ACJ Repair

ACROMIOCLAVICULAR JOINT FIXATION/REPAIR

 
Internal fixation with Kirschner-wires

ACJ reduction, fixation achieved by drilling steel Kirshner wires across the acromion, the AC Joint and into the lateral end of the clavicle.

Unfortunately the reduction of the ACJ is often lost soon after the wires are removed 6-8 weeks post-operatively

Worse this carries the risk of wire loosening and migration, this can be very dangerous.
Bosworth screw fixation(3)

ACJ reduction, fixation achieved by drilling a Bosworth screw through the clavicle, then inferiorly into base of the coracoid process, followed by coraco-clavicular ligament repair with sutures. Aftercare includes gentle mobilisation after 1 week and delaying more forceful mobilisation and lifting until after screw removal at 8 weeks.

Again there is risk of migration of the screw, and frequent loosening of the screw with erosion of bone around the implant.

This has also led to further fracture of the clavicle at the position of the screw.

There is the necessity for a second procedure to remove the screw.
Mumford- Distal clavicular excision

Indicated for chronic, symptomatic, type II subluxations. The acromion is sutured to raw end of the clavicle followed by prompt mobilisation after 1 week.

Variable results and does not address symptoms arising from clavicular instability
Weaver-Dunn -Distal clavicular excision with coraco-clavicular ligament reconstruction(4)
Coraco-acromial ligament is freed from the acromion and sutured to the remaining end of the clavicle through its intramedullary canal to achieve reduction. Patients may mobilise gently after one week in a sling, but delay more forceful mobilisation and lifting until after 6-8 weeks.

This procedure relies on a viable coraco-acromial ligament and can fail to stabilise the clavicle sufficiently, especially for the higher grade injuries (for these it is best combined with some form of coraco-clavicular ligament reconstruction or fixation).

Unavoidably disrupts the coraco-acromial arch.
Coraco-clavicular ligament reconstruction using various soft tissue autografts or allografts
free tendon grafts, e.g. fascial grafts; long head of biceps tendon, etc

These can require harvesting of either local or separate area tissue and the consequent loss of that tissue and either a bigger or a second operation site & wound.
Coraco-clavicular ligament reconstruction with prosthetic ligament

 

 
The Nottingham Surgilig:

The implant is made from polyester with braiding technology originally developed to produce the ABC, the ARD and the Soffix ligaments, which have been extensively used in the knee over many years.

Loops are woven into each end of the grafts, which come in a range of lengths. The prosthetic ligament is looped around the base of the coracoid process, then threaded through itself to provide a broad based fixation which will not erode or cut through the bone. A firm, smaller loop, at the clavicular end allowing secure screw fixation to the clavicle. The graft is threaded posteriorly around the circumference of the clavicle, thus allowing the natural rotation (45?) of the clavicle to occur without risk of erosion or fracture (as can occur with many other implants).

Over a period of time, fibrous ingrowth occurs, establishing the formation of a “neo-ligament” with host tissue, but retaining the excellent implant strength.

The strength of the construct exceeds that of the natural ligments thus allowing very early mobilisation, and early return to sporting and strenuous activities.

For those patients who have persistent symptoms following conservative treatment for AC dislocations types I –III, early operative intervention is advocated by many surgeons, especially for manual workers and athletes.

Results of early repair have been reported to be superior to those carried out late 10.

Drawbacks of earlier techniques such as the Weaver-Dunn (otherwise successful for relatively stable injuries) include the delay in recovery to full function and performing resistive shoulder exercises until soft tissue healing is sufficiently advanced at 10-12 weeks; as well as the need for further fixation with higher grade injuries.

Conversely, using an implant such as the Nottingham Surgilig, patients are able to resume normal activities from 2 weeks without the need for medium term protection.

References

  1. Rockwood Jr CA, Young DC. Disorders of the Acromioclavicular Joint. In Rockwood Jr CA, Matsen III FA (eds). The Shoulder. Philadelphia: WB Saunders, 1990: 413-468
  2. Rockwood Jr CA. Injuries to the Acromioclavicular Joint. In Rockwood Jr CA, Green DP (eds). Fractures in Adults. Philadelphia: JB Lippincott, 1984: 860-910
  3. Tossy JD, Mead NC, Sigmond HM. Acromio-claviculare separations: useful and practical classification for treatment. Clinical Orthopaedics and Related Research 1963; 28: 111
  4. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am. 1972 ; 54A:1187-94