know anything about A/C joint reconstruction - specifically modified weaver dunn!
Question: the modified weaver dunn procedure, as described by rockwood (c. '96) and others over the years seems to be the only solution to type 3 ACJ failure where physio alone has not yielded satisfactory results. (or is it.? if there is any alternative, i'd be interested to know!) i understand there have been many variations, including transfer of the coraco-acromial ligament, and reinforcement with permanant sutures. i also understand it is usual to excise the clavicle to prevent bony abuttment with the acromion, yet recent research shows that this resection of the clavicle can lead to a lateral plane instability in the shoulder. please anyone who knows anything about this - tell me what you know! i have read a few things (from galileo's original thoughts to more recent medical papers. tho in no way do i claim a comprehensive knowledge :) but i'm a physicist not a orthopaedic specialist! please any info on the injury/op/rehabilitation to sports (esp snowboarding :)
big thanks
D ;)
Answers:
The AC joint is formed by the lateral end of the clavicle and acromion process of the scapula, and has a cartilaginous intraarticular disc. The joint provides a connection between the trunk and upper extremity through the sternoclavicular joint, clavicle and acromioclavicular joint. The AC joint is stabilized by two separate ligamentous structures: the AC ligament and the scapuloclavicular ligaments. The much stronger stabilizing system consists of the conoid and trapezoid ligaments, which run obliquely from the coracoid to the clavicle in opposing directions and are analogous to the cruciate ligaments of the knee, preventing anterior-posterior and upward displacement of the clavicle and acting as a rotational guide. The acromioclavicular capsule is relatively more lax and is reinforced by a superior AC ligament. The most frequent mechanism of injury to the AC joint is a fall or a sharp blow on the acromion process which forces the scapula and the arm downward while the clavicle, locked by the ribs, is then pushed upward. According to Rockwood (1) these lesions are classified in six different types:
Figure 1
Type I: partial tear of the acromioclavicular ligament without real change in position of the distal clavicle in relation to the acromion.
Type II: Rupture of the acromioclavicular ligament with a partial tear of the coracoclavicular ligaments. The distal end of the clavicle is displaced in relation to the acromion less than the full width of the clavicle itself.
Type III: Rupture of the AC ligament and the coracoclavicular ligaments, with displacement of the distal clavicle more than its full width (Figure 1).
Type IV: posterior displacement of the distal clavicle through the muscle aponeuroses of trapezius. Deltoid and trapezius muscles are detached from the distal clavicle.
Type V: The distal clavicle is severely displaced upward toward the base of the neck, covered only by skin and subcutaneous tissue, with a complete rupture of the deltoid- trapezius musculature.
Type VI: Inferior dislocation of the clavicle under either the acromion or the coracoid process. Coracoclavicular ligaments and muscles are intact or disrupted.
"The multiplicity of procedures available is clear evidence that none is totally satisfactory; thus the search for more satisfactory methods continues" (2). However almost all authors note excellent or good results either with conservative or with surgical treatment (references 3-20). More than fifty different bandaging techniques and more than thirty different operations have been suggested for the treatment of complete AC joint dislocation. Surgical repairs fall into two general categories: those that attempt to restore the normal anatomy and those that alter the anatomy in order to achieve reduction and stability. Today most surgeons use various combinations of the techniques described as shown in Table I.
Surgical Indications
The management for acute dislocations of the acromioclavicular joint is controversial. Most of orthopaedists have agreed that Type I and II injuries require a conservative treatment; however the debate in case of type II injury concerns which type of non-surgical treatment to employ, either symptomatic only or bandaging in order to attempt an external reduction of the AC joint dislocation. Grade III injuries may be managed either with surgery or non-operatively. The trend in management of AC type III dislocations in young active people is suggested by results of a questionnaire sent by Cox (20) to the chairmen of all orthopaedic residency training programs in North America and to a group of orthopaedic surgeons active in sports medicine. Eighty-six per cent of physicians involved in care of collegiate and professional athletes and seventy-two per cent of the chairmen preferred non-surgical treatment. Among the physicians that were choosing a conservative treatment, 33% and 28% respectively (team physicians and chairmen) were using manual reduction of the dislocation and maintenance of that reduction by an acromioclavicular immobilizer. However, the questionnaire failed to ask whether the athlete was male or female, a thrower or not, or whether the dominant arm was injured (20). In our experience, throwers and other overhead athletes playing tennis, volleyball, and squash are significantly weakened by the grade III joint dislocation for up to a year after injury. In these athletes, and with patients concerned about the cosmetic appearance of the dislocation, we recommend prompt repair and rapid return to training.
Surgical Procedure
Our preferred approach for all shoulder surgery, both arthroscopic and open, is with the patient in the beach chair position. The arm is draped free and gravity provides a safe level of traction. The AC joint is exposed through a vertical longitudinal incision directly over the AC joint extending down just superior to the coracoid in Langer's lines. A sharp dissection is carried down to the superior surface of the clavicle.
The torn superior ligamentous connection between the clavicle and the acromion is carefully identified and preserved. Using sharp dissection, the remaining fascial fibers are dissected from the superior surface of the clavicle. Using blunt dissection, the tip of the coracoid is identified. A 4.5 millimeter AO drill and guide is brought into place. A Darrach retractor is placed inferior to the clavicle and a vertical 4.5 millimeter drill hole is placed from superior to inferior, directly in the mid body of the clavicle one centimeter from the distal clavicular end. A second 4.5 millimeter drill hole is then placed from superior to inferior through the distal tip of the coracoid process, taking care not to break through the distal tip of the coracoid, again, one centimeter from the distal tip. Careful identification of the coracoclavicular ligaments is then performed. If the ligaments are of sufficient quality, a #1 Ethibond suture is woven into the remaining coracoclavicular ligaments and passed through the periosteum of the clavicle, performing a primary repair of the coracoclavicular ligaments. A flexible Richard's suture passer is then passed through the clavicle, carrying a #1 Ethibond suture and through the distal tip of the coracoid from superior to inferior. The suture is then passed with a sharp needle through the end of a 4 millimeter Gore-Tex tape. The suture and tape are then pulled through from superior to inferior of the clavicle and the coracoid (Figure 2). The loop of the Gore-Tex tape is left on the superior surface of the clavicle and the Gore-Tex tape is looped over the distal tip of the coracoid back up to the loop on the superior surface of the clavicle and folded down over itself in a belt loop fashion (Figure 3). Using a large Kocher clamp, the distal end of the Gore-Tex is clamped and tension applied, reducing the clavicle to the level of the acromion (Figure 4). A #1 Ethibond suture is passed through the looped ends of the Gore-Tex tape, securing the vertical strands to each other, effectively stopping any further slippage of the Gore- Tex tape onto itself. The tape is then wound around itself in a candy-stick fashion (Figure 5). Two further #1 Ethibond sutures are passed through the vertical strands of the Gore-Tex tape, effecting final locking of the tape onto itself (Figure 6). This step defines the ultimate failure strength of the procedure. If the tape shreds or is weakened during needle passage, failure may occur by early rupture of the suture-tape construct. Closure is then undertaken by primarily repairing the superior ligamentous tissues overlying the clavicle and acromion. Soft tissue closure is performed by using 0 and 2-0 absorbable suture with 3-0 nylon in the skin. Marcaine is instilled in the incision to afford postoperative pain relief and a standard ABD dressing is applied to the superior aspect of the shoulder with a shoulder sling. An Aircast Cryo Cuff is applied to the shoulder and left in place until the dressing is changed on the first post operative day.
Other Answers:
i read that a procedure that grafts onto the ligament is being tested. i had surgery and it just is not right but i spoke with many in rehab who said the same and the nurses said that a/c never really repairs itself. best of luck.
you may find the link below interesting for joint replacement information
http://www.theflyingpatient.com/index.php?page=knee&menu=1
Source(s):
http://www.theflyingpatient.com/index.php?page=knee&menu=1
Answers: