Management of Grade III-V Symptomatic AC Injuries

Transcription

1 Grade III-V AC Injuries Acromioclavicular Joint Injuries Management of Grade III-V Symptomatic AC Injuries Sean Grey MD Orthopaedic Center of the Rockies Fort Collins, Colorado Unsolved Problem Controversy: Non-operative vs surgical Acute treatment vs Chronic Surgical technique Over 100 described surgical Predominately Non-Surgical Management SYMPTOMATIC AC seperations GI-II- essentially all non-surgical GIII- many or most non-surgical GV- many will do well non surgical 1

2 AC Separation Classification AC Separation Classification Grade III-V AC Seperations Rockwood classification G III injuries Complete disruption of AC and CC ligaments Up to 100% radiographic joint displacement G-V injuries >100% radiographic joint displacement Signifies disruption of delto-trapizial fascia X-rays: weighted vs non-weighted Rockwood classification G III injuries Complete disruption of AC and CC ligaments Up to 100% radiographic joint displacement G-V injuries >100% radiographic joint displacement Signifies disruption of delto-trapizial fascia X-rays: weighted vs non-weighted Who needs surgery? Acute? Chronic Symptomatic after 12 weeks non-surgical management Including scapular rehabilitation program 2

3 Acute Grade III Author Journal Study Conclusion Ceccarelli JOT 2008 Systematic review No Difference Tamaoki Chocrane 2008 Systematic review No Difference Schlegel AJSM 2001 Prospective review of Non-op treated 20% patients Phillips COOR 1998 Systematic review No Difference Tibone AJSM 1992 Retrospective review No Difference Larsen Acta Orthopedics Systematic review No Difference Acute Grade III Individualized decision Delayed treatment will not adversely affect outcome 80-85% will do fine Risk factors: Overhead athletes Overhead laborers Dominant arm Certain types of contact sports Avid weight lifters Acute Grade V Injuries Operative treatment? Banister JBJS Br Non-operative 7 Operative Operative Had improved outcomes Many do well Torkish AAOS patients with G-V injuries 58% returned to active duty non-op Reconstructed => all returned to active duty NO advantage to early operative treatment 3

4 Surgical Reconstruction (Mazzocca) Anatomic reconstruction of CC ligaments Technique? 100+ Anatomic CC ligament reconstruction () aka=mazzocca Braided polyester prosthetic ligament Repair (BPPLR) Open or Arthroscopic? Autograft or Allograft or No-graft? AC resection? Trapezoid= 25mm end of the clavicle Conoid= 45mm end of clavicle Autograft through bone tunnels to recreate normal relationship Addition of supplemental CC fixation 4

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8 #1 Careful about holes in the coracoid #2 Careful about Holes in clavicle #2 Careful about Holes in clavicle Avoid if possible 4.5mm vs 6mm about the limit <4mm recommendation Centered and toward the base best 5.5mm holes (1 or 2) with/without tenodesis screws All had decreased load to failure Smaller holes better Smaller hole=smaller graft Less holes... 3 seems like a pretty bad idea Interference screws don t decrease fracture risk 5.5mm holes (1 or 2) with/without tenodesis screws All had decreased load to failure Smaller holes better Smaller hole=smaller graft Less holes... 3 seems like a pretty bad idea Interference screws don t decrease fracture risk 8

9 #2 Careful about Holes in clavicle #2 Careful about Holes in clavicle # 3 Size (graft) is important Forces at the AC joint are tremendous 5.5mm holes (1 or 2) with/without tenodesis screws All had decreased load to failure Smaller holes better Smaller hole=smaller graft Less holes... 3 seems like a pretty bad idea Interference screws don t decrease fracture risk 5.5mm holes (1 or 2) with/without tenodesis screws All had decreased load to failure Smaller holes better Smaller hole=smaller graft Less holes... 3 seems like a pretty bad idea Interference screws don t decrease fracture risk Control= 1330N to failure = 948N to failure No clear recommendation in literature Clavicle wrapping allows for larger graft Need additional CC force neutralization 9

10 # 3 Size (graft) is important Forces at the AC joint are tremendous # 3 Size (graft) is important Forces at the AC joint are tremendous #4 Autograft vsallograft Control= 1330N to failure = 948N to failure No clear recommendation in literature Clavicle wrapping allows for larger graft Need additional CC force neutralization Control= 1330N to failure = 948N to failure No clear recommendation in literature Clavicle wrapping allows for larger graft Need additional CC force neutralization No difference Either is OK 10

11 #5 Arthroscopic vs Open Open Better reduction of CC distance Improved placement of clavicular holes Arthroscopic less soft tissue morbidity Better coracoid visualization #5 Arthroscopic vs Open Open Better reduction of CC distance Improved placement of clavicular holes Arthroscopic less soft tissue morbidity Better coracoid visualization #5 Arthroscopic vs Open Open Better reduction of CC distance Improved placement of clavicular holes Arthroscopic less soft tissue morbidity Better coracoid visualization 11

12 #6 AC resection? Leaving it improves stability Mazzocca technique(leave it) Small risk of late ACJ pain Need for DCR Contribution to stability is minimal Either is OK Outcomes Author year Journal # of Technique shoulder Nicholas 2007 AJSM 9 Open Tauber 2009 AJSM 12 Open Mazzocca 2010 JSES 17 Open Yoo 2010 AJSM 21 Open Yoo 2011 Int Orthop 13 A-A Milewski 2012 AJSM 27 Open/A-A Cook 2012 JSES 10 A-A Cook 2013 AJSM 28 Open/A-A Martetschlager 2013 AJSM 46 Open/A-A Fauci 2013 J Orthop Trauma 20 Open Jensen 2013 Arch Orthop Trauma Surg 16 A-A Mardani-Kivi 2013 Acta Orthop Trama 18 Open Millett 2015 Arthroscopy 31 A-A Outcomes 259 total patients Complication rate 39.8% (103 of 259) Loss of reduction Graft rupture Hardware failure Clavicle fractures Coracoid fractures 12

13 Alternative Technique? BPPL College Quarterback Chronic Grade III Variation of graft around clavicle and coracoid Supplemental CC fixation (tightrope) United Kingdom and Australia More aggressive treatment of AC separations Rapid return to contact sports Rugby Professor Angus Wallace 2011 Nottingham Shoulder and Elbow Unit. Nottingham, UK Braided Polyester Prosthetic Ligament (BPPL) November first US Competitive snowboarder Returned to competition that winter Several Advantages 1. Simplified technique 13

14 BPPL BPPL BPPL 2. No holes in coracoid 2. No holes in coracoid 2. No holes in coracoid 3. Only one hole in clavicle Filled with small frag screw Anterior to posterior 3. Only one hole in clavicle Filled with small frag screw Anterior to posterior 3. Only one hole in clavicle Filled with small frag screw Anterior to posterior 14

15 BPPL 4. Strong Substantial force across AC articulation= 1330N No comparative studies 5. Provides scaffold for ligament integration BPPL Disadvantages Non-anatomic Translated clavicle anterior in relation to scapula Restore conoid and trapazoid lig position? Clinical significance BPPL Outcomes AUTHOR YEAR JOURNAL # OF PT S F/U #OF COMP % GOOD + EXCELEN T Wallace 2007 Inury months 2 10/11 Wood 2009 Jl of British Army Corps 10 6 months 0 10/10 AC resection Necessary Carlos 2011 JSES British months 1 44/45 6. No graft Not a good arthroscopic technique Partial loss of reduction One outright failure Kumar 2014 Wright 2015 JOURNAL of Ortho Surgery months 2 22/24 JOURNAL of Ortho Surgery months 3 19/21 Autograft-graft site morbidity Allograft- cost, risk 15

16 Conclusions Surgical management of AC separations remains an unsolved problem Current techniques still have relatively high failure and complication rates (and it s variations) is the current technique of choice in US BPPL technique may offer an acceptable alternative, particularly in athletic population 16