Current Concepts in the Management of Acromioclavicular Injuries

Gregory N. Lervick, MD

CAQ in Orthopaedic Sports Medicine Twin Cities Orthopedics, Edina, MN Team Physician, Minnesota Vikings

Instructor, Shoulder and Elbow Surgery, MOSMI/Fairview Sports Medicine Fellowship Program

Current Concepts in the Management of Acromioclavicular Injuries

The following relationships exist:

1. Royalties and stock options: None

2. Consulting income: – None

3. Research and educational support – Tornier – Smith and Nephew

4. Other support: None

AC Injuries

EPIDEMIOLOGY • Common in hockey, football, wrestling, bicycling

• Majority in 1st 4 decades of life

• 5-10x more common in males

• Majority lower severity grade Fraser-Moodie et al, JBJS-B 2008

Pallis et al, AJSM 2012

AC Injuries

EPIDEMIOLOGY

• Most prevalent shoulder injury at NFL combine – 27% of all athletes – 12% required surgery

Kaplan et al, AJSM 2005

• 2nd only to upper leg contusions in NCAA football Dick et al, J Ath Training 2007

• 45% of all shoulder injuries in NCAA quarterbacks Tummala et al, Orth J Sports Med 2018

AC Injuries

ANATOMY

• Diarthrodial joint

• 6 degrees of freedom

• Hyaline cartilage

• Joint capsule

• Intra-articular disk of varying size/shape

AC Injuries

ANATOMY

• 3D kinematic analysis

• Open vertical MRI

• 14 shoulders – AP translation about 2 mm in

abduction/adduction of shoulder – Slight superior inferior translation with

movement – Scapula rotates through a specific screw axis

passing through insertions of both the AC and CC ligaments

– Average scapular rotation 34.9 deg Sahara et al, J Orth Res 2006

AC Injuries

ANATOMY

• Static stabilizers –AC ligaments –CC ligaments –CA ligament

• Dynamic stabilizers –Deltotrapezial

aponeurosis

Need pic and update references/discussion

AC Injuries

ANATOMY • AC ligaments – Horizontal stability – Posterior and

superior most critical

Klimkiewicz et al, JSES 1999

• CC ligaments – Vertical stability – Particularly true at

higher loads Fukuda et al, JBJS-A 1986

Costic et al, Scand J Med Sci 2004

AC Injuries

MECHANISM

• Direct trauma –Most common –Blow or fall on lateral

acromion with arm neutral or adducted

• Indirect reported – Fall on outstretched

hand

AC Injuries

PRESENTATION

• Ecchymosis

• Abrasion

• Pain

• Swelling

• Prominence of lateral clavicle

• Gross instability

• horizontal

• vertical

AC Injuries

PHYSICAL EXAMINATION • C spine evaluation

• Resting posture

• SC joint

• AC joint – Tenderness – Swelling – Translation/instabili

ty – Cross body

adduction – Always compare!

AC Injuries

PHYSICAL EXAMINATION

• Active range of motion

• Rotator cuff exam – Particularly in older

pts – Concomitant injuries

possible

• Labral pathology – Difficult to

differentiate on exam

• Serial examinations in training room

AC Injuries

IMAGING • Plain radiography – True AP clavicle – Axillary – Zanca Mazzocca et al, AJSM 2008

• Comparison films

• Stress views not necessary

• CT to evaluate fxs

• MRI to rule out associated soft tissue injury

Tischer et al, AJSM 2008

Jensen et al, Int Ortho 2017

AC Injuries

CLASSIFICATION

• Type I: – Sprained AC

ligaments – Intact CC

ligaments

AC Injuries

CLASSIFICATION

• Type II: – Ruptured AC

ligaments – Sprained CC

ligaments – Mild superior

translation of clavicle

AC Injuries

CLASSIFICATION

• Type III:

• Ruptured AC ligaments

• Ruptured CC ligaments

• Clavicle displaced superiorly 100% of diameter

AC Injuries

CLASSIFICATION

• Type IV: – Ruptured AC

ligaments – Ruptured CC

ligaments – Clavicle displaced

posterior relative to acromion

– Herniation of clavicle into or through deltotrapezial fascia

AC Injuries

CLASSIFICATION

• Type V: – Ruptured AC

ligaments – Ruptured CC

ligaments – Deltotrapezial

fascial injury – Clavicle superiorly

displaced 100-300% of its diameter

AC Injuries

CLASSIFICATION

• Type VI: – Clavicle

displaced inferior to coracoid / conjoint tendon

– Case reportable

AC Injuries

TYPE I/II INJURY MANAGEMENT

• Nonsurgical initially – May not be as benign as

once thought – Distal clavicle osteolysis – Mild instability with

subsequent arthrosis – 52% residual symptoms

at 10 yr follow up Mikek, AJSM 2008

– 27% required subsequent surgery at mean 26 mos.

Moushine et al, JSES 2003

AC Injuries

TYPE I/II INJURY MANAGEMENT

• Treatment of residual symptoms controversial – Distal clavicle resection

• Conflicting evidence • Some suggest loss of

strength, poor function • Others demonstrate success

– Ligament reconstruction – Different recovery periods – Implications for athletes

with need for rapid return to play

– No consensus!

AC Injuries

TYPE III INJURY MANAGEMENT • Historically controversial

• Nonsurgical tx still emphasized for acute injuries – 86% in prior survey Nissen / Chatterjee, Am J Ortho 2007

– Recent meta-analysis still argues that nonsurgical appropriate

Tang et al, Medicine 2018

– Canadian randomized control trial: no advantage to early surgery with hook plate

Mah et al, J Orth Trauma 2017

• No conclusive evidence that early surgery is better

AC Injuries

TYPE III INJURY MANAGEMENT

• Residual symptoms – Shoulder fatigue – Weight bearing and

loading complaints – Cosmetic – Pain

AC Injuries

TYPE IV/V INJURY MANAGEMENT

• Surgical

• Little debate

• Early better than delayed

• Skin lesions frequent – Increases infection

risk – Surgery may be

delayed until these resolve

AC Injuries

NONSURGICAL TREATMENT

• Phase I – Rest, ice, prn sling – AAROM rotation, elev/depression – Isometrics at low arm position

• Phase II – Full ROM exercises – Delt,rc, periscapular strengthening – Avoid bench, military presses

• Phase III – Presses – Sport specific

AC Injuries

NONSURGICAL TREATMENT

• Equipment modifications – High density padding – Custom equipment

• Return to play on strength and ROM criteria

• Injection?? – Anesthetic – Corticosteroid – Biologics – Placement in question

(40% accuracy rate) Bisbinas et al, Knee Sports Trauma

Arthr 2006

AC Injuries

SURGICAL INDICATIONS

• Type I/II/III with residual sxs – Arthrosis – Instability

• Type IV-VI acutely

• Numerous techniques

AC Injuries

SURGICAL GOALS: 2018

• Provide a durable reconstruction

• Restore and maintain normal anatomy

• Maximize functional return

• Minimize iatrogenic complications

• AC joint reconstruction: – No consensus on surgical technique •Non-anatomic •WD, modified WD

• Anatomic –MINAR –Dog Bone endobutton –LockDown –+/- graft (auto v. allo)

• Internal fixation • hook plate, Bosworth screw

• Arthroscopic and open approaches Simovitch et al, JAAOS 2009

Beitzel et al, Arthroscopy 2013

AC Injuries

SURGICAL GOALS: 2018

• Nonanatomic procedures – CA ligament transfers

(Weaver-Dunn) JBJS-A 1972

– Modified Weaver-Dunn

• Temporary fixation – Bosworth screw

– Absorbable suture

– CC stabilization

• Largely successful

AC Injuries

SURGICAL TX HISTORY

AC Injuries

SURGICAL OUTCOMES

• Modified Weaver-Dunn – Jiang et al, JBJS-A 2007 – 38 pts – Selected III, IV-V injuries – 89% satisfaction – 84% return to same level sport – 92% return to same level work

AC Injuries

SURGICAL OUTCOMES

• Why not a modified Weaver-Dunn? – Biomechanical concerns – Lee et al, AJSM 2003

• Free grafts stronger than suture or CA ligament • Load to failure for free grafts similar to native CC

ligaments (650 N)

– Mazzocca et al, AJSM 2006 • Anatomic reconstruction has superior mechanical

strength • Less AP clavicle translation

AC Injuries

ANATOMIC RECONSTRUCTION

• Tunnels at conoid and trapezoid ligament origins

• 6mm tunnels

• 5.5mm biotenodesis fixation

• Semitendinosis free graft Mazzocca et al, AJSM 2006

• Graft without augment / support likely inadequate Choi et al, JSES 2017

AC Injuries

ANATOMIC RECONSTRUCTION

• Coracoclavicular ligament reconstruction

• Auto or allograft

• Interference screw fixation?

• Bone tunnels in clavicle

• Anatomy reproduction

AC Injuries

ANATOMIC RECONSTRUCTION

• Coracoid fracture Gerhardt et al, JSES 2011

• Clavicle fracture Turman et al, JBJS-A 2010

• Learning curve

• More complex surgery = more problems?

Milewski et al, AJSM 2012

AC Injuries

ANATOMIC RECONSTRUCTION • Surgical concepts 2018 – Anatomic drill hole

location – SMALL drill holes – Subcoracoid suture

passage – Triple suture

technique – Extracortical graft Clevenger et al, Arthroscopy

2011

– Avoid interference screws

Tashjian et al, JSES 2012

AC Injuries

AFTER SURGERY

• Post-surgical care is important! – Conservative – Shoulder sling x 6 wks – Protected elbow/wrist ROM – Some aerobic activity – Delt isometrics at 4 wks

• Progress to full AROM/gradual strength program at 6 wks

• Full weight program at 10-12 wks

• Full activity 18-20 wks

AC Injuries

SUMMARY

• Common injuries

• Prevalent in collision athletes

• Majority direct trauma

• Majority of lower severity

• Treatment types I-III: generally nonsurgical

• Treatment types IV-VI: surgical

AC Injuries

SUMMARY

• Numerous surgical techniques described

• Trend toward anatomic technique when reconstruction indicated... – Beware of large clavicle bone tunnels – Avoid coracoid tunnels altogether

• Need of well-designed outcome studies

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