AC Joint Injuries In Football

AC Joint Injuries In Football
Edward V. Craig MD, MPH
• Types of financial relationships
and the companies with whom I
have relationships are as
follows:
 Royalty, Biomet—Total Shoulder System
 Consultant- Biomet
 Royalty, Wolters Kluwer Publications
Epidemiology—NFL Surveillance
Data
• Shoulder-28% AC
• QB –highest
incidence
• Time lost 9.8 days,
QB 17 days
• 1.7% Surgical
• Surgery—56 days
lost
Lynch et al, AJSM, 2013
Epidemiology—NCAA
Surveillance Data
• 4% of all injuries
• 96.5% Grade I,II
• Time Lost I ,II---11
days
• Grade III–Time lost
31 days
• Surgical 2.4%
Dragoo et. al. AJSM, 2012
Anatomy
 AC ligaments
 CC ligaments
 Trapezoid insertion
broad
 Conoid Insertion More
Medial
Rios et al, AJSM 2007
Biomechanics
 Joint stability
 Horizontal
 Joint capsule
 AC ligaments
 Vertical
 Coraco-clavicular ligaments
• Conoid>Trapezoid
Fukuda et al, JBJS 1986
Classification of Acromioclavicular
Separations
Grade I: isolated sprain
Grade II: rupture of the AC
of the AC ligaments
ligaments, stretching of CC
ligaments
Classification of Acromioclavicular
Separations
Grade III: disruption of
both the AC and CC
ligaments
Classification of
Acromioclavicular Separations
Grade IV:
Hallmark Is Posterior Displacement----Axillary View
Classification of
Acromioclavicular Separations
Grade V: AC and CC ligament disruption
with >300% displacement
All Have Marked AP and S/I Displacement
Classification of
Acromioclavicular Separations
Grade VI: inferior/subcoracoid displacement
Coracoid
Clavicle
Image Modalities for AC Separations
Zanca View
Zanca, Am J Roentgenol Radium Ther Nucl Med, 1970
Level of Evidence: V
Image Modalities for AC Separation-Axillary
Some Associated Injuries
• Rotator Cuff Tear
• S.L.A.P. Lesions
• Advanced
Imaging As
Needed
“Treatment Recommendations”
Dilemma
In-Season Treatment of AC Separations
Non-operative
vs
Operative Treatment ?
Initial Treatment
ATHLETE WILL ASK:
Can I play?
Will I do any more damage?
Do I need surgery?
Can I have surgery at the end of the season?
Will the surgery be as successful later?
Initial Treatment
TEAM PHYSICIAN NEEDS TO BE ABLE TO
ANSWER:
Decision will be determined by:
1) Degree of Separation
2) Position of Player
3) Decision after informed consent
Based on best available literature


Systematic review of the literature
 Operative vs nonoperative management
 Early vs delayed surgical intervention
 Anantomic vs nonanatomic techniques
821 citations
 14 comparing non-op vs operative treatment
 4 comparing early vs delayed treatment
 2 comparing anatomic vs nonanatomic
 Lack of evidence to support treatment options
Level of evidence: III
Treatment Algorithm

Grade I or II AC Separations
 Non–operative treatment
• Reduction of acute inflammation
• Early range of motion and strengthening
Non OpTreatment – Grade I and II
 23 patients nonop treatment
 Average follow-up 10.2 years
 12/23 patients (52%) reported at least
occasional AC joint symptoms
 No patients felt the impairment required
surgery
Level of Evidence: IV
Treatment Operative – Type IV, V, VI
Rockwood et al: The Shoulder 1990
Level of Evidence: V
Most Controversy– Treatment
 Grade III AC Separations
 Argument For Non – Operative-Phillips et al., CORR 1998
 Meta analysis of 1,172 pts with
type III injuries
•
88% vs 87% satisfactory
outcomes in non-op vs op,
respectively
Grade III AC Separations in Elite
Athletes
NFL COMBINE EXPERIENCE:
NFL Team Physicians Society Scientific Meeting ’96
45 AC Separations: 9 Grade III




All treated non-operatively
7 of 8 players satisfied with outcome
No functional disabilities
50% had loss of bench press/military strength
Schlegel et al unpublished
What About The Thrower? ( QB)
 McFarland ’97 (Level of Evidence: V)
 Survey of physicians for 28 pro baseball teams
 Hypothetical case presentation
 Glick, et al, AJSM ‘77 (Level of Evidence: III)
 2 Competitive QBs unaffected by injury
No available literature with specific clinical evaluation of the
effects in a throwing athlete
GRADE III AC SEPARATIONS
IN NFL QUARTERBACKS
Schlegel et al,
ASES Closed Meeting Dallas, TX
October 12, 2007
Results – Demographics 17 Injuries In
QB
Dominant
9
Non-Dominant 8
Mechanism of Injury
Tackled on a:
Pass
8
Carry
6
Fumble
3
Results – Dominant Extremity
Initial Treatment
Non-operative (8/9)
Good Outcome (6)
*All Returned to Play as
Starter
Residual Problems (2)
AC Reconstruction
Post-injury QB rating unchanged (www.nfl.com)
Limited Literature--Consider
Initial Treatment
 Attempt non-operative management
 Minimum 5 weeks lost
If Failed
 Consider AC
reconstruction
Use of Injections for Acute AC Injuries
 Orchard, et. al, AJSM 2010
 1023 injuries over 10 year
window (1 – 5 year follow-up)
 231 AC injuries – 98% of players
would repeat the injection
 97% Helpful
Level of Evidence: IV
Mean Time Lost / Degree
 Non-Injection –Before
1992
 Injection Group—After
1992
 Grade I – 0.45 days
 Grade I – 0.19 days
 Grade II- 2.0 days
 Grade III – 15.5 days
 Grade II – 15.2 days
 Grade III - NA
Mean Time Lost Fewer Days—All Grades
Hawkins, et.al.--Presented At NFL Team Physicians Meetings
Role For Injection ?
 Consider use of an acute
corticosteroid injection as an adjunct
to non-operative treatment regimen
“Risks for Delaying Surgery”
Early vs. Delayed Reconstruction
Is it reasonable to attempt a non-operative treatment
program first?
Timing of Surgery
Grade III
Early
Weinstein et al AJSM 1995
(Level of Evidence: IV)
 Significantly better results when
repaired early as compared to
those repaired after 3 months
Vs.
Delayed
Lazcano et al JBJS 1961 (Level
of Evidence: IV)
Weaver Dunn et al JBJS
1972 (Level of Evidence: IV)
 No difference in outcomes when
repaired early compared to those
repaired when chronic
Does Not Seem To Matter
“Surgical Options”
Two Basic Types• Non Anatomic—
C-C Only ; Many
Types—Higher
Failure?
Anatomic—C/C
and AC for S/I and
A/P stability-
Synthetic vs. Tendon Graft
Acromioclavicular Joint Mechanics
Debski et al, JBJS 2001
• AC Joint transection increased translations in
AP direction
• In in situ forces within CC
ligaments increased in
response to anterior and
posterior loads
If Forces Greater in C-C—Will A-C Repair be Protective?
Clinical Outcomes- Non-anatomic
 Retrospective review active duty patients
 CC ligament reconstruction





80% patients lost reduction avg. 7 weeks (range, 3-12)
4 patients (40 %) required revision surgery
5 excellent/good results
1 fair result
4 poor results
Level of Evidence: IV
AJSM, 2006
 Cadaver Biomechanical—Anatomic vs C-C Alone
 Findings: Anatomic reconstruction equal to intact
state in ALL planes
 Conclusions: At time zero, anatomic reconstruction
may be stronger
Level of evidence: III
What Does Literature Say?
 Literature search…
 Numerous BIOMECHANICAL studies
 Limited data on Clinical OUTCOMES For
For Anatomic Repair
Graft Can be Looped Around Clavicle or
Passed Through Drill Holes
Consider No Drill Holes—Contact Athlete
Passing graft—across AC
Both Reconstructed--Semitendinosis
Possible Treatment Algorithm
 Grade III AC Separations
 Non-thrower
•
Non-operative treatment
• Early range of motion /
strengthening as tolerated
• Protective AC pad
• If Inflammation—consider injection
Thrower—Try Non op—if cannot get back, then repair
Summary—AC Football
• Little Evidence
• Survey and
Expert Opinion
• Rare Need Mid
Season Surgery
• Maybe Thrower if
Fail Non Op
Dr Ted Schlagel, Richard Hawkins
Denver Broncos—Video ,Images
Role for Injections
High School
College
Professional
NO
?
YES
Timing of Surgery
Early vs. Late
Grade I, II, III:
Attempt Non Operative
Treatment
YES
Any risk for delayed
Surgery
NO
Is there a 3A and 3B?
Stable vs. Unstable
AP shoulder
Cross-body adduction
Treatment of Grade III AC Separations
in a Thrower
In Season: Attempt Non
Operative
YES
End of Season: AC
Reconstruction if Problems
YES
Surgical Techniques – Coracoclavicular
Reconstruction
Graft Looped Around Clavicle