Current Concepts AC joint injuries in the overhead athlete W. Ben Kibler, MD Medical director Shoulder stability, function Anterior- curved clavicle to SC joint Posterior- muscles to spine, chest wall Triangular support - arm stability and mobility A-C joint- stable link to control SHR A-C Separations What s wrong here? What structures are injured What bone is displaced What is best evaluation AllinaHealthSystem 1
3D functional anatomy Conoid ligamentinf/sup Trapezoid ligamentinf/sup, lateral Injury force is directed: anterior medial inferior Codman, 1934 AC ligamentsinf/sup, ant/post, lateral tilt Basamania AllinaHealthSystem 2
CONCLUSIONS A-C joint function is 3-D AC joint dysfunction is 3-D Evaluation should be 3-D- imaging, joint/scapula exam Treatment should address 3-D restorations Basamania Cross-body adduction AP Radiograph X-ray mimics injury forces and resultant instability AllinaHealthSystem 3
A- C separations Low grade - stable scapula - good biomechanics - Scapular dyskinesis (-) - Minimal sx except at jointsprain - 1/3 of cases- rehabilitation A- C separations High grade - unstable scapula with poor biomechanics - Scapular dyskinesis (+) - Sx at joint, in arm- changescapular position control - 2/3 cases- counsel surgery 3D functional loss IMPLICATIONS Re-evaluate 7-10 days Scapular position, motion- guide to altered AC, scapula mechanics Dyskinesis- (+), (-) PT, Patient education, counseling Surgery for altered function AllinaHealthSystem 4
IMPLICATIONS Surgical indications Dyskinesis, altered function, arm weakness, impingement, failed directed PT, patient request Allograft reconstruction- CC and AC structures- MADOK procedure Tendon allograft PDS internal splint Internal splint tied Graft/sutures passed Graft sutured CC AC ligament injury Skin incision Anatomic conoid, trapezoid drill holes Native ligament repair Anterior, posterior clavicle drill holes Double loaded suture anchors and sutures Acromial drill holes Graft passing suture Docking graft into acromion Completed AC joint reconstruction AC ligaments CC ligaments Native ligament repair AC ligament repair Superior Posterior Anterior AllinaHealthSystem 5
Arthroscopy April 2017 Prospective, 1.5-3 years N= 23- fall, deformity 5 low grade- no surgery 18- high grade- 16 surgeries, 5 revision, 6 acute, 5 chronic All AC/CC reconstruction Arthroscopy April 2017 Follow up- DASH- function Plain x-ray- static Scapular exam- dynamic Other- LOR, other surgery, complications AllinaHealthSystem 6
Pre DASH Post DASH Outcomes- DASH Mean (SD) 95% CI P-Value 54 (22) 44-63 P<.001 17 (19) 7-28 MDC 95%=7.9-14.8; MCID 10.2 Outcomes 1- Loss AC reduction after fall (> low grade AC) Static 2D x-ray stability, C-C distance 0.59-1.31 cm (avg 1.0) Dynamic 3D clinical stabilityneg ant/post, sup/inf laxity, no scapular dyskinesis Outcomes No surgical complication- infection, hardware No hardware removal RTP- football, soccer, police Comparable to Mazzocca s resultsstability, function Conclusions Overhead athletes need intact AC joint for function A-C injury- complex 3D injury of multiple ligaments Address 3-D componentsevaluation, restore anatomy/ 3D shoulder/arm function AllinaHealthSystem 7
Conclusions Conoid, trapezoid ligaments- anatomic positions at clavicle AC ligaments- native anterior, posteriorrepair, superior- reconstruction Techniques must address all components for optimal biomechanical stability www.shouldercenterofky.com THANK YOU AllinaHealthSystem 8