Distal Clavicle Fracture and AC Joint Reconstruction Inservice

Distal Clavicle Fracture and AC Joint Reconstruction In-service for Wake. Med North Healthplex OP Rehab Thomas Reid Medlin, SPT University of North Carolina at Chapel Hill

Objectives Anatomical and biomechanical review of shoulder complex Distal clavicle fractures and AC joint reconstructions Dr. Wood’s Sx technique with supporting research Q and A with Dr. Wood

Anatomy and Biomechanics Shoulder Complex Articulations: Sternoclavicular (SC) joint Acromioclavicular (AC) joint Glenohumeral (GH) joint Scapulothoracic (ST) joint

• Frontal Plane – Elevation/depression 45/15° • • Clavicle (convex) Manubrium (concave) • Transverse Plane – Protraction/retraction 15/15° • • Clavicle (concave) Manubrium (convex) • Sagittal Plane – Posterior rotation 30 -45° Shoulder Complex SC Joint

Shoulder Complex AC joint Ligaments Coracoclavicular (CC ligaments) Trapezoid Resists posterior/superior movement of clavicle Conoid Resists superior movement of clavicle Acromioclavicular Prmarily checks horizontal movement Capsule

Shoulder Complex Movement AC Joint Flexion / Extension (anterior / posterior tipping) Tipping of inferior angle Internal / External rotation Medial border winging Upward / Downward rotation (spin)

Shoulder Complex SC/AC Joint - muscles Pectoralis major Anterior deltoid* Upper trapezius* Sternocleidomastoid Subclavius

Distal clavicle Fxs/AC joint dislocations Type I-II: typically non-operative Type III: Debated 1, 4 Type IV-V-VI: typically operative Williams GR, Nguyen VD, Rockwood CR. Classification and radiographic analysis of acromioclavicular dislocations. Appl Radiol 1989; Feb: 29– 34.

Previous Research According to a recently published study by Rieser, et. al 1: Distal-third clavicle Fx account for 21% to 28% of all clavicle Fx Approx. 25% of distal clavicle Fx are unstable, leading to longer times to union and higher nonunion rates No agreement on standard of operative care, so dilemma for orthopaedic surgeons: Importance of CC ligaments in controlling superior migration forces (UT, SCM) Stable restoration of distal clavicle important for decr. nonunion rate

Previous Research Popular types of treatment can include (and are not 1, 2, 3 limited to) : CC screws Tension bands Kirschner wires Hook plates (under acromion) Nonlocked plates Locked plates

Possible Complications Infection (obviously) Fx through a drill hole Wire migration to other parts of the body Screw loosening/failure Removal of plate/screw before failure Loss of “purchase” of internal fixation Soft tissue (graft) failure “There is nowhere else in the body where the weight of an entire extremity is supported through so little fixation. 2” 1, 2

Observed Approach: Arthrex Distal Clavicle Plate and Dog Bone AC joint Reconstruction Dr. Paul Brady, MD recently presented current 3 research at an Arthrex Faculty Forum (2013) Arthrex procedure provides strong construct, minimizes potential complication, maximizes clinical/radiographic outcomes, and provides an arthroscopic technique

Procedure Background on pt: • The patient (B. F. ) had a complicated chronic Fx through distal clavicle (January) • B. F. ’s proximal clavicle had migrated superior/posteriorly and needed stable fixation for healing Distal clavicle plate with Dog Bone (see PDF) http: //www. arthrex. com/resources/animation/E 4 w. S myp. Rn. Ea. Caw. E 46 S 4 naw/ac-repair-using-dog-bonebutton-technology

Supporting Evidence • 8 mm drill removes ~ 850 mm bone 3 • Tightrope (4 mm drill) removes 3 ~ 380 mm bone • Fiber. Tape w/ Dog Bone (3 mm drill) only removes ~ 210 3 mm bone • Dog Bone not only removes less bone, but significantly reduces likelihood of failure via Fx (better outcomes if synthetic breaks vs. bone) *Burkhart Research Association of Shoulder Specialists (BRASS) study

Supporting Evidence BRASS group found that 2 Fiber. Tape construct w/ Dog 3 Bone button significantly increased load to failure

Q & A with Dr. Wood R: What did you do differently from the [attached] Arthrex procedure? W: I added PRP to the coracoclavicular interval to enhance healing- this was a chronic injury (from January) so I wanted to do everything possible to encourage healing. R: Can this particular procedure be done using an autograft or allograft, or can you only use the Fiber. Wire with the Arthrex equipment? W: Yes- there are procedures which use a tendon graft to reconstruct the CC ligaments, that is primarily done for grade 5 AC separations (not distal clavicle Fxs). In this case, the fracture needs to heal and the fiberwire fixation is there mainly to add stability and to hold the proximal fragment in the correct position for Fx healing (due to the relative poor fixation in the small distal fragment). R: What makes someone a good candidate for this type of Sx, besides having an acute injury? W: Grade 5 AC separations or distal clavicle Fx have better outcomes when fixed. Some pts elect not to have Sx and re-present later due to persistent symptoms. The procedure can be done chronically with good outcomes, but more predictable healing is expected when they are fixed acutely. In the chronic AC cases, I typically do a distal clavicle resection and grind up that bone and put it in the CC interval w PRP to promote biological healing. Without biological healing, the fixation devices will eventually fail.

Q & A with Dr. Wood R: What would be your rehab protocol for someone with a typical AC reconstruction? W: -NWB 6 wks Early active elbow/wrist Pendulums, PROM below shoulder -After 6 weeks, AROM, terminal motion -Strengthening at 3 months Sport specific training -Full activity at 5 -6 months R: Anything else you would want PTs to know about/ be aware of with this type of surgery? W: GO SLOW. The forces across the CC interval are pulling the fixation apart, even with prom. Once healing occurs (min 6 weeks) the fixation devices are little stress.

References 1. Rieser GR, Edwards K, Gould GC, Markert RJ, Goswami T, Rubino LJ. Distal-third clavicle fracture fixation: a biomechanical evaluation of fixation. J Shoulder Elbow Surg. 2013 Jun; 22(6): 848 -55. Pub. Med PMID: 23177169. 2. Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6 th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005. 3. Arthrex. AC Joint Reconstruction and Clavicle Fracture Update. Arthrex. http: //www. arthrex. com/resources/presentation/c. MNENPP 3 k-h. Mg. E 81 l 9 o. YA/ac-joint-reconstruction-and-clavicle-fractureupdate. Published February 27, 2013. Accessed July 27, 2013. 4. Tauber M. Management of acute acromioclavicular joint dislocations: current concepts. Arch Orthop Trauma Surg. 2013 Jul; 133(7): 985 -95. Pub. Med PMID: 23632779.