THE CLINICAL OUTCOME AFTER LIGAMENT RECONSTRUCTION
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.
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
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.
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
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)
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.
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.
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
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.
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).
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.
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
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.
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):180-182.
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.