 patients, of whom 39 were treated with a double velour Dacron graft, a procedure we developed. This procedure is relatively easy surgically, reduces the time of immobilization for the patient, and appears to offer results which do not diminish with time. CLINICAL MATERIAL In reviewing 134 patients with Types I, II, or III acromioclavicular separations, 85 of these patients sustained Type III separations. The mean age of the patients was 30.1 years, with a range of 13 to 68 years. The mean followup was 6.3 years, with the longest being 19 years and the shortest being 1 year. The mechanism of injury was a direct blow in 92% of the patients (Fig. 1). The diagnosis of acromioclavicular separations made on the basis of a history of trauma in most cases, with the clinical findings of deformity and tenderness, is often associated with an abrasion over the site of impact over the acromioclavicular joint of the shoulder. Roentgenographic evidence of clavicular Fig. 1. Mechanism of injury. displacement on Types II and III injuries was noted with stress views obtained of both acromioclavicular joints. All patients were evaluated using a standard rating system for the shoulder and humerus. The system was designed to evaluate wound appearance, deformity, range of motion of the shoulder, pain, and the presence of any postoperative complications. A number of points was assigned to each factor in the rating system; the total for perfect recovery being 100%. The rating was assessed at the time of the latest followup. Twenty-four patients with Type I separations were immobilized a mean of 19.5 days with a disability period of 6 weeks, a mean rating of 94 points. Two of the 24 patients required subsequent resection of the distal clavicle for painful degenerative arthritis of the acromioclavicular joint. Twenty-five patients with Type II separations were immobilized a mean of 27 days, and had a disability period of 6 weeks, rating 90 por s at the time of followup. Eighty-five patients with Type III acromioclavicular separations were followed. Seven patients were treated nonopera- with a disa- tively with an immobilization period of 27 days, bility period of 13 weeks, and a mean rating of 82. Of those patients who underwent surgical repair, excluding Dacron graft substitution, the mean immobilization period was 42 days, with 252

3 a disability period of 12 weeks, and a rating of 80. Pain and recurrence of deformity accounted for the lower rating in the majority of these patients. Fifty-eight patients underwent extraarticular repair with the Dacron prosthetic substitution for the coracoclavicular ligaments, combined with distal clavicular resection in all but two later in the patients. A double velour Dacron graft developed study was used in 39 of these patients. The surgical technique by Henry, 30 was modified by using a straight incision from the coracoid process to the acromion. The clavicular origin of the deltoid was exposed and the distal 1 cm of the clavicle along with its meniscus, and the acromioclavicular joint excised. Then, by traction on the clavicle in the posterior-superior direction, the coracoid process was exposed. The periosteum beneath the coracoid was elevated and a graft passed around the clavicle and beneath the coracoid process (Fig. 2). In doing so, the graft was placed posterior to the tendon or origin on the coracobrachialis muscle in order to obtain an anterior and posterior tether. The graft was then tied in a square knot with the knot deep within the substance of the wound and not resting on the clavicle, while the clavicle was held in the reduced position (Fig. 3). Fig. 3. Surgical technique-the completed appearance. Fig. 2. Surgical technique for passing coracoid. the Dacron around the Patients were allowed to discontinue their immobilization at their own discretion, dictated by discomfort. Isometric exercises were often begun by 3 days and always by 7 to 10 days. The mean immobilization period was 1 week, with a mean disability period of 3 weeks. The mean rating was 96, with 24 patients rating 100. The major cause for a rating less than 100 was light to moderate pain that persisted in a few cases, which was only occasional and associated with a particular activity. One infection occurred requiring graft removal 5 months after surgery, in the series was removed from a over the clavicle. This from the on the knot. Calcification in the area of the coracoclavicular ligaments was noted in 14 and one graft done early patient, whose knot was tied superiorly patient was a scuba diver who experienced pain pressure of his air tank straps lying patients. However, this did not affect the final rating, and recurrence of deformity was not noted. No significant clavicular wear or erosion has been noted since utilizing the new double velour Dacron grafts, although eight patients with the older vascular Dacron grafts had resorption of the clavicle at the site of the Dacron graft. (We believe this is due to the cable effect that is known of this fiber type in the knitted grafts and tapes vs. the dispersed texturized Dacron in the double velour graft.) Eight patients developed further resorption of the distal 253

4 clavicle, although significance of this finding did not affect the patients final rating. DISCUSSION is unknown and Dacron polyethylene teraphthalate has an extremely good track record in both knitted and woven form since Dr. Denton Cooley s work as a vascular substitute in the early 1950s, and reports of its use as a coracoacromial substitution graft have appeared more recently. 20,21 Since 1974 we have inserted the double velour Dacron graft into 62 dog knees, including medial collateral ligament and anterior cruciate substitutions. The double velour Dacron graft allows maximum fibrous ingrowth, whereas the knit and simple woven types did not stimulate collagen ingrowth as profusely. It was felt by the engineers at the University of Arkansas, as well as by us, that the double velour Dacron graft with an H- beam configuration that approached the modulus of elasticity similar to that of human ligament be used (Fig. 4) in both the canine studies and for the repair of acromioclavicular separations. The graft has two fiber types, including Fiber Type 56 by DuPont, which is the principle component of the Meadox double velour shoulder prosthesis. When substituted for the medial collateral ligament in canine models, examination at 6 attached to bone weeks grossly revealed the graft to be firmly at both the distal and proximal tibial attachments. The graft was observed to be covered with a thick fibrous tissue. Histologic examination reveals fibrous tissue invasion within the interstices of the mesh with a minimal giant cell response. Early woven bone ingrowth into the prosthesis is noted at the sites of attachment of the graft. At 6 months, fibrous tissue Defmite vascular development appears to be nearly complete. structures are observed within the lumen of the graft, with collagenization of the fibrous tissue. Mature bone is noted to be lying within the lumen of the graft at the site of the femoral and tibial attachments. Whereas earlier vascular grafts showed fibrous tissue surrounding the bundles of Dacron material, Fig. 4. Illustrations of the figure H-beams made of a 0.6 x 3.2 piece of double velour Dacron. Such H-beams are used to form grafts in the knee for repair of ligaments and the prosthesis in the shoulder for treatment of acromioclavicular separations. fibrous ingrowth within the bundles of the double velour graft are apparent. Based on the work of Bargren et al.,20 Barnhart,2l and Harrison and Sisler (in presentation, American Academy of Orthopaedic Surgeons, Symposium on The Shoulder, Dallas, Texas, 1974), we have used surgical Dacron velour prosthetic substitution for the coracoclavicular ligaments combined with III acromioclavicular resection of the distal clavicle in Type separations. The surgical procedure used to implant the double velour Dacron graft is relatively easy. This technique reduces the time of immobilization and allows earlier resumption of normal activities. It appears to give predictably good results with minimal discomforts, good range of motion, and no significant deformity after surgery. Results do not appear to diminish with time. As Dacron grafting would be expected to be just as effective secondarily as primarily, a wait-and-see attitude at the time of initial injury would not be contraindicated. The treatment of first- and second-degree acromioclavicular separations with conservative methods seems to offer satisfac- we have followed. tory results in the majority of patients Failure of treatment results from the development of degenerative changes of the acromioclavicular joint, and may be treated successfully with resection of the distal clavicle. The majority of Type III acromioclavicular separations must be treated surgically. The procedure we have developed with the use of the double velour Dacron graft seems to be the most effective for the patient of any treatment we have in our armamentarium at this time. REFERENCES 1. Allman FL: Fractures and ligamentous injuries of the clavicle and its articulation. J Bone Joint Surg 49A: , Bateman JE: Athletic injuries about the shoulder in throwing and body-contact sports. Clin Orthop 23: 75-83, Behling F: Treatment of acromioclavicular separations. Orthop Clin North Am 4: , Lazcano MA, Anzel SH, Kelly PJ: Complete dislocation and subluxation of the acromioclavicular joint. J Bone Joint Surg 43A: , Millbourn E.: On injuries to the acromio-clavicular joint. Treatment and results. Acta Orthop Scand 19: , Moseley HF: Athletic injuries to the shoulder region. Am J Surg 98: , Sage FP, Salvatore JE: Injuries of the acromioclavicular joint. A study of the results in 96 patients. South Med J 56: , Weaver JK, Dunn HK: Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg 54A: , Urist MR: Complete dislocation of the acromioclavicular joint. J Bone Joint Surg 45A: , Bergfeld JA, Andrish JT, Clancy WG: Evaluation of the acromioclavicular joint following first- and second-degree sprains. Am J Sports Med, 6: , Brosgol MP: Traumatic acromioclavicular sprains and subluxations. Clin Orthop 20: , Gurd FB: The treatment of complete dislocation of the outer end of the clavicle: A hitherto undescribed operation. Ann Surg 113: , Mumford EB: Acromioclavicular dislocation. A new operative treatment. J Bone Joint Surg 23: ,

5 H: Dislocation of the acromioclavic- on 56 cases. Acta Chir Scand 113: , Hart VL: Treatment of acute acromioclavicular dislocation. J Bone Joint Surg 23A: , Arner O, Sandahl U, Ohrling ular joint. Review of the literature and a report 16. Imatani RJ, Hanlon JJ, Cady GW: Acute, complete acromioclavicular separation. J Bone Joint Surg 57A: , April Rosenørn M, Pederson B: A comparison between conservative and operative treatment of acute acromioclavicular dislocation. Acta Orthop Scand 45: 50-59, Glick JM, Milburn LJ, Haggerty JF, et al: Dislocated acromioclavicular joint: Follow-up study of 35 unreduced acromioclavicular dislocations. Am J Sports Med 5: , Alldredge RH: Surgical treatment of acromioclavicular dislocations. J Bone Joint Surg, Proceedings: 1278, Bargren JH, Erlanger S, Dick HM: Biomechanics and comparison of two operative methods of treatment of complete acromioclavicular separation. Clin Orthop 130: , Barnhart JM: Acromioclavicular joint injuries. Proceeding of 1970 annual meeting. Clin Orthop 81: 199, Barley RW, Metten CF, O Connor GA, et al: A dynamic method of repair for acute and chronic acromioclavicular disruption. Am J Sports Med 4: 58-71, 1976 GS: Acromioclavicular dis- 23. Bearden JM, Hughston JC, Whatley location: method of treatment. Am J Sports Med 1: 5-17, Bosworth BM: Acromioclavicular separation. New method of repair. Surg. Gynecol Obstet 73: , Bosworth BM: Acromioclavicular dislocation: End-results of screw suspension treatment. Ann Surg 127: , Browne JE, Stanley RF, Tullos HS: Acromio-clavicular joint dislocations. Am J Sports Med 5: , Bundens WD, Cook JI: Repair of acromioclavicular separations by deltoid-trapezius imbrication. Clin Orthop 20: , Caldwell GD: Treatment of complete permanent acromioclavicular dislocation by surgical arthrodesis. J Bone Joint Surg 25: , Dewar FP, Barrington TW: The treatment of chronic acromioclavicular dislocation. J Bone Joint Surg 47B: 32-35, Henry AK: Extensile Exposure. Second Edition. Edinburgh, Churchill Livingstone, 1973, pp Jacobs B: Acromioclavicular joint injury. J Bone Joint Surg 48A: , Kappas GS, McMaster JH: Repair of acromioclavicular separation using a Dacron prosthesis graft. Clin Orthop 131: , Kennedy JC: Complete dislocation of the acromioclavicular joint 14 years later. J Trauma 8: , Kennedy JC, Cameron H: Complete dislocations of the acromioclavicular joint. J Bone Joint Surg 36B: , Murray G: Fixation of dislocations of the acromioclavicular joint and rupture of the coracoclavicular ligaments. Can Med Assoc J 43: , Murray JWG: Reconstruction of the dislocated acromioclavicular joint, a simplified method. Orthop Rev 2: 55-57, Neviaser JS: Acromioclavicular dislocation treated by transference of the coracoacromial ligament. Arch Surg 64: , Pettrone FA, Nirschl RP: Acromioclavicular dislocation. Am J Sports Med 6: , Phemister DB: The treatment of dislocation of the acromioclavicular joint by open reduction and threaded-wire fixation. J Bone Joint Surg 24: , Tyler GT Jr: Acromioclavicular dislocation fixed by a vitallium screw through the joint. Am J Surg 58: , Vargas L: Repair of complete acromioclavicular dislocation, utilizing the short head of the biceps. J Bone Joint Surg 24A: , Weitzman G: Treatment of acute acromioclavicular joint dislocation by a modified Bosworth method. J Bone Joint Surg 49A: , Norrell Jr H, Llewellyn RC: Migration pin from an acromioclavicular joint into the spinal report. J Bone Joint Surg 47A: , 1965 of a threaded Steinmann canal. A case COMMENTARY Dr. James R. Andrews, Columbus, Georgia: I would like to congratulate Dr. Park and his coauthors on a fine presentation. They allowed me the opportunity to inspect their paper well ahead of time. The paper was complete with an excellent bibliography for review of this subject. I would say that this paper s purpose is to introduce a new material for internal fixation of a Grade III sprain of the acromioclavicular joint and not to discuss the merits of openvs.-closed treatment. They basically have given rebirth to the for fixation of the clavicle to the Red Alldredge technique coracoid process and have introduced a new prosthetic material for fixation. In the past with the Alldredge technique the fixation has routinely been a double loop stainless steel wire. More recently a knitted or dacron tape has been used instead of wire. This paper deals with an H-beam double velour Dacron ligament prosthesis with a 40-lb tensile strength. The double loop wire technique has been proven to be effective except that it does require a second operation for removal. If left in it will break and the pieces of wire can migrate. The older Dacron tapes or knits have been known to cause cortical sawing of the clavicle. DISCUSSION I do not think that the purpose of this paper was to discuss the and I believe their proper treatment of Grades I or II sprains conclusions there were inconclusive. I also do not believe that this series settles the question of nonoperative vs. operative treatment of Grade III sprains. It primarily offers a surgical technique with a retrospective followup. I think that the authors would be wise to only report their last 39 cases with double velour Dacron graft fixation to be more specific about this prosthesis. I would like to point out a few areas of controversy with their technique: Can the graft be tied too tightly? (Direct blow in >90%.) Does the distal end of the clavicle always need resection and, if so, what effect does this have on the throwing shoulder? Have they done this technique on a throwing athlete s shoulder, i.e., baseball pitcher and/or quarterback and, if so, what were the results? Does the normal healing process of the acute acromioclavicular ligament rupture need the prosthetic ligament backup for proper healing function? If an infection occurs, how difficult is it to remove the graft? Should antibiotic coverage be used? Advantages of this technique can be summarized: (1) earlier return to active range of motion and athletic participation; (2) ease of surgical repair; (3) no cortical sawing; and (4) can be used equally as effective in the late secondary repair of the complete acromioclavicular separation. I would not consider any of their experimental work presented in this paper on knee ligament prosthetic replacement to be experimentally proven for any clinical use in the human knee yet. I would also warn you not to alter the double velour knitted pattern by splitting or cutting the prosthesis because that will significantly alter its biomechanical properties. 255

6 Again, I would like to congratulate the authors and I would like to thank Dr. Allman for allowing me to discuss this paper. Authors Reply 0 Can the graft be tied too tightly? In our experience, the normal stretch factor that is built into the graft allows for tight internal fixation and we have had no instances where the graft has been snugged too tightly with resultant impingement syndrome.. Does the distal end of the clavicle always need resection, and, if so, what effect does this have on the throwing shoulder? In our experience, distal clavicle excision is recommended we have seen has been because the only source of problems secondary to symptoms arising in the acromioclavicular joint, and in cases where the distal clavicle was not excised.. Has this technique been tried on a throwing athlete s shoulder, i.e., baseball pitcher and/or quarterback, and, if so, what are the results? This procedure has been performed on collegiate scholarship athletes, including one starting quarterback, and no detrimental symptoms have arisen affecting the athlete s performance after this procedure.. Does the normal healing process of the acute acromioclavicular ligament rupture need the prosthetic ligament backup for proper healing function? Recurrence of deformity after other types of fixation not utilizing the Dacron graft has been a common problem even after repairing the acromioclavicular ligament complex acutely. It appears that once these ligaments are stretched out they heal in a lenghthened position, and even after repair they do not provide sufficient ligamentous support to prevent recurrence of deformity. 0 If an infection occurs, how difficult is it to remove the graft? We have reported one graft infection here, however, this is one in which a previous vascular graft was utilized and not a double velour graft. The patient developed a seroma which was then opened for drainage and healed without sequela. Cultures were negative at all times from the wound. Perhaps more properly this should have been included as a wound complication rather than true infection. 0 Should antibiotic coverage be used? Antibiotic coverage with initial antibiotics anesthesia. As this we recommend antibiotic has been utilized for a 24-hr period, being given as the patient is induced during is a large graft with a woven pattern, coverage on a prophylactic basis. 256