Acromioclavicular joint hurt are common among immature active persons. Stability of this shoulder complex compose of musculus ( deltoid and cowl muscle ) , ligament ( acromioclavicular and coracoclavicular ) and acromioclavicular articulation capsule. Clinical and radiographic scrutinies are important to name this hurt. Non operative intervention is indicated for type I and II hurt. Surgical intervention is indicated for type IV, V and VI hurt. Treatment for type III hurt are still controversy. Method of intervention autumn into 3 classs: arrested development of acromioclavicular articulation, arrested development of coracoclavicular articulation and ligament Reconstruction. Tendencies of intervention goes to minimal invasive anatomic acromioclavicular articulation Reconstruction.
Cardinal words: acromioclavicular, coracoclavicular
Acromioclavicular ( AC ) joint hurt represents 40-50 % of shoulder injury.1 Some facets of intervention options between conservative and surgery are still controversy2. Categorization by Tossy3 and Allman4 in 1960 was modify by Rockwood5 in 1989. Recently, minimum invasive surgical intervention tends to acquire more popularity.
Anatomy and biomechanics
The AC articulation is a diathrodial articulation located between distal terminal of collarbone and median boundary line of acromial process procedure of the scapular. Inclination of joint possibly about perpendicular or may be inclined from downward medially with collarbone overruling acromial process by the angle of 50 grades. Articular surface of collarbone overrides the articular surface of acromial process about 50 % of the clip. Fibrocartilagenous intra-articular disc are divide in 2 types: complete and partial ( meniscoid ) . Meniscus become degenerated and reached non-functional province at 4th decennary. Nerve supply to the AC articulation is from alar, suprascapular and sidelong thoracic nervousnesss.
The dynamic stabilizers to the AC joint compose of anterior part of deltoid musculus which provide suspensory support and the upper part of trapezius musculus. In the presence of break of the AC and CC ligament, the importance of these musculus increased.
AC articulation is surrounded by a thin capsule and reinforced by superior, inferior, anterior and posterior AC ligaments. These construction preponderantly control horizontal gesture of the collarbone. Posterosuperior capsule is the construction to forestall posterior interlingual rendition of the clavicle6. Distal collarbone resection up to 1 centimeter may rendered the stableness of the AC articulation by addition buttocks interlingual rendition up to 32 % .
The coracoclavicular ( CC ) ligament is a really strong heavy ligament which run from the outer inferior surface of the collarbone to the base of the coracoid procedure. The CC ligament has two constituents: cone and trapezoid ligaments. Average distance between the collarbone and the coracoid procedure is 1.3 centimeter ( CC interspace ) and the mean distance from the sidelong terminal of the collarbone to the most sidelong extent to trapezoid ligament was 1.53 centimeter.
Clavicle rotate about 40-50 grade through longitudinal axis during full abduction but existent gesture of the collarbone is 5-8 degree relation to the acromial process because of the downward rotary motion of the shoulder blade ( synchronal scapuloclavicular rotary motion ) . The CC ligament is responsible in ordering scapulothoracic gesture. The primary map of the CC ligament is the premier suspensory ligament of the upper appendage.
Mechanism of hurt
An acute hurt to the AC articulation can be devided in two class: direct and indirect mechanism. Direct hurt is produced by patient falling onto the point of the shoulder with the arm at the side in adducted place. This mechanism is likely the most common cause of AC joint hurt. The force thrust the acromial process downward and medially. If no break occurs, the force foremost sprained the AC ligament, so AC tear, CC tear and eventually rupture the deltoid and trapezius musculus.
Indirect force, which are far less common, generated by a autumn on outstretch arm with superior directed force. The force are transmitted to the AC articulation instead than CC ligament.
AC articulation are classified harmonizing to the extent of harm by the grade of force. Injury to the AC articulation are graded harmonizing to the sum of hurt to the AC and CC ligament. Allman4 and Tossy and colleague3 differentiate AC disruption into 3 types depending on the intregity of the AC and CC ligaments. Rockwood5 added type IV, V and VI AC disruption to the original categorization strategy.
Type I injury: Sprain of the acromioclavicular ligament
Integral acromioclavicular articulation, coracoclavicular ligament, deltoid and cowl muscle
No seeable malformation, no stamp over CC interspace
Minimal puffiness and stamp over AC articulation
Type II hurt: Disrupt acromioclavicular ligament ( widening both AC and CC interspace )
Sprain of the coracoclavicular ligament
Integral deltoid and cowl muscle
Type III hurt: Disrupt both acromioclavicular and Coracoclavicular ligament
Deltoid and trapezius musculus normally detached
Dislocate AC articulation and increase CC distance ( 25-100 % of normal shoulder )
Type III discrepancies: Fracture coracoids procedure
Pseudodislocation ( integral periosteal arm )
Type Four: Disrupt both acromioclavicular and Coracoclavicular ligament
Deltoid and trapezius musculus normally detached
Clavicle is displaced posteiorly into or through trapezius musculus
CC interspace may look integral
Type Volt: Disrupt both acromioclavicular and Coracoclavicular ligament
Deltoid and trapezius musculus normally detached
AC joint grossly dislocated superiorly
Markly addition CC distance ( 100-300 % of normal shoulder )
Type Six: Disrupt both acromioclavicular and Coracoclavicular ligament
Deltoid and trapezius musculus normally detached
Acromion is displaced inferior to acromial process or coracoid procedure
As a consequence of hyperabduction and external rotary motion
During physical scrutiny, patient should be in a standing or sitting place without limb support to the injured arm. The weight of the arm will do the malformation more evident. Findingss on physical scrutiny are related to the badness of the hurt. Local puffiness, malformation, bruise, ecchymosis possibly seen. Trouble with arm gesture every bit good as localized tenderness over the AC articulation and CC interspace can be noted. Pain is frequently accentuated by abduction and cross organic structure adduction. Oaa‚¬a„?Brien active compaction trial may be positive.
In the subacute stage, perpendicular and horizontal stableness of the AC articulation should be tested. By stabilising the collarbone and placing and upward force under the ipsilateral cubitus. Once the AC articulation is reduced, hold on the collarbone with index and pollex and effort to interpret the collarbone anteriorly and posteriorly to entree horizontal stableness.
Sternoclavicular articulation should ever exam for associated anterior disruption. Besides the neurological position of the affected appendage should be evaluated to govern out a brachial rete hurt.
Standard radiogram are indispensable to name and sort AC joint hurt. Routine radiogram for AC joint requires one tierce to one half the x-ray incursion needed for everyday glenohumeral radiogram. Everyday radiogram include true anterioroposterior and alar sidelong position. Additionally Zanca positions ( 10o-15o cephalic joust ) is utile when little break or loose organic structure is suspected on the everyday position. Comparative radiogram of the uninjured might be needed to the normal CC distance and the comparative normal place of the normal collarbone.
Stress position is utile to prove the unity of the CC ligament and should be performed when AC disruption is suspected ( differentiate between type II and type III hurts ) .
Coracoid break should ever be suspected when face with AC disruption with the presence of normal CC distance. Axillary position can show break coracoid. If fracture coracoid is suspected on the alar position, Stryker notch position will about ever show this pathology.
Most writers suggested that nonsurgical intervention are indicated in type I and type II hurts. Many methods of decrease and immobilisation such as sling, plaster dramatis personae, adhesive tape strapping, brace, harnesses and grip techniques are proposed. Urist 7 reviewd the literature and summarized more than 35 signifiers of non-operative direction. A period of immobilisation is needed to relieve the emphasis to both AC and CC ligament. Type I injury can be treated utilizing simple catapulting 7-10 yearss or until hurting subsided. Type II require longer clip for immobilisation ( normally 10-14 yearss ) . Once hurting has subsided, gradual rehabilitation plan is started get downing with inactive or active aided scope of gesture exercising. After full painless ROM is achieved, isometric beef uping plan is begun. Contact athletics should be avoid for 2-3 months to avoid farther hurt to the shoulder.
The most controversial issue is the intervention of type III hurt. Several surveies have demonstrated long term disablement and hurting with non-operative intervention. Bannister et al2 conducted a randomized, prospective, controlled test comparing surgical intervention of AC joint hurt type III and V utilizing CC prison guards versus catapulting immobilisation ( 2 hebdomads ) . Following with the same rehabilitation plan. Patient with AC supplanting less than 2 centimeter had better consequence with nonsurgical intervention. In terrible AC joint hurt ( AC displacement more than 2 centimeter ) , 20 % had good consequence with non-operative intervention while 70 % in the surgical group had good to first-class consequence.
In contrast, meta-analysis by Phillips8 demonstrated that consequence of operative and non-operative groups of type III hurt are similar in the facet of patient return to work, strength and scope of gesture but found higher complication rate in the operative group.
The cardinal success of non-operative intervention is appropriate rehabilitation plan. The active rehabilitation plan focal point on deriving strength of shoulder girdle musculus including deltoid, cowl muscle, sternocleido mastoideus, periscapular stabilizer and rotator turnup musculus.
After hurt, the shoulder is immobilized with arm sling for 2 hebdomads. Cold compaction can be apply to cut down hurting and puffiness. Active and inactive scope of gesture exercising is initiate after hurting resolved. In this stage frontward flexure should non transcend 90 degree and raising weight more than 5 pounds. should be prohibited. At 8 hebdomads, full active gesture and initial resistive exercising should be started. Patient can return to work and full athletics activity at 12 hebdomads.
Relative indicant for surgery in acute AC joint hurt is immature grownup with high demand athletics or labour worker. In chronic type III AC joint hurt, hurting and instability may bespeak surgical intercession.
Acute type IV, V and VI disruption wholly required surgical intercession. Still there is no consensus which technique is the best. Surgical intercession are categorized into 3 groups: arrested development of the AC articulation, arrested development between coracoids procedure and the collarbone and ligament Reconstruction and dynamic musculus transportation. Today most surgeon usage combinations of processs to accomplish maximum stableness of the shoulder articulation in order to cut down hurting and addition maximal strength
Arrested development of the AC articulation
Historically, the first instrument used to stabilise the AC articulation is smooth or threaded pin. Lizaur11 advocated the usage of 1.8 mm k-wire to stabilise the joint and emphasized on the fix of deltoid and trapezius musculus. Several surveies reported good long term consequence utilizing non-threaded K-wire across the AC joint.12 Sage and Salvatore13 recommended fix of the AC ligament to heighten the stableness of the AC articulation. This technique are fring popularity because of its major ruinous complications of pin migration which is reported to migrate to the great vas, spinal canal, lung and bosom.
Hook home base is an alternate technique of arrested development of the AC articulation. After decrease the sidelong terminal of the home base is inserted deep to the acromial process and pry down the collarbone its anatomic place. Bicortical prison guard is used to procure the home base to the collarbone. Plate remotion is recommended at 8 hebdomads. Recent work from Salem and Schmelz study good clinical result with this technique.16
Ladermann et. Al. reported good intermediate consequence of AC and CC cerclage Reconstruction with nonabsrobable sutures.17
Arrested development between coracoid and collarbone
Assorted methods of CC stabilisation have been reported including prison guards, sutura, man-made or metallic loop.17 Bosworth in 1941 advocated slowdown screw arrested development between coracoid and collarbone without fix AC and CC ligament. Esenyel et.al.18 modified original Bosworth technique by combine prison guard arrested development with fix the CC ligament. In chronic hurt, several sawboness combine screw arrested development with ligament Reconstruction and study satisfactory consequences.
Recent technique utilizing metallic button with heavy non-absorbable sutura ( Tightrope and Graftrope: Arthrex, Endobutton: Simth & A ; Nephew ) go throughing through the coracoids and secure to the superior boundary line of the collarbone with another button.21-28 Biomechanical survey comparing Tightrope versus Mesh tape demonstrated that Tightrope have superior mechanical belongings in commanding horizontal and perpendicular stability.25 Walz et.al.26 demonstrated that Tightrope is a stable and functional Reconstruction with equal and even higher force than native ligament. This technique can be used in concurrence with ligament Reconstruction.
Man-made cringle placed between coracoid and the collarbone addition more popularity today. This technique may be usage in combination with CC ligament Reconstruction. Main advantage of this technique is it does non necessitate remotion of the implant such as home base or prison guard. However, instances of sterile reaction and collarbone osteolysis have been reported.
This technique of utilizing CA ligament to restore AC joint stableness origionally was described by Weaver and Dunn.32 The CA ligament is detached from deep surface of acromial process with or without bone and transferred to the distal collarbone. This concept may be augmented with cringle of sutura, man-made stuff allow protection of the healing ligament besides combine with other ligament reconstruction.33-36 Major alteration of this technique is to eviscerate distal collarbone to avoid late devolution of the AC articulation which might caused hurting. Recently, all-arthroscopic technique was proposed for CA ligament transportation.
Semitendinosus transplant is now normally used to retrace the CC ligament by doing a cringle under the coracoid or through the coracoids tunnel and hole with intervention screw.38-40 Modifications of this technique varied from choice of transplant, method of arrested development, transplant route..Anatomical biomechanic survey by Kristen43 demonstrated that anatomic semitendinosus homograft Reconstruction give superior biomechanical belongings than other Reconstruction mode ( Graftrope, nonanatomic homograft, modify Weaver- Dunn technique, anatomic sutura ) . Several biomechanical surveies demonstrated important superior result of semitendinosus sinew transplant comparing to the modify Weaver-Dunn process. Cleverger et.al. demonstrated no important difference in biomechanical strength of adjuncted CA ligament transportation in patient undergo AC joint Reconstruction with hamstring graft.36
Distal collarbone resection
Deletion of the distal terminal of the collarbone is referred to as the Mumford or Gurd.10 This operation is suited for chronic diagnostic AC joint hurt. Amount of resection are vary from 1-2.5 centimeter. This process must be performed in patient which have integral CC ligament or execute combine with CC ligament Reconstruction. When this process are performed in patient with horizontal and perpendicular instability the consequence are compromised.
Complications can happen both surgical and nonsurgical intervention of AC joint hurt. The most common complications associated with nonsurgical intervention are relentless instability and development of late arthrosis of the AC articulation.
Complications following surgical intervention are relate to which technique chosen. Hardware failure and migration to major vas and lung have been described. Foreign organic structure reaction and infection occurred after usage of man-made stuff. Fracture of the coracoid procedure and collarbone are related to the process which have been choosen. Brachial rete and alar arteria can be endangered if go throughing the transplant or man-made stuff medial to the coracoids. Recurrent instability have been report in every techniques.
After CC arrested development with prison guard or sutura, the shoulder should be immobilized in an arm sling for 2 hebdomads. After 2 hebdomads, active and inactive scope of gesture exercising is initiated. Forward flexure more than 90 grades should be avoided. After taking prison guard ( 2-3months ) full active and inactive gesture is started and limited light opposition exercising for 8 hebdomads. After achieved full gesture and strength, patient can return to usual activities before hurt.
After AC joint Reconstruction with sinew transplant ( autoplasty or homograft ) , place the patient in an arm sling for 2 hebdomads. Pendulum exercising at 2 hebdomads and light activity of day-to-day life at 4 hebdomads. Active and inactive scope of gesture exercising is started at 8 hebdomads. Light opposition can be initiated at 3 months. Once full gesture and strength achieved, normal labour work is permitted.