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AAMJ, Vol. 8, N. 3, Sep, (Suppl 2), 2010
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TREATMENT OF TYPE III ACROMIOCLAVICULAR DISLOCATION
WITH MODIFIED WEAVER –DUNN PROCEDURE
Abdalla Abo Senna, Hussein Abou El-Ghait, Mohamed Abdel Aal
and Faysal Hasan
Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University
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ABSTRACT
Background: Acromioclavicular joint injuries represent 40%-50 % of
shoulder injuries in athletics . The majority of traumatic dislocations of the
acromioclavicular joint occur either during sports or other daily activities. Most
frequently, the mechanism of injury is force' acting on the shoulder from the lateral
side with the arm in an adducted position. Patients and method: Ten patients with
an acromioclavicular disruption type III by modified Rockwood classification were
surgically treated with modifiedWeaver-Dunn procedure. There were 8 men and 2
women with a mean age of 35 years (range 25 - 50). The surgery was done at an
average of 12 days after trauma (range 4-20 days). Results: Patients were
followed-up for a period ranged from 8- 16 months (Average 10 m). According to
Constant score, eight patients had excellent score, one good, one fair while no
poor results were obtained. Complications were superficial wound infections
occurred in one case and needed no further surgical treatment, only dressing and
oral antibiotic for two weeks. Shoulder impingement in one case and treated with
subacromial decompression. No deep infections or nerve palsies were found.
Conclusion: Resection of lateral end of clavicle with transfer of the
coracoacromial ligament to its distal part augments the strength and biologic
healing of the reconstruction and it can be augmented with suture loop around the
coracoids to the lateral end of the clavicle that provide protection while the
reconstructed ligament heals. (The modified Weaver- Dunn procedure) is the most
common procedure performed for treatment of these injuries and good method for
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treatment of type III Rockwood type acromioclavicular dislocation with little rate
of subluxation, joint stiffness or ligament ossification.
INTRODUCTION
Acromioclavicular joint injuries—or separations, are commonly described
sports-related injuries resulting from falls or other direct forces on the superolateral
aspect of the shoulder pushing the acromion in an inferior direction(1)
Acromioclavicular joint injuries represent a spectrum of severity, ranging from
a simple sprain of the acromioclavicular ligament with no displacement to widely
displaced injuries associated with severe soft-tissue injury to the acromioclavicular
ligament, the coracoclavicular ligament, and the deltotrapezial fascia. (Table 1)
Treatment options vary according to the severity of the injury and logically
reflect the associated soft-tissue involvement.
(Table 1): Modified Rockwood System for Classification of Acromioclavicular
Separations
Type Acromioclavicular LigamentCoracoclavicular LigamentDeltotrapezial Fascia
1
Sprained
Intact
II
Torn
Intact
III
Torn
Torn
Intact
IV
Torn
Torn
Torn
V
Torn
Torn
Tom
VI
Torn
Torn
Torn
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On the basis of the direction and amount of clavicular displacement, Rockwood
introduced a classification of acromioclavicular joint (ACJ) dislocations from grade
1 to VI(2) It is mostly accepted that grade I and II lesions arc benign and can be
treated conservatively(3). There is also wide consensus that type IV to VI injuries"
should be treated operatively. Nevertheless.for type III ACJ injuries the discussion
concerning conservative or operative treatment is still controversial.
There is a great variety of operative treatment options: Open reduction of the
acromioclavicular joint and reconstruction of the ligaments without any further
fixation. The different fixation methods can be grouped into transarticular acromioclavicular techniques, coracoclavicular fixation techniques and secondary
interventions like excision of the lateral clavicle or muscle transfer procedures.
Transarticular fixation by K-wires, screws or tension-band techniques is
commonly used. Several authors have described a high rate of complications, such
as bending, breakage or migration of the pins(4) Stabilization by the use of hinged
plates, definitely improves stability of the repair and allows early mobilization. On
the other hand, it represents an extensive procedure with the necessity of eventual
of implant removal. (5)
Additional repair of the acromioclavicular ligaments is optional, but not
recommended in all cases. The coracoclavicular ligaments are normally not
addressed during these procedures, Extra-articular fixation techniques such as the
Bosworth screw, coracoclavicular loop' wire, Dacron loop or polyethylene
augmentation devices represent an indirect fixation method of the joint
The aim of this prospective study is to report the functional outcome of type III
acromio-clavicular separations managed by modified Weaver- Dunn procedure.
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PATIENTS AND METHODS
From January 2009 to July 2010, Ten patients with an acromioclavicular
separation type III by Rockwood(5) were surgically treated by modified WeaverDunn procedure . There were 8 men and 2 women with a mean age of 35 years
(range 25 - 50). The surgery was done at an average of 12 days after trauma (range
4-20days).
The cause of trauma in eight cases was falling during manual work, and sports
injury in two cases. Initial radiographic evaluations included an AP view, a
scapular y-view of the injured shoulder and a weighted AP stress view of both
acromioclavicular joints on a single wide. All patients were treated with by
modified Weaver- Dunn procedure.
Operation technique
1. A Longitudinal incision (strap) is made over the AC joint extending
down over the coracoid. The lateral end of clavicle will be found to have ruptured
the delto-trapezial fascia and possibly button-holed through trapezius.
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2. The lateral end of clavicle is excised, obliquely including the
intraarticular disc a
and the articular surface to avoid late degeneration of AC
joint
3.The acromioclavicular ligaments(CAL) is mobilized with or without a
small amount of bone from the acromion.
4. Drill holes are made in the clavicle
.
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5. A thick suture loop is passed around the coracoid using a rotator cuff passer (Linvatec).
6. The suture can be passed through a drill hole in the clavicle, to avoid excessive anterior
translation of the clavicle.
7. The suture is tied, whilst the clavicle is held down and the scapula pushed up - reducing
the dislocation. The CAL is then transferred to the lateral end of clavicle with two
interposing sutures.
8. When reducing the joint it is essential to ensure translation is anterior, as well as
inferior.
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Post-operative care: After AC reconstruction by modified Weaver- Dunn
procedure the arm is maintained in simple sling. At 2 week, pendulum exercise is
initiated followed by light activities of daily living at 4 week.
With further graft maturation at 8 week , active and passive range of motion is
encouraged with therapist and light resistance can be initiated after 3 months .once
full ROM and strength are obtained ,return to athletic competition or manual work
is permitted.
At follow-up, each patient was examined in outpatient's clinic. We reported the
Constant Score (CS)(7) the clinical stability of the ACJ, the patient's satisfaction and
the serial X-rays- findings(table2).
RESULTS
Patients were followed-up for a period ranged from 6 - 16 months (Average 10
m). The functional outcome was evaluated by the constant-Murley score The
Constant score represents a maximum of 100 points. According to the achieved
points, the results were grouped into an excellent (> 89 points), good (80- 89
points), fair (70-79 points) and poor (< 70 points) outcome. Subjective functional
evaluation by the patient in comparison to the contralateral shoulder was reported
as patient satisfaction. According to Constant score, eight patients had excellent
score, one good, one fair while no poor results were obtained.
Complications
Superficial wound infections occurred in one case and needed no further
surgical treatment, only dressing and oral antibiotic for two weeks. Shoulder
impingement in one case and treated by subacromial decompression. No deep
infections or nerve palsies were found. (Table 3)
Radiological evaluation by stress view films to be sure about the reduction and
healing of the coracoclavicular and acromioclavicular ligaments revealed good
reduction. No ossification was noted and stable joint with stress view in all
patients. All patients returned to previous work after a maximum of six months
especially in manual workers.
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A
B
C
D
E
Fig. 1: A male patient 32 years old with grade III left acromioclavicular dislocation
according to Rockwood
(a& b) Pre-operative X-ray.
(C) X-ray 45 days post-operative.
(d) X-ray three months post-operative. (e) post-operative patient photo showing full ROM
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A
B
C
D
Fig. 2 male patient 45 years old with grade III left acromioclavicular dislocation
according to Rockwood
(a) Pre-operative X-ray
(b) Post-operative X-ray;
(c) X-ray 3 months post-operative;
(d) Patient photos with full range of movements
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Table 2: Constant score for clinical shoulder evaluation
Parameter
Degree
Points
Pain
None
15
Mild
10
Moderate
5
Severe
0
Full work
4
Full
4
Activities of daily living (Activity level)
recreation/sport
Positioning
Unaffected sleep
2
Up to waist
4
Up to xiphoid
2
Up to neck
6
Up to top of head
8
Above head
10
Total
20
Range of Motion
40
Power (1 point per pound of weight held in abduction
25
by arm at 90°)
Total
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Table 3 Clinical and results of the follow up period
parameter Post-operative complications Clinical Constant score values
Superficial infection
Total
1
Excellent
8
Good
1
1
Impingement
1
Fair
No complication
8
Poor
10
10
DISCUSSION
Repair of ACJ dislocations provides overall good clinical results independent
of the surgical method(8)
Whereas surgical treatment is recommended for type IV to VI ACJ injuries, the
management of type III injuries is still controversial.
several authors recommend surgical reconstruction exclusively for young patients,
in athletes or for heavy workers and there is still discussion whether ACJ injuries
of type III should be treated conservative or operative. Regarding to the equivalent
results of surgical and conservative treatment, many authors come to the conclusion
that the risks of operation cannot further be accepted (9)
For conservative treatment, Rawes and Dias stated overall good outcomes at
long term follow- up, although all joints were dislocated or subluxed and nearly all
patients
developed
ossificationsf(10)They
reviewed
30
patients
treated
conservatively with type III ACJ injury according to Rockwood. All were
examined clinically and radiographically, most patients comfort was administered,
only one patient with unsatisfactory result.
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In contrast, Mouhsine et al (11) reported poor results of conservative treatment
in grad I and II acromioclavicular dislocations.
Olaf Rolf ct al (12) compared the early and delayed reconstructed ACJ injuries
in order to analyze clinical results of the patients which first got conservative
treatment after a Rockwood III injury and failed after some time because of
persisting instability, pain or weakness. The clinical outcome in the delayed
reconstructed group was inferior to the early reconstructed group with a statistically
significant difference. Also the delayed reconstructed group suffered more complications and had statistically significant worse results regarding the degree of
ACJ reduction in the radiograph at follow-up.
Additionally, patient's satisfaction was much better in the early reconstructed
group. They concluded that the risks of surgical treatment were acceptable and of
little influence on the clinical outcome and they recommended surgical treatment in
type III ACJ- injuries immediately after trauma.
In our study, the follow-up period ranged from 8 - 16months (Average 10-m).
Clinically, according to Constant-Murley score there were eight patients had
excellent score, one good: one fair and no poor results were obtained.
Radiologically, stress view films revealed good reduction, no ossification was
noted and stable joint in all patients. We had minor complications without great
effect on the final results as superficial wound infections in one case and mild
shoulder impingement in one case and treated with arthroscopic subacromial
decompression. We had no deep infections or nerve palsies.
The modified Weaver- Dunn procedure is the most common procedure
performed for treatment of type III Rockwood type acromioclavicular dislocation
with little rate of subluxation, joint stiffness or ligament ossification.
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REFERENCES
1.
Bannister GC, Wallace WA, Stableforth PC, Hutson MA; The
management of acute acromioclavicular dislocation. A randomised prospective
controlled trial J Bone Joint Surg (1989) Br 71:848- 850.
2.
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