Shoulder:Disorders of the Acromioclavicular Joint - Revision history

Alexandre.laedermann: /* Biomechanics of the Acromioclavicular Joint */

2021-08-17T04:15:43Z

Biomechanics of the Acromioclavicular Joint

Alexandre.laedermann: /* Biomechanics of the Acromioclavicular Joint */

2021-08-17T04:13:47Z

Biomechanics of the Acromioclavicular Joint

Alexandre.laedermann at 04:13, 17 August 2021

2021-08-17T04:13:13Z

Alexandre.laedermann at 04:03, 17 August 2021

2021-08-17T04:03:53Z

Alexandre.laedermann: /* Anatomical Considerations */

2021-08-17T04:01:25Z

Anatomical Considerations

Alexandre.laedermann: /* Anatomical Considerations */

2021-08-17T04:00:35Z

Anatomical Considerations

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Alexandre.laedermann at 05:57, 15 August 2021

2021-08-15T05:57:12Z

Alexandre.laedermann at 10:37, 26 May 2021

2021-05-26T10:37:56Z

Alexandre.laedermann at 10:35, 26 May 2021

2021-05-26T10:35:18Z

Alexandre.laedermann: /* Indications */

2021-05-26T10:33:14Z

Indications

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 ==Biomechanics of the Acromioclavicular Joint==
-#REDIRECT [[https://wiki.beemed.com/view/Shoulder:Biomechanics]<nowiki>]</nowiki>
+#REDIRECT [[https://wiki.beemed.com/view/Shoulder:Biomechanics#Acromioclavicular_Joint]<nowiki>]</nowiki>
 The acromioclavicular joint is stabilized both by static and dynamic stabilizers. The static stabilizers include 1) the four acromioclavicular ligaments (superior, inferior, anterior, and posterior), 2) the lateral coracoclavicular ligaments (conoid and trapezoid), 3) the medial coracoclavicular ligaments (Figure and Video) and 4) the coracoacromial ligament.<ref name=":1">Stimec BV, Lädermann A, Wohlwend A, Fasel JH. Medial coracoclavicular ligament revisited: an anatomic study and review of the literature. Arch Orthop Trauma Surg 2012;132:1071-5</ref><ref>Moya D, Poitevin LA, Postan D, Azulay GA, Valente S, Giacomelli F, Mamone LA. The medial coracoclavicular ligament: anatomy, biomechanics,and clinical relevance-a research study. JSES Open Access. 2018 Sep 22;2(4):183-189</ref> The latter, when transferred during standard Weaver-Dunn repair is only 1/4 as strong as the intact coracoclavicular ligaments; such technique of stabilization does not provide sufficient strength and is considered by many as obsolete.<ref>Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 1972;54:1187-94.</ref><ref>Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 2004;32:1929-36.</ref><ref name=":4">Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML, Arciero RA. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 2006;34:236-46</ref><br />

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 <br />
 ==Radiological or Radiographic Evaluation of the Acromioclavicular Joint==
 ===X-ray===

@@ Line 14: / Line 14: @@
 ==Anatomical Considerations==
-#REDIRECT [[https://wiki.beemed.com/view/Shoulder:Biomechanics]<nowiki>]</nowiki>
+#REDIRECT [[https://wiki.beemed.com/view/Shoulder:Anatomy_of_the_Shoulder#Acromioclavicular_Joint]<nowiki>]</nowiki>
 The acromioclavicular joint that anchors the clavicle to the scapula. It is a diarthrodial joint that primarily rotates as well as translates in the anterior-posterior and the superior-inferior planes. The joint is surrounded by a capsule with synovium and an articular surface that is made up of hyaline cartilage containing an intra-articular meniscus-type structure. The mean width of the articular surface is 24.3+/-3 mm (range, 17-30 mm) for the acromial side and 24.6+/-3 mm (range, 17-30 mm) for the clavicular side.<ref name=":0" /> The mean anterior overhang of the acromion (anterior acromion-anterior joint distance) is 2.6+/-2.6 mm (range, 0-10 mm), whereas the mean anterior oversize of the clavicle (anterior clavicle-anterior joint distance) is 2.2+/-1.9 mm (range, 0-5 mm) (Figure). Only 60% of the acromioclavicular joints are aligned anteriorly, 3% have minor overhang of the acromion, 3% have minor overhang of the clavicle, 24% have major overhang of the acromion, and 10% have major overhang of the clavicle (Figure). Therefore, major misalignment anteriorly is found in 34% of the cases. The only reliable landmarks are the articular facets of both the acromion and the clavicle.<ref name=":0">Barth J, Boutsiadis A, Narbona P, et al. The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study. J Shoulder Elbow Surg 2017;26:1121-7</ref> The center of the conoid ligament inserts under the posterior part of the clavicle 46 mm medially to the acromioclavicular joint. The center of the trapezoid ligament has an anterior insertion under the clavicle, 25 mm medially to the acromioclavicular joint.<ref>Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clinics in sports medicine 2003;22:219-37.</ref><ref>Boehm TD, Kirschner S, Fischer A, Gohlke F. The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection. Acta Orthop Scand 2003;74:718-21.</ref><ref>Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med 2007;35:811-7.<br /> The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.</ref><ref>Miller M, Thompson S. Delee & Drez's Orthopaedic Sports Medicine: Principles and Practice: Elsevier; 2003.</ref> The normal coracoclavicular distance (superior coracoid to inferior clavicle) is 11-13 mm. The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.  [[File:1562643120067-lg.jpg|Photograph (a) and drawing (b) showing measurement methods. The anterior (A) and posterior (P) borders of the capsule are marked and connected with a straight line (AP line). Two parallel lines perpendicular to the AP line are created that passed through points A and P. Two anterior parallel lines perpendicular to the AP line are drawn: one passing at the most anterior edge of the acromion (acromion anteriorly [ACA]) and the other passing at the most anterior edge of the clavicle (clavicle anteriorly [CLA]). The same procedure is followed for the posterior part of the joint, and the lines passing from the acromion posteriorly (ACP) and clavicle posteriorly (CLP) were drawn. Reproduced with permission from Barth et al.<ref name=":0" />|alt=|thumb|858x858px|center]]

@@ Line 14: / Line 14: @@
 ==Anatomical Considerations==
 The acromioclavicular joint that anchors the clavicle to the scapula. It is a diarthrodial joint that primarily rotates as well as translates in the anterior-posterior and the superior-inferior planes. The joint is surrounded by a capsule with synovium and an articular surface that is made up of hyaline cartilage containing an intra-articular meniscus-type structure. The mean width of the articular surface is 24.3+/-3 mm (range, 17-30 mm) for the acromial side and 24.6+/-3 mm (range, 17-30 mm) for the clavicular side.<ref name=":0" /> The mean anterior overhang of the acromion (anterior acromion-anterior joint distance) is 2.6+/-2.6 mm (range, 0-10 mm), whereas the mean anterior oversize of the clavicle (anterior clavicle-anterior joint distance) is 2.2+/-1.9 mm (range, 0-5 mm) (Figure). Only 60% of the acromioclavicular joints are aligned anteriorly, 3% have minor overhang of the acromion, 3% have minor overhang of the clavicle, 24% have major overhang of the acromion, and 10% have major overhang of the clavicle (Figure). Therefore, major misalignment anteriorly is found in 34% of the cases. The only reliable landmarks are the articular facets of both the acromion and the clavicle.<ref name=":0">Barth J, Boutsiadis A, Narbona P, et al. The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study. J Shoulder Elbow Surg 2017;26:1121-7</ref> The center of the conoid ligament inserts under the posterior part of the clavicle 46 mm medially to the acromioclavicular joint. The center of the trapezoid ligament has an anterior insertion under the clavicle, 25 mm medially to the acromioclavicular joint.<ref>Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clinics in sports medicine 2003;22:219-37.</ref><ref>Boehm TD, Kirschner S, Fischer A, Gohlke F. The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection. Acta Orthop Scand 2003;74:718-21.</ref><ref>Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med 2007;35:811-7.<br /> The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.</ref><ref>Miller M, Thompson S. Delee & Drez's Orthopaedic Sports Medicine: Principles and Practice: Elsevier; 2003.</ref> The normal coracoclavicular distance (superior coracoid to inferior clavicle) is 11-13 mm. The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.  [[File:1562643120067-lg.jpg|Photograph (a) and drawing (b) showing measurement methods. The anterior (A) and posterior (P) borders of the capsule are marked and connected with a straight line (AP line). Two parallel lines perpendicular to the AP line are created that passed through points A and P. Two anterior parallel lines perpendicular to the AP line are drawn: one passing at the most anterior edge of the acromion (acromion anteriorly [ACA]) and the other passing at the most anterior edge of the clavicle (clavicle anteriorly [CLA]). The same procedure is followed for the posterior part of the joint, and the lines passing from the acromion posteriorly (ACP) and clavicle posteriorly (CLP) were drawn. Reproduced with permission from Barth et al.<ref name=":0" />|alt=|thumb|858x858px|center]]
 ==Biomechanics of the Acromioclavicular Joint==
 The acromioclavicular joint is stabilized both by static and dynamic stabilizers. The static stabilizers include 1) the four acromioclavicular ligaments (superior, inferior, anterior, and posterior), 2) the lateral coracoclavicular ligaments (conoid and trapezoid), 3) the medial coracoclavicular ligaments (Figure and Video) and 4) the coracoacromial ligament.<ref name=":1">Stimec BV, Lädermann A, Wohlwend A, Fasel JH. Medial coracoclavicular ligament revisited: an anatomic study and review of the literature. Arch Orthop Trauma Surg 2012;132:1071-5</ref><ref>Moya D, Poitevin LA, Postan D, Azulay GA, Valente S, Giacomelli F, Mamone LA. The medial coracoclavicular ligament: anatomy, biomechanics,and clinical relevance-a research study. JSES Open Access. 2018 Sep 22;2(4):183-189</ref> The latter, when transferred during standard Weaver-Dunn repair is only 1/4 as strong as the intact coracoclavicular ligaments; such technique of stabilization does not provide sufficient strength and is considered by many as obsolete.<ref>Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 1972;54:1187-94.</ref><ref>Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 2004;32:1929-36.</ref><ref name=":4">Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML, Arciero RA. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 2006;34:236-46</ref><br />
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← Older revision		Revision as of 04:01, 17 August 2021
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	==Anatomical Considerations==		==Anatomical Considerations==
−	The acromioclavicular joint that anchors the clavicle to the scapula. It is a diarthrodial joint that primarily rotates as well as translates in the anterior-posterior and the superior-inferior planes. The joint is surrounded by a capsule with synovium and an articular surface that is made up of hyaline cartilage containing an intra-articular meniscus-type structure. The mean width of the articular surface is 24.3+/-3 mm (range, 17-30 mm) for the acromial side and 24.6+/-3 mm (range, 17-30 mm) for the clavicular side.<ref name=":0" /> The mean anterior overhang of the acromion (anterior acromion-anterior joint distance) is 2.6+/-2.6 mm (range, 0-10 mm), whereas the mean anterior oversize of the clavicle (anterior clavicle-anterior joint distance) is 2.2+/-1.9 mm (range, 0-5 mm) (Figure 1). Only 60% of the acromioclavicular joints are aligned anteriorly, 3% have minor overhang of the acromion, 3% have minor overhang of the clavicle, 24% have major overhang of the acromion, and 10% have major overhang of the clavicle (Figure). Therefore, major misalignment anteriorly is found in 34% of the cases. The only reliable landmarks are the articular facets of both the acromion and the clavicle.<ref name=":0">Barth J, Boutsiadis A, Narbona P, et al. The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study. J Shoulder Elbow Surg 2017;26:1121-7</ref> The center of the conoid ligament inserts under the posterior part of the clavicle 46 mm medially to the acromioclavicular joint. The center of the trapezoid ligament has an anterior insertion under the clavicle, 25 mm medially to the acromioclavicular joint.<ref>Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clinics in sports medicine 2003;22:219-37.</ref><ref>Boehm TD, Kirschner S, Fischer A, Gohlke F. The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection. Acta Orthop Scand 2003;74:718-21.</ref><ref>Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med 2007;35:811-7.<br /> The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.</ref><ref>Miller M, Thompson S. Delee & Drez's Orthopaedic Sports Medicine: Principles and Practice: Elsevier; 2003.</ref> The normal coracoclavicular distance (superior coracoid to inferior clavicle) is 11-13 mm. The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve. [[File:1562643120067-lg.jpg\|Photograph (a) and drawing (b) showing measurement methods. The anterior (A) and posterior (P) borders of the capsule are marked and connected with a straight line (AP line). Two parallel lines perpendicular to the AP line are created that passed through points A and P. Two anterior parallel lines perpendicular to the AP line are drawn: one passing at the most anterior edge of the acromion (acromion anteriorly [ACA]) and the other passing at the most anterior edge of the clavicle (clavicle anteriorly [CLA]). The same procedure is followed for the posterior part of the joint, and the lines passing from the acromion posteriorly (ACP) and clavicle posteriorly (CLP) were drawn. Reproduced with permission from Barth et al.<ref name=":0" />\|alt=\|thumb\|858x858px\|center]]	+	The acromioclavicular joint that anchors the clavicle to the scapula. It is a diarthrodial joint that primarily rotates as well as translates in the anterior-posterior and the superior-inferior planes. The joint is surrounded by a capsule with synovium and an articular surface that is made up of hyaline cartilage containing an intra-articular meniscus-type structure. The mean width of the articular surface is 24.3+/-3 mm (range, 17-30 mm) for the acromial side and 24.6+/-3 mm (range, 17-30 mm) for the clavicular side.<ref name=":0" /> The mean anterior overhang of the acromion (anterior acromion-anterior joint distance) is 2.6+/-2.6 mm (range, 0-10 mm), whereas the mean anterior oversize of the clavicle (anterior clavicle-anterior joint distance) is 2.2+/-1.9 mm (range, 0-5 mm) (Figure). Only 60% of the acromioclavicular joints are aligned anteriorly, 3% have minor overhang of the acromion, 3% have minor overhang of the clavicle, 24% have major overhang of the acromion, and 10% have major overhang of the clavicle (Figure). Therefore, major misalignment anteriorly is found in 34% of the cases. The only reliable landmarks are the articular facets of both the acromion and the clavicle.<ref name=":0">Barth J, Boutsiadis A, Narbona P, et al. The anterior borders of the clavicle and the acromion are not always aligned in the intact acromioclavicular joint: a cadaveric study. J Shoulder Elbow Surg 2017;26:1121-7</ref> The center of the conoid ligament inserts under the posterior part of the clavicle 46 mm medially to the acromioclavicular joint. The center of the trapezoid ligament has an anterior insertion under the clavicle, 25 mm medially to the acromioclavicular joint.<ref>Renfree KJ, Wright TW. Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints. Clinics in sports medicine 2003;22:219-37.</ref><ref>Boehm TD, Kirschner S, Fischer A, Gohlke F. The relation of the coracoclavicular ligament insertion to the acromioclavicular joint: a cadaver study of relevance to lateral clavicle resection. Acta Orthop Scand 2003;74:718-21.</ref><ref>Rios CG, Arciero RA, Mazzocca AD. Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med 2007;35:811-7.<br /> The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve.</ref><ref>Miller M, Thompson S. Delee & Drez's Orthopaedic Sports Medicine: Principles and Practice: Elsevier; 2003.</ref> The normal coracoclavicular distance (superior coracoid to inferior clavicle) is 11-13 mm. The acromioclavicular joint has dual innervation from both the suprascapular nerve and the lateral pectoral nerve. [[File:1562643120067-lg.jpg\|Photograph (a) and drawing (b) showing measurement methods. The anterior (A) and posterior (P) borders of the capsule are marked and connected with a straight line (AP line). Two parallel lines perpendicular to the AP line are created that passed through points A and P. Two anterior parallel lines perpendicular to the AP line are drawn: one passing at the most anterior edge of the acromion (acromion anteriorly [ACA]) and the other passing at the most anterior edge of the clavicle (clavicle anteriorly [CLA]). The same procedure is followed for the posterior part of the joint, and the lines passing from the acromion posteriorly (ACP) and clavicle posteriorly (CLP) were drawn. Reproduced with permission from Barth et al.<ref name=":0" />\|alt=\|thumb\|858x858px\|center]]

@@ Line 91: / Line 91: @@
 This will improve visualization of the distal clavicle, and then resect 7 mm of the clavicle. It is important to preserve at least one of the acromioclavicular ligaments, if possible the superior that contributes for 56% (versus 25% for the posterior) of the resistance to posterior displacement of the clavicle. The end-point is to create a 1 cm space. The use of a 70° scope through the posterior or the anterolateral portal allows a better view of the superior part of the joint.
 ===Coplaning of Distal Clavicle===
 ====Indication====
 Coplaning of distal clavicle is indication when the acromioclavicular joint is not painful but associated to a prominent inferior osteophyte that make an impression on the musculotendinous junction of the supraspinatus. The latter osteophyte might be responsible for musculotendinous junction lesion.<ref>Lädermann A, Christophe FK, Denard PJ, Walch G. Supraspinatus rupture at the musclotendinous junction: an uncommonly recognized phenomenon. J Shoulder Elbow Surg 2012;21:72-6.</ref> It is important to limit the removal of inferior clavicle osteophytes, to avoid partial resection of the distal clavicle that could destabilize the joint and generate more pain.<ref>Bouchard A, Garret J, Favard L, Charles H, Ollat D. Failed subacromial decompression. Risk factors. Orthop Traumatol Surg Res. 2014 Dec;100(8 Suppl):S365-9.</ref> <br>
@@ Line 102: / Line 99: @@
 If an acromioplasty is indicated, begin by acromioplasty first. All soft tissue from the undersurface of the distal clavicle must be cleaned while viewing through a posterior or a lateral portal. Coplaning of the distal clavicle is achieved by alternately viewing through a posterior portal while using a burr through a lateral portal, then viewing through a lateral portal while using a burr through an anterolateral or an anterior portal.
 ===Postoperative Care===
 Isolated distal clavicle excision or coplaning do not require any type of postoperative immobilization. Range of motion is regained actively the day after the surgery. Day life activities then begin according to the pain. Light sports such as brake stroke is authorized after two to four weeks. Strengthening is not recommended.
 ==Acromioclavicular Joint Dislocation==
 ===Prevalence===
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
 ===Mechanism===
 Two common mechanisms account for acromioclavicular joint injury. Direct injuries occur during falls or blow onto acromioclavicular joint with the arm in the adducted position. Indirect injury occurs as the result of a fall on an outstretched hand driving the humeral head into the acromion.
 ===Physical Examination===
 Swelling, deformity and tenderness locally at the acromioclavicular joint are observed.
@@ Line 134: / Line 127: @@
 Reducibility of the dislocation should be tested if not too painful. These are the most reliable symptoms/signs. The cross body adduction stress is performed with the arm elevated to 90 degrees and then adducted across the chest. This produce pain specifically at the acromioclavicular joint due to compression across the joint and may reveal posterior intricateness of the clavicle in the trapezius (Video 5).
 [[File:1562648331066-lg.mp4|alt=|thumb|490x490px|center|Video 5.]]
 ==Classification==
@@ Line 172: / Line 162: @@
 ==Scores==
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
 ==Treatment option==
-The main goals of treatment, whether surgical or non-surgical, are to achieve a pain-free shoulder with full range of motion, normal strength, and no limitations in activities. The demands on the shoulder will differ from patient to patient, and these demands should be considered during the initial evaluation.
+===Clinical Practice Guideline===
+The goal of this section is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible. The main goals of treatment, whether surgical or non-surgical, are to achieve a pain-free shoulder with full range of motion, normal strength, and no limitations in activities. The demands on the shoulder will differ from patient to patient, and these demands should be considered during the initial evaluation.
 ===Conservative Treatment (Nonoperative Treatment)===

@@ Line 222: / Line 222: @@
 <br />
 ==Complications==
-Hardware migration is not anymore a complication as most surgeons abandon their use. Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommonly (Figures 12, 13).
+Hardware migration is not anymore a complication as most surgeons abandon their use. Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommonly (Figures 12,13).
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@@ Line 233: / Line 233: @@
 [[File:Capture d’écran 2021-02-14 à 08.50.57.png|thumb|Figure 14. Complication of primary and revision coracoclavicular reconstructions in the same patient. A) Left Acromioclavicular Joint Dislocation. B) Postoperative coracoclavicular and acromioclavicular joint reconstruction demonstrating an anatomic reduction. C) 6 months follow-up showing a loss of reduction. Observe the enlargement of bony tunnels in clavicle. D) Postoperative left X-ray after revision surgery by a modified Mazzocca technique with coracoclavicular cerclage passing under the coracoid process and through the clavicular holes and gracilis allograft passing under the coracoid and above the clavicle. E) Fatigue clavicular fracture medial to initial reconstructions.]]
-Coracoclavicular calcification are frequent but should not be considered as a complication as they do not influence clinical results. In fact, the calcification maintained reduction and the stability of the reconstruction seems to be enhanced. Similarly, acromioclavicular arthritis is frequently found on both operated and nonoperated sides and do not compromise clinical outcome.<ref name=":2" /><ref>Hessmann M, Gotzen L, Gehling H. Acromioclavicular reconstruction augmented with polydioxanonsulphate bands. Surgical technique and results. Am J Sports Med 1995;23:552-6.</ref><br />
+Coracoclavicular calcification is frequent but should not be considered as a complication as they do not influence clinical results. In fact, the calcification maintained reduction and the stability of the reconstruction seems to be enhanced. Similarly, acromioclavicular arthritis is frequently found on both operated and nonoperated sides and do not compromise clinical outcome.<ref name=":2" /><ref>Hessmann M, Gotzen L, Gehling H. Acromioclavicular reconstruction augmented with polydioxanonsulphate bands. Surgical technique and results. Am J Sports Med 1995;23:552-6.</ref><br />
 ==References==
 <references />

@@ Line 222: / Line 222: @@
 <br />
 ==Complications==
-Hardware migration is not anymore a complication as most surgeons abandon their use. Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommonly (Figures).
+Hardware migration is not anymore a complication as most surgeons abandon their use. Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommonly (Figures 12, 13).
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-![[File:1562651945957-lg.jpg|thumb]]
+![[File:1562651945957-lg.jpg|thumb]]Figure 12
 ![[File:1562651947800-lg.jpg|thumb]]
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-Osteolysis of the distal clavicle can be observed particularly when the graft or the non absorbable materials goes around the clavicle, creating a complete discontinuity between the medial and lateral clavicle (Figure).
+Osteolysis of the distal clavicle can be observed particularly when the graft or the non absorbable materials goes around the clavicle, creating a complete discontinuity between the medial and lateral clavicle (Figure 14).
-[[File:1562651947933-lg.jpg|none|thumb|800x800px]]
+[[File:1562651947933-lg.jpg|none|thumb|800x800px|Figure 13.]]
-[[File:Capture d’écran 2021-02-14 à 08.50.57.png|thumb|Complication of primary and revision coracoclavicular reconstructions in the same patient. A) Left Acromioclavicular Joint Dislocation. B) Postoperative coracoclavicular and acromioclavicular joint reconstruction demonstrating an anatomic reduction. C) 6 months follow-up showing a loss of reduction. Observe the enlargement of bony tunnels in clavicle. D) Postoperative left X-ray after revision surgery by a modified Mazzocca technique with coracoclavicular cerclage passing under the coracoid process and through the clavicular holes and gracilis allograft passing under the coracoid and above the clavicle. E) Fatigue clavicular fracture medial to initial reconstructions.]]
+[[File:Capture d’écran 2021-02-14 à 08.50.57.png|thumb|Figure 14. Complication of primary and revision coracoclavicular reconstructions in the same patient. A) Left Acromioclavicular Joint Dislocation. B) Postoperative coracoclavicular and acromioclavicular joint reconstruction demonstrating an anatomic reduction. C) 6 months follow-up showing a loss of reduction. Observe the enlargement of bony tunnels in clavicle. D) Postoperative left X-ray after revision surgery by a modified Mazzocca technique with coracoclavicular cerclage passing under the coracoid process and through the clavicular holes and gracilis allograft passing under the coracoid and above the clavicle. E) Fatigue clavicular fracture medial to initial reconstructions.]]
 Coracoclavicular calcification are frequent but should not be considered as a complication as they do not influence clinical results. In fact, the calcification maintained reduction and the stability of the reconstruction seems to be enhanced. Similarly, acromioclavicular arthritis is frequently found on both operated and nonoperated sides and do not compromise clinical outcome.<ref name=":2" /><ref>Hessmann M, Gotzen L, Gehling H. Acromioclavicular reconstruction augmented with polydioxanonsulphate bands. Surgical technique and results. Am J Sports Med 1995;23:552-6.</ref><br />

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 ======Indications======
-Proper indications are irreducible dislocations or dislocations with severe displacement for patients who complains of persistent pain, muscle fatigue, popping, loss of strength, or scapular dyskinesis after a reasonable period of appropriate physiotherapy, in a supple shoulder. The use of a free tendon graft placed in an anatomic position reproduce the conoid and trapezoid ligaments and perform as the intact coracoclavicular ligament complex.<ref name=":4" /><ref>Boutsiadis A, Baverel L, Lenoir H, Delsol P, Barth J. Arthroscopic-assisted Acromioclavicular and Coracoclavicular Ligaments Reconstruction for Chronic Acromioclavicular Dislocations: Surgical Technique. Tech Hand Up Extrem Surg. 2016 Dec;20(4):172-178.</ref><br />
+Proper indications are irreducible dislocations or dislocations with severe displacement for patients who complain of persistent pain, muscle fatigue, popping, loss of strength, or scapular dyskinesis after a reasonable period of appropriate physiotherapy, in a supple shoulder. The use of a free tendon graft placed in an anatomic position reproduce the conoid and trapezoid ligaments and perform as the intact coracoclavicular ligament complex.<ref name=":4" /><ref>Boutsiadis A, Baverel L, Lenoir H, Delsol P, Barth J. Arthroscopic-assisted Acromioclavicular and Coracoclavicular Ligaments Reconstruction for Chronic Acromioclavicular Dislocations: Surgical Technique. Tech Hand Up Extrem Surg. 2016 Dec;20(4):172-178.</ref><br />
 ==Postoperative Rehabilitation==
-Immobilization is recommended during six weeks, time needed for the reconstruction to develop biologic stability. Immediate glenohumeral mobility exercises such as internal/external rotation elbow at the side and flexion/extension of the elbow with the arm supported or in the supine position are recommended to avoid potential secondary frozen shoulder. After six weeks, progressive forward elevation is allowed and exercises against resistance are added. Emphasis should be placed on strengthening the scapular stabilizers. Consequently, sports such as brace stroke, nordic walking, elliptic machine and rowing are permitted at six weeks. Overhead sports and heavy labor are not allowed before three to four months postoperative.
+Immobilization is recommended during six weeks, the time needed for the reconstruction to develop biologic stability. Immediate glenohumeral mobility exercises such as internal/external rotation elbow at the side and flexion/extension of the elbow with the arm supported or in the supine position are recommended to avoid potential secondary frozen shoulder. After six weeks, progressive forward elevation is allowed and exercises against resistance are added. Emphasis should be placed on strengthening the scapular stabilizers. Consequently, sports such as brace stroke, nordic walking, elliptic machine and rowing are permitted at six weeks. Overhead sports and heavy labor are not allowed before three to four months postoperative.
 <br />
 ==Complications==
-Hardware migration is not anymore a complication as most surgeons to abandon their use.  Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommon (Figures).
+Hardware migration is not anymore a complication as most surgeons abandon their use. Loss of reduction of the acromioclavicular joint is found in around 30% of the cases. The cause depends of the type of repair. The weight of the arm and scapula places tremendous static forces on the coracoclavicular reconstruction. The quality of the AC reduction comparing a reduced, subluxated (<50%) or dislocated (>50%) joint affected the clinical outcome scores (Constant, DASH) in a statistically significant manner (P < .005), with improved results with a better reduction. Persistent instability explains most of the chronic pain found after reconstruction.<ref name=":2" /><ref name=":3" /><ref>Mayr E, Braun W, Eber W, Ruter A. [Treatment of acromioclavicular joint separations. Central Kirschner- wire and PDS-augmentation]. Der Unfallchirurg 1999;102:278-86.</ref> Migration of the fixation device or erosion through the clavicle or the coracoid process from non absorbable materials used to augment the repair not uncommonly (Figures).
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