The Clinical Outcome After Ligament Reconstruction Of Complete Cromioclavicular Dislocation.
THE CLINICAL OUTCOME AFTER LIGAMENT RECONSTRUCTION
OF
COMPLETE ACROMIOCLAVICULAR DISLOCATION
Hermawan Nagar Rasyid, M.D
Department of Orthopaedic Surgery, Faculty of Medicine Universitas
Padjadjaran,
Hasan Sadikin Hospital, Bandung, Indonesia
Since
1998,
three
patients
with
complete
acromioclavicular
joint
dislocation were treated at our hospital. The major cause of this injury was
traffic
accident.
The
clinical
records
and
roentgenograms
were
retrospectively reviewed.
The purpose of this study is to evaluate patient satisfaction after
acromioclavicular joint reconstruction, by the Constant evaluation system,
the results in two patients were excellent, shoulder range of motion
limitation was found in one patient. Complications were not found in all
cases. Post traumatic degenerative was noted in one case.
Our treatment for complete acromioclavicular dislocation (Grade-III of
Allman) is surgical intervention with ligament reconstruction by Neviaser’s
method.
INTRODUCTION
Of all joint dislocations, those of the acromioclavicular (AC) joint amount to
4 to 8 % (Rehn et al., 1970; Thelen and Rehn, 1976; Leithe et al., 1982).1
Acromioclavicular joint separation is the second most common dislocation
or subluxation involving the shoulder girdle, after dislocation of the
glenohumeral joint.
The injuries are simply graded according to the extent of anatomical
displacement. Acromioclavicular dislocations are grouped on the lines
proposed by Almann and Tossy into three stages. The displacement of the
acromioclavicular joint is directly related to the degree of stretching or
even tearing of the acromioclavicular ligament and muscle attachments.
1,2,3,4
Based on Almann’s classification it has been our policy to treat Type I
and II injuries conservatively. The Type III injury has been treated
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
1
operatively.
The purpose of the study is to report the results of the Type III injury,
which had been repaired by ligament reconstruction. Constant scoring
system was used to evaluate the shoulder function.
MATERIALS
During a three year period from 1998 to 2001, three patients with chronic
acromioclavicular
dislocation
were
seen.
Based
on
Allman’s
classification they were Type III. This disorder was treated operatively
by performing ligament reconstruction
The patients were treated on an average six days post-injury (range 3 to
10 days). Patients age range from 19 to 57 years with an average 32
years. Follow-up evaluation average 25.3 months from date of injury
(range 13 to 47 months)
The mechanism of injury in all cases was either a direct blow to or a fall
onto the injured shoulder
METHODS
Following initial examination, classification, and X-ray of the shoulder
(trauma series of the shoulder) the treatment was decided by ligament
reconstruction. Neviaser’s procedure was the treatment of choice. It
consists of:
–
Reconstruction of coracoclavicular ligament
–
Reconstruction of superior acromioclavicular ligament
–
Reefing of deltoid and trapezius muscles
Constant scoring system was used to estimate shoulder function after
performing reconstruction. It measured of pain, activities of daily living,
range of motion, and muscles power. Total score is 100 (excellent)
EVALUATION OF RESULTS
•
Follow-up average 25.3 months post-injury (range 13 to 47 months)
•
The patients rated any remaining symptoms of pain, decrease in
motion, and weakness
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
2
Case 1
A 57-year old retired male was involved in a traffic accident. His left
shoulder was direct fall onto the shoulder. On clinical examination he
demonstrated an anterosuperior projection of the left clavicle.
Roentgenogram revealed acromioclavicular joint dislocation (Type III of
Allman) (Figure 1-A). Ligament reconstruction had been performed for
this pathological condition. After surgery the left shoulder was
immobilized in an arm sling for 6 weeks. The temporary transarticular
fixation by Kirschner-wires were removed in two months. At 13 months
after surgery follow-up was done and the result was excellent, but in
the X-ray control showed post-traumatic degenerative arthritis. Active
range of motion of the shoulder joint at follow-up was excellent [Score:
100]. The full range of motion of the left shoulder was demonstrated in
Figure 1-B.
A
B
Figure 1 A, Case 1. Anteroposterior roentgenogram of left clavicle at initial
examination after Type III acromioclavicular joint dislocation of the left shoulder.
B, Photograph made at the latest follow-up (13 months after surgery), showing full
range of motion of the left shoulder joint.
Case 2
A 20 year old male student sustained a dislocation of the right
acromioclavicular joint
(Type III of Allman) when he fell from the
motorcycle and right shoulder bumped against the ground. Associated
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
3
injuries were sustained: head injury, fracture of the left 2 nd and 3rd ribs.
On clinical examination he had an anterosuperior projection of the left
clavicle. Roentgenogram demonstrated distal end of the clavicle was
above the superior surface of the acromion (Figure 2-A).
Ligament
reconstruction was performed for this pathological condition. The
temporary Kirschner-wires were removed in two months after surgery.
At the latest follow-up 25 months postoperatively, the integrity of the
acromioclavicular joint was maintained, but there were a little bit of
limitation of external rotation (200). Motion of the shoulder joint at
follow-up [Score: 90] can be seen in Figure 2-B.
A
B
Figure 2-A, Case 2. Anteroposterior roentgenogram of right shoulder post
operation of Type III acromioclavicular joint dislocation. B, Photograph made at the
latest follow-up (25 months after surgery), the integrity of the acromioclavicular
joint was maintained, showing right shoulder in
full abduction, but external
rotation still slightly limited (200).
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
4
Case 3
A 19 year old male sustained a right acromioclavicular joint dislocation
(Type III of Allman) when he had a traffic accident. He fell down from
the motorcycle and
the trauma went directly onto the shoulder.
Roentgenogram revealed Type III acromioclavicular joint dislocation.
On clinical examination he had an anterosuperior projection of the
right clavicle, and piano-key sign was positive (Figure 3-A). Surgery
was
performed
to
reconstruct
this
pathological
condition.
The
temporary Kirschner-wires were removed in two months after surgery.
At the latest follow-up 47 months postoperatively, the integrity of the
acromioclavicular joint was maintained. The result in this patient was
excellent, he had no complain. Motion of the shoulder joint at follow-up
[Score: 100].
Figure 3, Case 3. Photograph made at pre-operation, showing anterosuperior
projection of the right acromioclavicular joint.
DISCUSSION
The treatment for complete acromioclavicular dislocation (Type III of
Allman) is somewhat controversial, there being disagreement whether
surgical treatment is preferable to conservative closed methods of
management. Although over thirty operative procedures have been
advocated, most proponents of open treatment advocate reduction of
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
5
the dislocation, repair of the involved ligaments, and internal fixation
across the acromioclavicular joint.
4
We are more aggressive in treating the chronic acromioclavicular joint
dislocation since we assumes by restoring this joint as soon as possible
will attenuate further complication such as winging of the scapula, dull
ache around axio-scapular muscles, and muscle weakness.
Neviaser’s procedure has been reasonable way to restoring the function of
clavicle since this technique will hold the clavicle in its position by using
the fascia lata. By surgical intervention the acromioclavicular ligament are
important adjuncts to rotational stability.5
Constant’s scoring system has been found useful, easy to perform and
reliable in following patient progress after surgery. 6
CONCLUSIONS
We have experienced three cases of acromioclavicular dislocation (Type III
of Allman). They were treated by ligament reconstruction using
Neviaser’s procedure. Two cases have excellent results and in one
case has light limitation of range of motion in external rotation.
REFERENCES
1. Mlawosky B, Brenner P, Duben W, and Heymann H. Repair of
complete acromioclavicular dislocation (Tossy Stage III) using Balser’s
hook plate combined with ligament sutures. Injury 1998; 19:227-232.
2. Post M. Current concepts in the diagnosis and management of
acromioclavicular dislocations. Clin Orthop 1985; 200:234-247.
3. Skjeldal S, Lundblad R, and Dullerud R. Coracoid process transfer
for acromioclavicular dislocation. Acta Orthop Scand 1998; 59(2):180182.
4. Allman Fl Jr. Fractures and ligamentous injuries of the clavicle and its
articulation. J Bone Joint Surg Am 1967; 49A, pp.774-84.
5. De Palma AF. Biomechanics of the shoulder. In Surgery of the
shoulder. 3rd ed. Philadelphia: JB Lippincott Co; 1983, pp.65-85.
6. Constant CR, and Murley AHG. Functional assessment of the
shoulder. Clinical Orthopaedics and Related Research Number 214,
January, 1987, pp.160-164
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
6
OF
COMPLETE ACROMIOCLAVICULAR DISLOCATION
Hermawan Nagar Rasyid, M.D
Department of Orthopaedic Surgery, Faculty of Medicine Universitas
Padjadjaran,
Hasan Sadikin Hospital, Bandung, Indonesia
Since
1998,
three
patients
with
complete
acromioclavicular
joint
dislocation were treated at our hospital. The major cause of this injury was
traffic
accident.
The
clinical
records
and
roentgenograms
were
retrospectively reviewed.
The purpose of this study is to evaluate patient satisfaction after
acromioclavicular joint reconstruction, by the Constant evaluation system,
the results in two patients were excellent, shoulder range of motion
limitation was found in one patient. Complications were not found in all
cases. Post traumatic degenerative was noted in one case.
Our treatment for complete acromioclavicular dislocation (Grade-III of
Allman) is surgical intervention with ligament reconstruction by Neviaser’s
method.
INTRODUCTION
Of all joint dislocations, those of the acromioclavicular (AC) joint amount to
4 to 8 % (Rehn et al., 1970; Thelen and Rehn, 1976; Leithe et al., 1982).1
Acromioclavicular joint separation is the second most common dislocation
or subluxation involving the shoulder girdle, after dislocation of the
glenohumeral joint.
The injuries are simply graded according to the extent of anatomical
displacement. Acromioclavicular dislocations are grouped on the lines
proposed by Almann and Tossy into three stages. The displacement of the
acromioclavicular joint is directly related to the degree of stretching or
even tearing of the acromioclavicular ligament and muscle attachments.
1,2,3,4
Based on Almann’s classification it has been our policy to treat Type I
and II injuries conservatively. The Type III injury has been treated
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
1
operatively.
The purpose of the study is to report the results of the Type III injury,
which had been repaired by ligament reconstruction. Constant scoring
system was used to evaluate the shoulder function.
MATERIALS
During a three year period from 1998 to 2001, three patients with chronic
acromioclavicular
dislocation
were
seen.
Based
on
Allman’s
classification they were Type III. This disorder was treated operatively
by performing ligament reconstruction
The patients were treated on an average six days post-injury (range 3 to
10 days). Patients age range from 19 to 57 years with an average 32
years. Follow-up evaluation average 25.3 months from date of injury
(range 13 to 47 months)
The mechanism of injury in all cases was either a direct blow to or a fall
onto the injured shoulder
METHODS
Following initial examination, classification, and X-ray of the shoulder
(trauma series of the shoulder) the treatment was decided by ligament
reconstruction. Neviaser’s procedure was the treatment of choice. It
consists of:
–
Reconstruction of coracoclavicular ligament
–
Reconstruction of superior acromioclavicular ligament
–
Reefing of deltoid and trapezius muscles
Constant scoring system was used to estimate shoulder function after
performing reconstruction. It measured of pain, activities of daily living,
range of motion, and muscles power. Total score is 100 (excellent)
EVALUATION OF RESULTS
•
Follow-up average 25.3 months post-injury (range 13 to 47 months)
•
The patients rated any remaining symptoms of pain, decrease in
motion, and weakness
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
2
Case 1
A 57-year old retired male was involved in a traffic accident. His left
shoulder was direct fall onto the shoulder. On clinical examination he
demonstrated an anterosuperior projection of the left clavicle.
Roentgenogram revealed acromioclavicular joint dislocation (Type III of
Allman) (Figure 1-A). Ligament reconstruction had been performed for
this pathological condition. After surgery the left shoulder was
immobilized in an arm sling for 6 weeks. The temporary transarticular
fixation by Kirschner-wires were removed in two months. At 13 months
after surgery follow-up was done and the result was excellent, but in
the X-ray control showed post-traumatic degenerative arthritis. Active
range of motion of the shoulder joint at follow-up was excellent [Score:
100]. The full range of motion of the left shoulder was demonstrated in
Figure 1-B.
A
B
Figure 1 A, Case 1. Anteroposterior roentgenogram of left clavicle at initial
examination after Type III acromioclavicular joint dislocation of the left shoulder.
B, Photograph made at the latest follow-up (13 months after surgery), showing full
range of motion of the left shoulder joint.
Case 2
A 20 year old male student sustained a dislocation of the right
acromioclavicular joint
(Type III of Allman) when he fell from the
motorcycle and right shoulder bumped against the ground. Associated
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
3
injuries were sustained: head injury, fracture of the left 2 nd and 3rd ribs.
On clinical examination he had an anterosuperior projection of the left
clavicle. Roentgenogram demonstrated distal end of the clavicle was
above the superior surface of the acromion (Figure 2-A).
Ligament
reconstruction was performed for this pathological condition. The
temporary Kirschner-wires were removed in two months after surgery.
At the latest follow-up 25 months postoperatively, the integrity of the
acromioclavicular joint was maintained, but there were a little bit of
limitation of external rotation (200). Motion of the shoulder joint at
follow-up [Score: 90] can be seen in Figure 2-B.
A
B
Figure 2-A, Case 2. Anteroposterior roentgenogram of right shoulder post
operation of Type III acromioclavicular joint dislocation. B, Photograph made at the
latest follow-up (25 months after surgery), the integrity of the acromioclavicular
joint was maintained, showing right shoulder in
full abduction, but external
rotation still slightly limited (200).
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
4
Case 3
A 19 year old male sustained a right acromioclavicular joint dislocation
(Type III of Allman) when he had a traffic accident. He fell down from
the motorcycle and
the trauma went directly onto the shoulder.
Roentgenogram revealed Type III acromioclavicular joint dislocation.
On clinical examination he had an anterosuperior projection of the
right clavicle, and piano-key sign was positive (Figure 3-A). Surgery
was
performed
to
reconstruct
this
pathological
condition.
The
temporary Kirschner-wires were removed in two months after surgery.
At the latest follow-up 47 months postoperatively, the integrity of the
acromioclavicular joint was maintained. The result in this patient was
excellent, he had no complain. Motion of the shoulder joint at follow-up
[Score: 100].
Figure 3, Case 3. Photograph made at pre-operation, showing anterosuperior
projection of the right acromioclavicular joint.
DISCUSSION
The treatment for complete acromioclavicular dislocation (Type III of
Allman) is somewhat controversial, there being disagreement whether
surgical treatment is preferable to conservative closed methods of
management. Although over thirty operative procedures have been
advocated, most proponents of open treatment advocate reduction of
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
5
the dislocation, repair of the involved ligaments, and internal fixation
across the acromioclavicular joint.
4
We are more aggressive in treating the chronic acromioclavicular joint
dislocation since we assumes by restoring this joint as soon as possible
will attenuate further complication such as winging of the scapula, dull
ache around axio-scapular muscles, and muscle weakness.
Neviaser’s procedure has been reasonable way to restoring the function of
clavicle since this technique will hold the clavicle in its position by using
the fascia lata. By surgical intervention the acromioclavicular ligament are
important adjuncts to rotational stability.5
Constant’s scoring system has been found useful, easy to perform and
reliable in following patient progress after surgery. 6
CONCLUSIONS
We have experienced three cases of acromioclavicular dislocation (Type III
of Allman). They were treated by ligament reconstruction using
Neviaser’s procedure. Two cases have excellent results and in one
case has light limitation of range of motion in external rotation.
REFERENCES
1. Mlawosky B, Brenner P, Duben W, and Heymann H. Repair of
complete acromioclavicular dislocation (Tossy Stage III) using Balser’s
hook plate combined with ligament sutures. Injury 1998; 19:227-232.
2. Post M. Current concepts in the diagnosis and management of
acromioclavicular dislocations. Clin Orthop 1985; 200:234-247.
3. Skjeldal S, Lundblad R, and Dullerud R. Coracoid process transfer
for acromioclavicular dislocation. Acta Orthop Scand 1998; 59(2):180182.
4. Allman Fl Jr. Fractures and ligamentous injuries of the clavicle and its
articulation. J Bone Joint Surg Am 1967; 49A, pp.774-84.
5. De Palma AF. Biomechanics of the shoulder. In Surgery of the
shoulder. 3rd ed. Philadelphia: JB Lippincott Co; 1983, pp.65-85.
6. Constant CR, and Murley AHG. Functional assessment of the
shoulder. Clinical Orthopaedics and Related Research Number 214,
January, 1987, pp.160-164
To be presented at the 4th Asian Shoulder Association (ACASA) Meeting, Seoul,
Korea, 2002
6