Acj instability mac 2012
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Transcript of Acj instability mac 2012
09/12/2012
1
AC Joint "Dislocations & Instability
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Is the ACJ Important? ! YES – for overhead athletes:
! Following ACJ Dislocations:
! 30% of overhead athletes had to reduce sport
! 9% had to change sport
! Climbers and patients performing strength training had to reduce their activities or give up sports
! Altered activities in overhead ball sports
Rangger et al. Orthopade 2002 Jun;31(6):587-90
Is the ACJ Important? ! YES – for high demand professions:
! Following ACJ Injuries:
! 164 US Naval Cadets ! Residual symptoms found at 6 month follow-up:
! 36% of Grade 1
! 48% of Grade 2 ! Major in 13%
! Minor in 35% ! 69% of Grade 3
Cox. Am J Sports Med, 1981
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Indications for Stabilisation ! Literature = Type 4, 5 & 6
Ceccarelli et al. 2008
! “From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, "but complications are more evident in the surgery group. "
! Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation.
! More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.”
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What are we trying to achieve?
• “A pain free & stable shoulder "that has enough mobility, strength "& muscle control for a patient’s "desired level of activity & participation”
• Peter Rheinlaender
My indications ! Patient Demands
! Work demands
! Society demands ! Overhead Athlete
Review 3 weeks
Approach Acute Injury < 1 week
Review"3 months Surgery
Coping Not Coping
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Surgical procedures
Coracoclavicular "Ligaments
! Strength – 500N (+/- 134) ! Stiffness – 103N/mm (+/- 30)
! Uniaxial Tension 25mm/min
Harris et. al. Am J Sports Med. 2000
Harris et al. AJSM 2000
• “None of the reconstruction techniques analyzed in the present study were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”
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ACJ Ligaments ! Two thirds of the superior stability
for lesser displacements
! 90% the posterior stability
Fukuda et al. JBJSA. 1986
Dynamic Stability ! Delto-trapezial fascia
Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.
Lizaur et al. JBJS. 1994
My Experience
2001 2008
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Revisions !!!
LARS Ligament (Corin)
! Braided Polyethylenetraphthalate ! 1500N tensile strength (30 LAC)
! No reduction in mechanical resilience after over 10 million wear cycles loaded in torsion, traction and flexion [Fialka et al. 2005;
! Vascularisation & Fibrous ingrowth - Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005; Pelletier & Durand]
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Standard repair
Shoulderdoc.co.uk
Modification 1
Shoulderdoc.co.uk
Modification 2
Shoulderdoc.co.uk
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Closure ! Repair the Superior AC Ligaments ! Repair the Delto-Trapezial Fascia
x-rays - "Day 1, 3 weeks, 3 months, 1yr, 2yrs
Shoulderdoc.co.uk Shoulderdoc.co.uk
Shoulderdoc.co.uk Shoulderdoc.co.uk
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! Phase 1: (Level 1-2 Exercises) ! Core stability & Scapula control
! Proprioceptive exercises (minimal weightbearing below 90 degrees)
! Active ROM as comfortable ! Do not force or stretch ! No resistance exercises
! Phase 2: (Level 2-3 Exercises) ! Progress to light resistance exercises as tolerated
! Sports-specific rehabilitation - Plyometrics and pertubation training
! Phase 3: (Level 3+ Exercises) ! Regain scapula & glenohumeral stability working for shoulder joint control
rather than range
! Gradually Strengthen
POST-OP
THANK YOU