Anotomic-Biological Reconstruction of Acromio-Clavicular Joint Injuries-Dr. Utsav Agrawal

1. Anatomic-Biological
Reconstruction
of
Acromio-clavicular Joint Injuries
Dr Utsav Agrawal
Dr Vikram Sapre
Dr Samir Dwidmuthe
Department of Orthopaedics
Lata Mangeshkar Hospital
Nagpur

2. INTRODUCTION
 Analysis of shoulder function in 11 patients with chronic
(>6weeks) acromio-clavicular joint injuries managed by
ANATOMIC-BIOLOGIC
ACROMIO-CLAVICULAR JOINT RECONSTRUCTION
• > Grade III injuries
• A Retrospective case series
• Study period of 2 years with a minimum follow-up of
6 months
• All patients were evaluated by questionnare based on
Constant score and ASES score (Association of shoulder
and elbow surgeons) for shoulder function.

3. Cause
 Direct injury
 Fall on lateral aspect of shoulder
on an adducted arm
• Lead to chronic shoulder pain
and instability
• Should thus be managed
actively, especially in arm
dominant individuals

4. Stabilizers of AC joint
AC Ligament
Trapezoid and
Conoid
part of CC ligment

5. Classification

6. Management Options
 Conservative
 Intra-articular fixation
 Extra-articular fixation
 Acromio-clavicular joint reconstruction
Bosworth Screw Weaver-Dunn Procedure

7. Sood A, Wallwork N, Bain GI.
Int J Shoulder Surg. 2008 Jan;2(1):13-21.
The traditional surgeries for acromioclavicular joint disruptions like
Bosworth’s Screw , Modified Weaver-Dunn procedure, has been
associated with high rate of recurrence of deformity and
complications
Thomas K, Litsky A, Jones G, Bishop JY.
Am J Sports Med. 2011 Apr;39(4):804-10
Compared five different techniques for reconstruction of AC
joint and concluded :
Anatomic AC joint techniques gives biomechanically more
stringer construct when compared to traditional
techniques.

8. Lee SJ, Keefer EP, McHugh HP, et al.
Am J Sports Med. 2008;36:1990.
Cadaver study
All of the un-augmented Weaver-Dunn reconstructions failed
with low loading. None of the augmented (with ethibond #5)
Weaver Dunn reconstructions failed at low load while all failed
under high load.
The semitendinosus graft reconstructions did not fail under the
low- or high-load conditions.
Milewski MD, et al
Am J Sports Med. 2012 Jul;40(7):1628-34.
27 cases of anatomic ACJ reconstruction - 10 cases with coracoid tunnel and 17 cases
of coracoid sling.
They found high incidence of complication with coracoid tunnel(80%) as
compared to sling technique(35%).
They concluded that newer techniques have high complication rates more in
coracoid tunnel technique. They emphasized the real danger of clavicle
fracture while drilling two tunnels in clavicle.

10. Anatomic-Biologic
Acromio-clavicular Joint
reconstruction
 Open reconstruction of coracoclavicular ligament
(both conoid and trapezoid part) and
acromioclavicular ligament with semi-tendinosus graft
 2 tunnels in clavicle and looping semi-tendinosus from
under coracoid

11. • 40 years, Male patient
• Pain in right shoulder
• History of Road traffic accident
 Deformity at right shoulder

12. Radiography

13. Semitendinosus Harvested
from Ipsilateral Knee

14. Marking anatomical landmarks

15. Vertical incision from
ACJ to coracoid

16. Osteotomy
at Lateral
end of
Clavicle
8-10 mm of lateral end clavicle excised

17. Tunnels created for graft placement
Mazzocca et al. The anatomic coracoclavicular ligament reconstruction.
Op Tech in Sports Med, Vol12, No1 (Jan), 2004: 56-61

18. 2 Tunnels created in clavicle for conoid
and trapezoid part of CC ligament

19. Looping the graft and
2 strands of ethibond No.5
Stetnsky clamp

21. Graft hooked from under coracoid and
fixed over clavicle with endo-button

23. Final Reconstruction

25. PRE-OP Immediate POST-OP
AT 1 year

27. Constant score
 Pain 15
 Activities of Daily living 20
 ROM 40
 Power 25
 Total Score 100

28. A
S
E
S

29. Valuation Score
 Excellent 91-100
 Good 81-90
 Satisfactory 71-80
 Adequate 61-70
 Poor <60

30. Sr.
No
Patien
t Age Sex
RESULTS
D.O.S
x Post op xrays
ASES
score pain /15 ADL/20 ROM/40
Power
/25
Total
Scor
e Result
1 LMH 1 45 male Oct-11
Reduction
maintained,no osteolysis 96.66 15 20 40 22 97 Excellent
2
LMH
2 55 male
Mar-
12
Reduction Maintained,
Superficial Infection 89.99 10 18 40 24 92 Excellent
3 NOC 25 maleApr-12 reduced 89.97 15 14 40 20 89 Excellent
4 NOC 1 34 male
Nov-
12
min loss of reduction
<5mm 89.99 15 16 40 18 89 Good
5 MT 1 46 male Jan-13 Reduction maintained 88.32 10 18 40 22 90 Good
6 MT2 54 male Jan-13 Reduction maintained 96.66 15 18 40 24 97 Excellent
7 RG 1 49 male Feb-13 Reduction maintained 93.32 15 16 40 22 93 Excellent
8 RG 2 52 male
May-
13 Reduction maintained 86.66 10 16 40 20 86 Excellent
9 RG3 47 male Jun-13 Reduction maintained 69.99 10 12 40 13 75 Satisfactory
10 RG4 42 Male Aug’13 No loss of reduction 96.66 14 19 38 22 93 Excellent
11 NOC 2 44 Male Jan ’14 Satisfactory reduction 91.22 13 20 36 21 90 Excellent

31. Out of 11 patients
8 had excellent outcome
2 good outcome
and
1 satisfactory outcome

32. Complications
 Minimal loss of reduction in one patient (<5mm)
 Wound edge necrosis in 1 patient
 No clavicle fracture/osteolysis

33. Conclusion
 The anatomic coracoclavicular joint reconstruction
technique is designed to place tendon grafts in the
exact anatomic location
 Also attempts to reproduce AC ligament
 Use of internal splint with ethibond helps to keep joint
reduced till ligamentization occurs
 Endobutton helps preventing cut through of tunnels
 Looping of graft from under coracoid avoids chances of
fracture
 Use of minimal and cheaper implants

34. Drawbacks of study and technique
 Less no. patients studied
 More biomechanical studies are required to validate
the procedure
 Need long term evaluation to know specific
complications of the procedure

35. Dr Utsav Agrawal
N.K.P. Salve Institute of Medical sciences
Nagpur