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ACJ Revision Surgery

Lennard Funk

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CC Ligaments

1.5mm

Beardon

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AC Ligaments

• Superior AC Lig = 56% Posterior Translation• Posterior AC Lig = 25% Posterior Translation

– Klimkiewikcz• Superior AC Lig = Rotational Stability

– Branch et al.

Urist, JBJSA. 1946

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Note:• Post-op pain correlates with Translation, but not amount of

bone resected– Blazar et al. CORR. 1998

• Superior & Posterior not capable of stabilising clavicle - 32% incr. of posterior translation after Ant & Inf capsular resection

– Corteen & Teitge

– No difference if superior or inferior AC lig. cut (horizontal, vertical & rotatory instability)

– Branch et al. AJSM 1996

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Failed ACJ Excision (Basmania, 1995)

1. Diagnostic Error2. Inadequate resection3. Joint Instability4. Weakness5. Miscellaneous

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Failed ACJ Excision (Strauss et al. 2010)

Common Causes Less Common Causes

Instability Distal Clavicle Fracture

Under Resection Suprascapular neuropathy

Over Resection Other Cause - Neck pain, SLAP, etc.

Stiffness (29%)

Bony regrowth

Untreated Concomitant Pathology

Infection

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Failed ACJ Excision (Robinson, Phandis, Torrance, Funk - in press 2016)

Common Causes Less Common Causes

Instability - 22% Distal Clavicle Fracture

Under Resection - 3% Suprascapular neuropathy

Over Resection - 8% Other Cause - Neck pain, SLAP, etc.

Stiffness - 12%

Bony regrowth

Untreated Concomitant Pathology - 4%

Infection - 0.8%

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Unstable ACJ• Excess translation ‘with pain’ in any direction,

compared to the opposite side• Clinical• USS

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Granville-Chapman, Robinson, Phandis, FunkIn press, 2016

• 23 revisions betw. 2008 - 2015• Mean Age = 32yrs (20-57)• M:F = 18:5

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Original Procedure N/23Tightrope or equivalent 6Lockdown / Surgilig 6LARS 4Weaver-Dunn 3Hook Plate 3Bosworth Screw 1

Granville-Chapman, Robinson, Phandis, FunkIn press, 2016

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ACJ Reconstructions

>100 PUBLISHED!!

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Harris et al. AJSM 2000“None of the reconstruction techniques were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”

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Revision Technique

• Anatomical Reconstruction• Very strong, but flexible• Allows early Rehab.• Biological• Avoid donor site• Allows variable options

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LARS Ligament (Corin)

• Braided Polyethylenetraphthalate• 1500N tensile strength (30 LAC)

• No reduction in mechanical resilience after over 10 million wear cycles loaded in torsion, traction and flexion [Fialka et al. 2005;

• Vascularisation & Fibrous ingrowth - Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005; Pelletier & Durand]

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Nottingham Approach

Shoulderdoc.co.uk

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Procedure(s)1. Remove all previous fix & Scar tissue2. Micro samples3. CC Ligs - LARS anatomical + ‘Biceps Flip’4. AC Ligs - LARS + Reverse CAL Transfer5. Delto-trapezial Reefing

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• 23 cases over 7 years

• Follow-up = 37 months (24-48)• Constant Score = 51.8 pre to 85.2 post• 10% re-displaced radiologically• 13% superficial infections• No further revisions

Results (failed Recons)Robinson, Phandis, Torrance, Funk - in press 2016

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Results (failed Excisions)Baxter, Robinson, Phandis, Torrance, Funk - in press 2016

• 13 cases over 5 years

• Follow-up = 34 months (24-48)• Constant Score = 26 pre to 73 post• 1 re-displaced radiologically• 1 chronic pain• No further revisions

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Management

• Each case is unique• May be multiple problems

• Retained bone & unstable• Excess excision & scar neuroma

• Blame• Medicolegal• Multiple Opinions

• Diagnostic Injection

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Summary

• Awareness• Test for Horizontal & Vertical Instability• Ultrasound• CT Scan

• Revise if Symptomatic• Strong• Anatomical• Biological

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THANK YOU