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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 40-43

Evaluation of surgical management of Rockwood Type 3 acromioclavicular joint injuries by autogenous semitendinosus graft ligament reconstruction: A retrospective study


1 Department of Orthopaedics, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
2 Department of Orthopaedics, Apollo Hospitals, Jaipur, Rajasthan, India
3 Department of Orthopaedics, Metro Hospitals, Faridabad, Haryana, India
4 Department of Orthopaedics, RUHS Medical College, Jaipur, Rajasthan, India

Date of Web Publication17-Aug-2018

Correspondence Address:
Dr. Ashish Agrawal
60, Mahashweta Nagar, Ujjain, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_36_17

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  Abstract 

Background: As many as 40% of the shoulder injuries involve acromioclavicular (AC) joint. AC joint injuries have been classified by Rockwood into six types. Treatment of Type 3 AC joint injuries has been controversial. We present a series of 15 cases of Rockwood Type 3 AC joint injuries treated surgically with a method that addresses both superior- inferior as well as anteroposterior AC joint instability. Materials and Methods: Fifteen cases of Rockwood Type 3 AC joint injuries presented to us between November 2011 and November 2015. There were 11 male and four female patients. All patients were treated surgically with the reconstruction of AC and coracoclavicular (CC) ligaments using autogenous semitendinosus graft. The patients were evaluated pre operatively and postoperatively by radiological and functional (using American Shoulder and Elbow Surgeons [ASES] and Constant-Murley scores) methods. Results: X-rays done immediate postoperatively and at 6 weeks, 6 months, and 12 months postoperatively showed good maintenance of the reduction of the AC joint. The ASES score improved from a preoperative score of 41 to a postoperative score of 81 and 95 at 6 and 12 months, respectively. Constant-Murley score improved from a preoperative score of 42 to a post operative score of 79 and 93 at 6 and 12 months, respectively. Conclusion: Surgical management of Rockwood Type 3 AC joint injuries by AC and CC ligament reconstructions using autogenous semitendinosus graft leads to good functional results.

Keywords: Acromioclavicular and coracoclavicular ligaments, acromioclavicular joint, autogenous semitendinosus graft


How to cite this article:
Agrawal A, Sharma N, Singh SP, Singh V. Evaluation of surgical management of Rockwood Type 3 acromioclavicular joint injuries by autogenous semitendinosus graft ligament reconstruction: A retrospective study. J Orthop Traumatol Rehabil 2018;10:40-3

How to cite this URL:
Agrawal A, Sharma N, Singh SP, Singh V. Evaluation of surgical management of Rockwood Type 3 acromioclavicular joint injuries by autogenous semitendinosus graft ligament reconstruction: A retrospective study. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2021 Sep 20];10:40-3. Available from: https://www.jotr.in/text.asp?2018/10/1/40/239258


  Introduction Top


As many as 40% of the shoulder injuries involve acromioclavicular (AC) joint.[1] AC joint injuries have been classified by Rockwood into six types.[1],[2],[3] A review of literature shows that the treatment of the Type 3 AC joint injuries has been controversial, with some preferring conservative management of these injuries, while others have preferred one or the other surgical methods for the management of these injuries.[3],[4],[5],[6],[7] Surgical management of these injuries by anatomic coracoclavicular (CC) ligament reconstruction [8],[9] using a semitendinosus autograft achieves stability in superior-inferior direction; however, anteroposterior instability of the AC joint persists due to torn AC ligaments.[10] There are no many clinical studies of anatomical CC along with AC ligament reconstruction available in the literature.[11],[12],[13],[14] We present a series of 15 cases of Rockwood Type 3 AC joint injuries treated surgically with a method that addresses both superior- inferior as well as anteroposterior AC joint instability.


  Materials and Methods Top


Fifteen cases of Rockwood Type 3 AC joint injuries presented to us betweenNovember 2011 and November 2015. The patients presented to us between 15 days and 2 months after the injury, with a mean period of 36 days. Therewere 11 male and four female patients [Chart 1]. All the patients selected in the study had closed AC joint injury with no associated injuries elsewhere in the body. All the patients were treated surgically with the reconstruction of AC and CC ligaments using autogenous semitendinosus graft. Mean surgical time was 1 h 15 min. Average blood loss was 150 mL. X-ray evaluation of the patients was done preoperatively [Figure 1] and at 6 weeks, 6 months, and 12 months postoperatively. All the patients were evaluated functionally using American Shoulder and Elbow Surgeons [ASES] and Constant-Murley scores preoperatively and at 6 and 12 months postoperatively. The patients with a minimum follow-up period of 12 months were included in the study.

Figure 1: Preoperative X-ray

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Surgical technique

Patient was placed in supine position with ipsilateral shoulder and knee painted and draped. The graft was harvested under tourniquet control by taking a longitudinal incision 1 cm medial to the tibial tubercle. Blunt dissection was done till the Sartorius fascia was reached. This fascia was incised to reach the conjoint tendon. Semitendinosus was separated from the gracilis, and the accessory adhesion bands were cut. With the help of tendon stripper, semitendinosus graft was harvested. The graft was approximately 30 cm in length. The graft was denuded of all the muscular tissues and whipstitch suturing was done at the free end and the donor site was closed. The graft was pretensioned and was safely secured on the sterile trolley.

A curved incision was given starting from the acromion to the coracoid process [Figure 2]. Blunt dissection was done to expose the clavicle, coracoid, and acromion, taking care of hemostasis. AC dislocation was identified and the instability was confirmed in both the anteroposterior and superior-inferior plane in a gentle manner. With the help of 4.5-mm drill bit, a hole was made for the conoid ligament at around 3 cm from the AC joint slightly posterior to the midline of the clavicle from above downward. Similarly, a hole was made for the trapezoid ligament at around 1.5 cm from the AC joint slightly anterior to the midline on the clavicle from above downward to correctly reproduce the anatomic location of the respective ligaments. A drill hole was made in the acromion with the help of the 4.5-mm drill bit from anteromedial to posterolateral direction for the reconstruction of AC ligament. The semitendinosus graft was then taken and passed beneath the coracoid process, and the two ends passed superiorly through the holes on the clavicle made previously. The lateral part of the graft was then taken further laterally and passed through the hole made in the acromion (from anterior to posterior direction) and was taken back to the clavicle to meet the medial end of the graft. Both the ends of the graft were tightly held, and stability of the clavicle in both anteroposterior and superior-inferior plane was rechecked. After confirming the AC joint stability, the two ends of the graft were sutured to each other with the help of nonabsorbable sutures. A 2-mm smooth Kirschner wire (K-wire) was used to transfix the AC joint to provide additional support to the graft [Figure 3]. Closure was done in layers. ThePatients were followed up at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months. Suture removal was done at 2 weeks. Postoperatively, the shoulder was immobilized in a sling for 6 weeks after which the K-wire was removed and range of motion exercises were started. Strengthening exercises were started at 3 months postoperatively.
Figure 2: Intraoperative picture showing curved incision at shoulder

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Figure 3: Intraoperative picture showing semitendinosus graft reconstruction with Kirschner wire fixation of acromioclavicular joint

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  Results Top


Immediate postoperative X-rays of the shoulder showed good reduction of the AC joint. X-rays done at 6 weeks, 6 months, and 12 months postoperatively showed good maintenance of the reduction of the AC joint [Figure 4]. The ASES score improved from a preoperative score of 41 to a postoperative score of 81 and 95 at 6 and 12 months, respectively [Chart 2]. Constant-Murley score improved from a preoperative score of 42 to a postoperative score of 79 and 93 at 6 and 12 months, respectively [Chart 3]. No case had postoperative wound complications. No case required revision surgery.
Figure 4: X-ray at 6 months postoperative

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  Discussion Top


Management of Rockwood Type 3 AC joint injuries has long been controversial. Although many surgical procedures have been reported in the literature to manage these injuries, it has been difficult to achieve good long- term functional outcome. Hardware prominence and loss of fixation have been a common complications of many procedures. Jones et al. first described the use of autogenous semitendinosus tendon graft for reconstructing the CC ligament. However, they did not reconstruct the AC ligament or attempt to restore the anatomical configuration of the trapezoid and conoid ligaments.[15] Lee et al. biomechanically compared the strength and stiffness of the native CC ligament with that of reconstructions with AC ligament or free tendon grafts (semitendinosus, gracilis, or long-toe extensor tendons). They reported that all tendon grafts had strengths equivalent to the native CC ligament strength, and all were significantly stronger (P < 0.05) than the AC ligament reconstruction.[9] Fukuda et al. showed that AC ligaments provide support in the anteroposterior plane contributing to the stability at physiological and pathological loading.[11] Urist showed that the AC ligament was the primary restraint to the anteroposterior displacement of the AC joint.[16] Lee et al. showed that the CC ligaments provide superior and posterior stability and AC ligament provides the anterior stability.[12] Debski et al. showed biomechanically that the conoid and trapezoid ligaments act separately but synergistically in restraining anteroposterior and superior loading of the AC joint.[13] Management of Rockwood Type 3 AC joint injuries with anatomic CC ligaments reconstruction along with AC ligament reconstruction with autogenous semitendinosus tendon graft provides good long-term stability and has been associated with good long-term functional outcome. As the graft used is autogenous in this procedure, allograft compatibility and rejection problems do not arise. The semitendinosus autograft is easy to harvest and if properly harvested is of adequate length to be used as a single graft for this procedure. Furthermore, the strength of the semitendinosus graft is good enough to maintain good long-term reduction of the AC joint, thereby allowing good long-term functional outcome. Thus, reconstruction of both the CC and AC ligaments with autogenous semimembranosus graft can be taken as a treatment of choice in the treatment of Rockwood Type 3 AC joint injuries.


  Conclusion Top


Our series shows that in addition to the anatomic CC ligament reconstruction, addressing the AC ligament instability to achieve stability in both superior-inferior and anteroposterior plane leads to good functional results in Rockwood Type 3 AC joint injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rockwood CA Jr., Williams GR Jr., Young DC. Disorders of the acromioclavicular joint. In: Rockwood CA Jr., Matsen FA 3rd, Wirth MA, Lippitt SB, editors. The Shoulder. 3rd ed. Philadelphia, PA: Saunders; 2004. p. 521-95.  Back to cited text no. 1
    
2.
Lassen JF, Morrey BF, An KN. Surgical anatomy and function of the acromioclavicular and coracoclavicular ligaments. Oper Tech Sports Med 1997;5:60-4.  Back to cited text no. 2
    
3.
Neer CS 2nd, Rockwood CA. Fractures and dislocations of the shoulder. In: Rockwood CA Jr., Green DP, editors. Fractures in Adults. 2nd ed. Philadelphia, PA: Lippincott; 1984. p. 675-985.  Back to cited text no. 3
    
4.
Lemos MJ. The evaluation and treatment of the injured acromioclavicular joint in athletes. Am J Sports Med 1998;26:137-44.  Back to cited text no. 4
    
5.
Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 1972;54:1187-94.  Back to cited text no. 5
    
6.
Bjerneld H, Hovelius L, Thorling J. Acromio-clavicular separations treated conservatively. A 5-year follow-up study. Acta Orthop Scand 1983;54:743-5.  Back to cited text no. 6
    
7.
Li X, Ma R, Bedi A, Dines DM, Altchek DW, Dines JS, et al. Management of acromioclavicular joint injuries. J Bone Joint Surg Am 2014;96:73-84.  Back to cited text no. 7
    
8.
Tauber M, Gordon K, Koller H, Fox M, Resch H. Semitendinosus tendon graft versus a modified weaver-dunn procedure for acromioclavicular joint reconstruction in chronic cases: A prospective comparative study. Am J Sports Med 2009;37:181-90.  Back to cited text no. 8
    
9.
Lee SJ, Keefer EP, McHugh MP, Kremenic IJ, Orishimo KF, Ben-Avi S, et al. Cyclical loading of coracoclavicular ligament reconstructions: A comparative biomechanical study. Am J Sports Med 2008;36:1990-7.  Back to cited text no. 9
    
10.
Mazzocca AD, Conway JE, Johnson S, Rios CG, Dumonski ML, Arciero RA, et al. The anatomic coracoclavicular ligament reconstruction. Oper Tech Sports Med 2004;12:56-61.  Back to cited text no. 10
    
11.
Fukuda K, Craig EV, An KN, Cofield RH, Chao EY. Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 1986;68:434-40.  Back to cited text no. 11
    
12.
Lee KW, Debski RE, Chen CH, Woo SL, Fu FH. Functional evaluation of the ligaments at the acromioclavicular joint during anteroposterior and superoinferior translation. Am J Sports Med 1997;25:858-62.  Back to cited text no. 12
    
13.
Debski RE, Parsons IM 4th, Woo SL, Fu FH. Effect of capsular injury on acromioclavicular joint mechanics. J Bone Joint Surg Am 2001;83-A: 1344-51.  Back to cited text no. 13
    
14.
Shin SJ, Campbell S, Scott J, McGarry MH, Lee TQ. Simultaneous anatomic reconstruction of the acromioclavicular and coracoclavicular ligaments using a single tendon graft. Knee Surg Sports Traumatol Arthrosc 2014;22:2216-22.  Back to cited text no. 14
    
15.
Jones HP, Lemos MJ, Schepsis AA. Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee. Surgical technique and case report. Am J Sports Med 2001;29:234-7.  Back to cited text no. 15
    
16.
Urist MR. Complete dislocations of the acromiclavicular joint; the nature of the traumatic lesion and effective methods of treatment with an analysis of forty-one cases. J Bone Joint Surg Am 1946;28:813-37.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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