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Ligamento Acromio Clavicular y Reparación Quirúrgica
Ligamento Acromio Clavicular y Reparación Quirúrgica
DOI 10.1007/s00590-013-1186-1
TECHNICAL NOTE
Received: 16 January 2013 / Accepted: 4 February 2013 / Published online: 13 February 2013
Ó Springer-Verlag France 2013
Abstract Acromio-clavicular joint (ACJ) injuries repre- the hook plate is useful in fracture-dislocation of ACJ, but
sent nearly half of all athletic shoulder injuries. Stability of this requires another surgery to remove it. On the contrary,
this joint depends on the integrity of the acromio-clavicular the use of the tight-ropeÒ system does not require a new
and coracoclavicular ligaments. Although the traumatic surgery or use of expensive synthetic graft or a graft har-
acromioclavicular joint separation is a well-known topic, vested from a distant donor site.
there are different classifications, diagnostic procedures,
Keywords AC joint Surgery Technique Results
concepts of intervention, and a great variety of implants. In
Sports injury Shoulder trauma
this paper, we present an overview of the recent literature
about this issue and the results of a retrospective non-
randomized study with 2 different techniques. At the first Introduction
Orthopedic Department of University of Pisa, a retrospec-
tive study was performed starting from January 2007 to The acromio-clavicular joint (ACJ) is a robust articulation
February 2011 in our electronic database. We selected that anchors the scapula and the upper extremity of the
patient treated with two different techniques (tight-ropeÒ clavicle. Even if ACJ injuries represent most of the athletic
system and hook plate) by the same senior surgeon with shoulder injuries, the true incidence of ACJ injuries is
experience in shoulder surgery. The mean Costant score likely underestimated [1]. Most are minor sprains, with
was 90 for the tight-ropeÒ system group and 75 for the incidence of subluxations approximately twice as high as
hook plate group. At the final follow-up, most of the those of dislocations. However, they occur five times more
patients had returned to their preinjury level of activity. frequently in men than in women, with the highest inci-
Two patients had a breakage of the fixating system. The dence in the 20–30 years age group [2].
above-mentioned techniques provided satisfactory results Depending on the grade of the injury, the treatment
with no loss of reduction except in two cases. The use of options range from non-surgical measures allowing quick
return to athletic activity to various forms of surgical
L. Andreani (&) E. Bonicoli P. Parchi N. Piolanti reconstruction of the joint. This article reviews the anatomy
L. Michele
and biomechanics of the ACJ and describes the evaluation,
Orthopedics and Tramatology I Department, University of Pisa,
via Paradisa 2, 56121 Pisa, Italy diagnosis, non-surgical and surgical treatment of various
e-mail: l.andreani@hotmail.it injuries involving the joint adding our experience.
E. Bonicoli The ACJ is a diarthrodial articulation between the lateral
e-mail: enrico.bonicoli@libero.it end of the clavicle and the medial end of acromion. Both
P. Parchi static and dynamic stabilizers ensure the stability of the
e-mail: parchip@tiscali.it ACJ. The static stabilizers include the ACJ capsule rein-
N. Piolanti forced with the AC ligaments and the coracoclavicular
e-mail: nicpio@hotmail.it (CC) ligaments The CC ligaments include the conoid lig-
L. Michele ament medially and the trapezoid ligament laterally, both
e-mail: michele.lisanti@tin.it of which provide vertical stability by preventing superior
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238 Eur J Orthop Surg Traumatol (2014) 24:237–242
and inferior displacement of the clavicle [3, 4]. Complete chronic ACJ separations, previous ACJ injuries, and a
sectioning of the CC ligaments is necessary for complete disease process that would preclude accurate evaluation
ACJ dislocation with either superior or inferior displace- (e.g., neuromuscular, rheumatic, significant psychiatric, or
ment of the entire scapulohumeral complex. metabolic disorders). There were 22 men and 6 women.
AC injuries are most commonly the result of direct The average age at the time of surgery was 32.3 (range
trauma. For the athlete, the injury is usually due to a direct 19–60) years. The duration between the time of injury and
hit, either by another player or by contact with the ground the date of surgery varied between 2 and 21 days, with an
[5]. Direct injury is the consequence of a direct force on the average of 7.2 days. The non-dominant side was affected
acromion with the shoulder adducted, resulting in move- in 8 cases. Sixteen patients were injured while participating
ment of the acromion while the clavicle remains stabilized in sports. Injuries were documented by preoperative plain
by the sterno-clavicular ligaments. The severity of injury is X-rays of the affected shoulder in the anteroposterior (AP)
determined by the magnitude of the force. standing, axillary views, and AP in stress mode. The AP
Different classification systems are in use: Allman, view was obtained with a 50 % decrease in penetrance with
Tossy, and the most widely accepted is the Rockwood the X-ray beam tilted cephalad by 10°–15°. The decrease in
system which puts in six different degrees (1990s) [6, 7]. penetrance prevents overexposure, and the 15° cephalic tilt
Surgical treatment is advocated for types IV, V, and VI and helps to remove the scapula from being superimposed onto
in some cases type III where there is complete ACJ dis- the acromioclavicular joint. The axillary radiograph helps
location. Since the first reported procedure for ACJ repair to show the position of the clavicle relative to the acro-
by Cooper in 1861 [8], numerous techniques have been mion. The stress-mode AP radiographs were obtained with
used to treat AC dislocation. The techniques have tended to a 10-kg weight suspended from the affected arm with wrist
fall into five groups: primary fixation of the ACJ, second- straps (Fig. 1). The degree of displacement of the ACJ was
ary stabilization linking the distal clavicle and the corac- evaluated and compared with the contralateral side. The
oids, distal clavicle excision, dynamic stabilization or coracoclavicular distance was measured in each side and
combined approach. Despite such attention, the lack of a the increase of height on the operated side was compared to
dominant procedure suggests that the ideal repair is yet to the unaffected side and calculated in percent. Ossifications
be found [9]. Timing from the trauma seems to be funda- were classified as absent, minor, or major; minor ossifica-
mental for achieving better [10]. Our experience involves tions represented spots or small ossicles located in the
primary fixation of the ACJ using two different techniques. coracoclavicular ligaments, whereas major ossifications
were considered as almost complete bridging between the
clavicle and the coracoid process. Patients were pre- and
Materials and methods postoperatively evaluated using the University of Califor-
nia Los Angeles (UCLA) and Costant scoring systems. In
This retrospective comparative study was approved by the Table 1 is summarized the classification of our case series
local institutional review board and all patients gave according to Rockwood.
written informed consent. Nineteen patients were treated with the tight-ropeÒ
Between January 2007 and February 2011, twenty-eight system (ArthrexTM, Naples, Florida) and 9 patients using
consecutive cases of acute ACJ dissociation were assessed hook plate (SynthesTM, Bettlach, Switzerland). The tight-
in our trauma center. All patients had type IV, V, or VI ropeÒ system is a device that consists in two buttons, one
ACJ injuries according to Rockwood classification; sur- round clavicle button and one oblong coracoid button.
geries were performed within a maximum of 3 weeks of The buttons are joined by a continuous loop of 5-0
injury by the same experience surgeon. We did not con- FiberWireÒ. The clavicle is drilled, the system is passed
sider grade I to III because we believe, according to the through it and then is opened (Fig. 2). We added 2 K-
majority of the literature, that in this case, the conservative wires when we used the tight-ropeÒ system that we left in
management is the treatment of choice. Injuries occurred place for just 3 weeks. The hook plate was used to fix
predominantly during sporting activities: cycling/moto- ACJ dislocation and distal clavicular fracture; then, a
cycling (n = 12), team sports (n = 10), alpine sports second surgery was performed in 3 cases to remove the
(n = 2), other trauma (n = 4). Injury mechanism was a plate following patient request without loosening of
direct trauma to shoulder (n = 24) or an indirect trauma to reduction. The hook plate is positioned through a standard
the elevated arm (n = 4). All patients gave their written surgical incision; we perform temporary fixation of the
consent before undergoing the surgery. Inclusion criteria fracture using bone-holding forceps. The shaft of the plate
were as follows: acute lesion (\3 weeks after trauma), is fixed onto the superior aspect of the clavicle and the
high-grade ACJ injury Rockwood type IV to VI, patients end of the hook is in contact with the underside of the
age [18, and monotrauma. The exclusion criteria were: acromion. We are used to perform a ligament and capsule
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240 Eur J Orthop Surg Traumatol (2014) 24:237–242
Fig. 2 a–c Technical steps of tight-ropeÒ system, d, e pre- and postoperative X-ray, f 1 month X-ray control
calcifications have appeared in a low percentage of cases, meta-analysis failed to find any significant benefit in a
but showed no correlation to our clinical results. Two surgical approach. Moreover, the incidence of complica-
patients developed at 2 years postoperatively roentgeno- tions in terms of infection, revision surgery, osteoarthritis,
graphic evidence of asymptomatic AC arthritis. and unsightly scars is clearly higher in surgically treated
patients [17, 18]. Our personal approach is to treat a type
III AC injury conservatively, with surgical stabilization
Discussion considered only if the athlete specifically requests it. One
of the most important factors seems to be the timing of
Injuries to the ACJ are among the most commonly occur- surgery. In fact, acute reduction of the AC joint is easier
ring problems in the athletic population. However, the when surgery is performed within the first 2–3 weeks after
choice of the best operative technique for the treatment of injury. Early repair of acute ACJ dislocation provides
the ACJ dislocation is a controversial issue. Studies pub- overall good clinical results independent of the surgical
lished over the past three decades remain inconclusive in method [19].
establishing the ideal method of acromioclavicular joint The use of the tight-ropeÒ system is quite easy and is
surgery [11, 12]. Reviewing the literature, there are over minimal invasive both in arthroscopic than in open tech-
100 operative methods to reconstruct the ACJ. However, nique. Obviously, the reduction must be anatomic and the
never anatomic techniques are being adopted to reduce meniscus must be reduced in the right place. We are used
complication and improve the outcome by using both to adding 2 K-wire trans acromion-clavicle left in place for
biological [13] and artificial tissue for treatment [14, 15]. 3 weeks to reach a better fixation and to allow a better
The treatment for grade I and II is certain to be non- healing and scaring of residual ligaments.
operative, as it is for acute, uncomplicated, grade III ACJ Sometimes an osteolysis area around the clavicle and/or
dislocation [16]. Indeed, comparative studies have reported coracoidal buttons can be observed, but most of the time it
similar results for conservative and surgical treatment, and is asymptomatic. Using this system, we were able to reach
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Eur J Orthop Surg Traumatol (2014) 24:237–242 241
a good reduction in most of the patients, but we have to plate is the subacromial impingement, but some studies,
underline the fact that in 2 cases, we have the breakage of like in our, did not find this complication [20, 21]. Once the
the implant without any significant new trauma. These fracture has healed, it is possible but not mandatory to
failures were probably caused by an initial poor reduction, remove the hook plate. We performed it in 3 cases, and we
deficient reconstruction of the deltotrapezoidal fascia, cla- did not found any loss of reduction as instead was descri-
vicular movement, and inadequate healing of the injured bed by Scheibel et al. [22].
ligaments (Fig. 4). This study showed a high level of patient satisfaction; the
The hook plate is useful in case of fracture of clavicle difference between the two groups must probably be added
and dislocation of ACJ. The main concern using the hook to the fact that we used the hook plate for the worst case.
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