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Acromioclavicular Joint Disorders BY EMAD ZAYED (M.D) LECTURER OF ORTHOPAEDIC SURGERY FACULTY OF MEDICINE AL AZHAR UNIVERSITY 2016 • AC joint is a common source of shoulder pain. SPECTRUM OF DISORDERS • TRAUMATIC DISORDERS • NONTRAUMATIC DISORDERS • Injuries • Post-traumatic degeneration • Osteolysis • Arthritis • Part of Impingement Syndrome ANATOMY • Diarthrodial Joint. • Thin capsule Stability The orientation of the sagittal plane of the joint is variable, ranging from nearly vertical to angulations approaching 50 degrees, results in greater overriding of the lateral clavicle on the medial acromion • Ligaments: Main stabilizer C.C. Lig A.C. Lig • Horizontal Stability is accomplished by the AC lig • Vertical stability is obtained through C.C. Lig. EVALUATION • History Pain is the most common symptom of an AC joint disorder Physical Examination Patient preparation for physical examination requires unimpeded access to both shoulders. Surface landmarks helping to identify ACJ, which lies directly anterior to the soft spot at the apex of the triangle formed by the scapular spine, the clavicle, and the base of the neck. The cross-body adduction stress test Pain localized to the AC joint is the hallmark examination findings The AC resisted-extension test The Paxinos test The thumb and finger are squeezed together AC joint injections are easier said than done. Plain Radiographs The Zanca view is taken with the x-ray directed 10 to 15 degrees cephalad. Enables assessment for anterior or posterior displacement of the clavicle with respect to the acromion. Stress Views Magnetic Resonance Imaging • Displays the pathologic changes that result from injuries and nontraumatic disorders. Osteolysis of lat end clavicle NONTRAUMATIC DISORDERS AC Osteolysis • Radiographic findings • Irregular or absent subchondral bone • Alteration of the distal clavicle morphology such as tapering, cysts, calcification, and osteophytes. • MRI, reveal edema within the marrow elements of the distal clavicle, cortical erosions, and cysts. Traumatic Atraumatic (limited) specially with bilateral involvement. • Systemic diseases such as • Hyperparathyroidism • Rheumatoid arthritis • Scleroderma • Local processes that can resemble classic osteolysis are • Infections • Metastatic malignancy • Primary bone tumors such as multiple myeloma • Crystal arthropathy, especially gout Acromioclavicular Arthritis • Primary (not commonly symptomatic) • Secondary (especially trauma-related osteoarthritis, is more prevalent). Eccentric joint space narrowing, osteophytes, and subchondral cysts. Rheumatoid Arthritis • The AC joint is affected in at least 50% of patients with rheumatoid arthritis; even more commonly than the glenohumeral joint. • Only rarely is operative treatment performed. Crystal Arthritis • Gout and pseudogout of the AC joint have been reported Conservative Treatment • Rest • Activity Modification. • Nonsteroidal anti-inflammatory medication • Corticosteroid Injection • Excision of the lateral end clavicle will definitively terminate the process and, in nearly all cases, result in an excellent or good outcome Excision of the lateral end clavicle TRAUMATIC DISORDERS • AC joint injuries represent nearly half of all athletic shoulder injuries. Classification ACL sprained • Type I: ACJ intact • C.C. lig intact • C.C. distance intact • Muscles intact • No displacement • Type II: • AC lig disrupted • C.C. lig sprained • C.C. Distance slightly increased < 25% Type III • AC lig and CC lig disrupted • ACJ dislocated • C.C. Distance increased (25 to 100%) of normal Rockwood added three types caused by 3 different mechanism TREATMENT • Nonsurgical treatment is indicated for type I and II injuries. • Surgery is almost always recommended for type IV, V, and VI injuries. • Management of type III injuries remains controversial. TREATMENT Type I & II • Sling ( 1wk for type I and 2 wks. for type II) • Once the shoulder pain has subsided, an early and gradual rehabilitation program is instituted, with the focus on passive- and active-assisted ROM. Taping the AC joint Taping of the AC joint has been used for first or second degree sprains, because it can provide some external support while not limiting the athlete’s range of motion. Protection of the AC Joint • Adequate protection should be provided to the AC joint to prevent further injury specially in athletes (football and ice hockey). Impact AC prefabricated pad Spider pad Type III Controversial • Numerous studies have failed to demonstrate superior outcomes after surgical treatment as compared to non operative treatment. Operative treatment reserved for: 1. Young athletes 2. Concern of cosmesis 3. Associated injuries 4. Failure of conservative treatment Operative Treatment 1- Primary ACJ fixation 2- Primary CC fixation 3- C C Ligament reconstruction 4- Dynamic muscle transfer Primary AC Joint Fixation • Pinning - risk of: - loss of fixation - pin breakage - pin migration - Injury to meniscus and articular cartilage Degen arthritis - Second surgery for removal • HOOKED PLATE Primary CoracoClavicular Fixation • Rigid construct: Screws wires • Non Rigid construct: Sutures (absorbable or nonabsorbable) Grafts CoracoClavicular ligament Reconstruction Modification of Weaver-Dunn • Resection of the distal end of clavicle • Coracoacromial lig detached from the acromion with a piece of bone and transferred to the hollowed canal of the calvicle. • Augmentation by non absorbable sling between the clavicle & coracoid. BIOLOGICAL ANATOMICAL RECONSTRUCTION Thank You