1. Acromioclavicular Joint Disorders BY EMAD ZAYED (M.D) LECTURER OF ORTHOPAEDIC SURGERY FACULTY OF MEDICINE AL AZHAR UNIVERSITY 2016

2. AC joint is a common source of shoulder pain.

3. SPECTRUM OF DISORDERS TRAUMATIC DISORDERS NONTRAUMATIC DISORDERS

4. Injuries

5. Post-traumatic degeneration

6. Osteolysis

7. Arthritis

8. Part of Impingement Syndrome

9. Diarthrodial Joint. Thin capsule ANATOMY

10. 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 Stability

11. Ligaments: Main stabilizer C.C. Lig A.C. Lig

12. Horizontal Stability is accomplished by the AC lig

13. Vertical stability is obtained through C.C. Lig.

14. EVALUATION History Pain is the most common symptom of an AC joint disorder

15. Physical Examination Patient preparation for physical examination requires unimpeded access to both shoulders.

16. 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.

17. The cross-body adduction stress test Pain localized to the AC joint is the hallmark examination findings

18. The AC resisted-extension test

19. The Paxinos test The thumb and finger are squeezed together

20. AC joint injections are easier said than done.

21. The Zanca view is taken with the x-ray directed 10 to 15 degrees cephalad. Plain Radiographs

22. Enables assessment for anterior or posterior displacement of the clavicle with respect to the acromion.

23. Stress Views

24. Magnetic Resonance Imaging Displays the pathologic changes that result from injuries and nontraumatic disorders.

25. Osteolysis of lat end clavicle

26. NONTRAUMATIC DISORDERS

27. 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.

28. Atraumatic ( limited) Systemic diseases such as Local processes that can resemble classic osteolysis are specially with bilateral involvement. Hyperparathyroidism Rheumatoid arthritis Scleroderma Infections Metastatic malignancy Primary bone tumors such as multiple myeloma Crystal arthropathy, especially gout Traumatic

29. Acromioclavicular Arthritis Primary (not commonly symptomatic) Secondary (especially trauma-related osteoarthritis, is more prevalent). Eccentric joint space narrowing, osteophytes, and subchondral cysts.

30. 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

31. 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 Conservative Treatment

32. Excision of the lateral end clavicle

33. AC joint injuries represent nearly half of all athletic shoulder injuries. TRAUMATIC DISORDERS

34. Type I: ACL sprained ACJ intact C.C. lig intact C.C. distance intact Muscles intact No displacement Classification

35. Type II: AC lig disrupted C.C. lig sprained C.C. Distance slightly increased < 25%

38. Type III AC lig and CC lig disrupted ACJ dislocated C.C. Distance increased (25 to 100%) of normal

42. Rockwood added three types caused by 3 different mechanism

43. 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

44. 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. Type I & II

45. 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.

46. 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 padSpider pad

47. Numerous studies have failed to demonstrate superior outcomes after surgical treatment as compared to non operative treatment. Type III Controversial

48. Operative treatment reserved for: 1.Young athletes 2.Concern of cosmesis 3.Associated injuries 4.Failure of conservative treatment

49. Operative Treatment 1- Primary ACJ fixation 2- Primary CC fixation 3- C C Ligament reconstruction 4- Dynamic muscle transfer

50. 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

51. HOOKED PLATE

52. Primary CoracoClavicular Fixation Rigid construct: Screws wires Non Rigid construct: Sutures (absorbable or nonabsorbable) Grafts

53. CoracoClavicular ligament Reconstruction

54. Resection of the distal end of clavicle Augmentation by non absorbable sling between the clavicle & coracoid. Coracoacromial lig detached from the acromion with a piece of bone and transferred to the hollowed canal of the calvicle. Modification of Weaver-Dunn

55. BIOLOGICAL ANATOMICAL RECONSTRUCTION

60. Thank You