Skip to main content

Advertisement

SpringerLink
Log in

Aktuelle operative Therapiestrategien bei chronischer Akromioklavikularsgelenkinstabilität

Current operative strategies for surgical treatment of chronic acromioclavicular joint instability

  • Übersicht
  • Published:
Obere Extremität Aims and scope Submit manuscript

Zusammenfassung

Chronische Instabilitäten des Akromioklavikulargelenks (AC-Gelenk) sind das Resultat übersehener oder insuffizient behandelter akuter Luxationen. Im Unterschied zu den akuten Verletzungen ist das biologische Heilungspotential aufgrund des posttraumatischen Intervalls kompromittiert und somit die Behandlung erschwert. Die Diagnostik chronischer Instabilitäten sollte daher die differenzierte Erfassung unterschiedlicher Instabilitätskomponenten (statisch vs. dynamisch, vertikal vs. horizontal) anhand einer eigenständigen Klassifikation (Hedtmann und Heers) beinhalten, um in eine zielgerichtete operative Therapie zu münden. Eine eigene Technik zur operativen Stabilisation wurde biomechanisch evaluiert. Die Technik beinhaltete einen modifizierten Transfer des coracoacromialen Bandes (CA-Band) in Kombination mit einer minimal invasiven korakoklavikulären Augmentation (MINAR). Die Technik ist in der Lage, das anteriore und superiore Translationsverhalten des intakten AC-Gelenkes wiederherzustellen. Allerdings bleibt die posteriore Translation gegenüber dem intakten Gelenk erhöht (127%: 3,8 mm intakt vs. 4,6 mm rekonstruiert; p<0,05). Die biomechanischen Ergebnisse der eigenen Studie decken sich mit den Ergebnissen anderer Autoren, die die posteriore Instabilität als kritische Variable bei der Rekonstruktion chronischer AC-Gelenksverletzungen ermittelten. Daher scheint eine additive Augmentation der AC-Bänder (postero-superior), der primären dorsalen Stabilisatoren des AC-Gelenkes, vorteilhaft. Die vorgestellte Technik kann als Alternative zu invasiven Rekonstruktionstechniken auf der Basis von autologen Sehnentransplantaten (M. semitendinosus, M. gracilis) dienen.

Abstract

Chronic instability of the acromioclavicular joint (AC joint) results if the initial acromioclavicular joint luxation has been missed or if the rehabilitative or surgical treatment was not successful. Late repairs after a traumatic luxation are difficult to deal with because the biological healing response for reconstitution of the ligaments seems to be compromised. A meticulous diagnostic examination should be performed paying special attention to the character and direction of instability (static versus dynamic and vertical versus horizontal). For this purpose a specified classification system should be used (Hedtmann and Heers). A new surgical technique for stabilization of chronic AC joint instability has been established and biomechanically evaluated. The technique includes an augmented modified coracoacromial ligament (only the medial half of the ligament) transfer supplemented by coracoclavicular polyester augmentation. In an in vitro model the technique was shown to restore anterior and superior translation of the intact AC joint. An increase of translation compared to the level of the intact joint was statistically significant only for the posterior direction (127%, 3.8 mm intact versus 4.6 mm following reconstruction; p<0.05). Therefore, for further improvement of the technique some form of acromioclavicular ligament reconstruction (posterosuperior) could be profitable. In conclusion the presented surgical technique (augmented CA ligament transfer) reveals promising biomechanical results in an in vitro model and may serve as an alternative to current coracoclavicular ligament reconstruction techniques using autologous tendon grafts.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7

Literatur

  1. Mazzocca AD, Arciero RA, Bicos J (2007) Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 35:316–329

    Article  PubMed  Google Scholar 

  2. Tossy JD, Mead NC, Sigmond HM (1963) Acromioclavicular separations: useful and practical classification for treatment. Clin Orthop Relat Res 28:111–119

    CAS  PubMed  Google Scholar 

  3. Rockwood C (1984) Injuries in the acromioclavicular joint: subluxations and dislocations about the shoulder. In: Rockwood CA Jr, Green D (eds) Fracture in adults. JB Lippincott, Philadelphia, PA, pp 860–910

  4. Weinstein DM, McCann PD, McIlveen SJ et al (1995) Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med 23:324–331

    Article  CAS  PubMed  Google Scholar 

  5. Hedtmann A, Fett H (2009) Erkrankungen und Verletzungen des Akromio- und Sternoklavikulargelenkes. In: Habermeyer P (Hrsg) Schulterchirurgie, 4. Aufl.,Urban & Fischer, München. Im Druck

  6. Walton J, Mahajan S, Paxinos A et al (2004) Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg Am 86-A:807–812

    Article  PubMed  Google Scholar 

  7. Alexander OM (1949) Dislocation of the acromioclavicular joint. Radiography 15:260

    CAS  PubMed  Google Scholar 

  8. Mazzocca AD, Spang JT, Rodriguez RR et al (2008) Biomechanical and radiographic analysis of partial coracoclavicular ligament injuries. Am J Sports Med 36:1397–1402

    Article  PubMed  Google Scholar 

  9. Berg EE, Ciullo JV (1997) The SLAP lesion: A cause of failure after distal clavicle resection. Arthroscopy 13:85–89

    Article  CAS  PubMed  Google Scholar 

  10. Tischer T, Salzmann GM, El Azab H et al (2009) Incidence of associated injuries with acute acromioclavicular joint dislocations types III through V. Am J Sports Med 37:136–139

    Article  PubMed  Google Scholar 

  11. Hedtmann A, Fett H, Ludwig J (1998) Management of old neglected posttraumatic acromioclavicular joint instability and arthrosis. Orthopade 27:556–566

    Google Scholar 

  12. Klimkiewicz JJ, Williams GR, Sher JS et al (1999) The acromioclavicular capsule as a restraint to posterior translation of the clavicle: A biomechanical analysis. J Shoulder Elbow Surg 8:119–124

    Article  CAS  PubMed  Google Scholar 

  13. Ludewig PM, Behrens SA, Meyer SM et al (2004) Three-dimensional clavicular motion during arm elevation: Reliability and descriptive data. J Orthop Sports Phys Ther 34:140–149

    Article  PubMed  Google Scholar 

  14. Ludewig PM, Phadke V, Bramann JP et al (2009) Motion of the shoulder complex during multiplanar humeral elevation J Bone Joint Surg Am 91: 378–389

    Article  PubMed  PubMed Central  Google Scholar 

  15. Broos P, Stoffelen D, Van de SK et al (1997) Surgical management of complete Tossy III acromioclavicular joint dislocation with the Bosworth screw or the Wolter plate. A critical evaluation. Unfallchirurgie 23:153–159

    Article  CAS  PubMed  Google Scholar 

  16. Ryhanen J, Leminen A, Jamsa T et al (2006) A novel treatment of grade III acromioclavicular joint dislocations with a C-hook implant. Arch Orthop Trauma Surg 126:22–27

    Article  PubMed  Google Scholar 

  17. Smith ET (1963) Complete disruption of acromioclavicular joint: treatment by open reduction and repair and fixation with bosworth screw. Tex Med 59:976–979

    CAS  Google Scholar 

  18. Weaver JK, Dunn HK (1972) Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 54:1187–1194

    Article  CAS  PubMed  Google Scholar 

  19. Motamedi AR, Blevins FT, Willis MC et al (2000) Biomechanics of the coracoclavicular ligament complex and augmentations used in its repair and reconstruction. Am J Sports Med 28:380–384

    Article  CAS  PubMed  Google Scholar 

  20. Harris RI, Wallace AL, Harper GD et al (2000) Structural properties of the intact and the reconstructed coracoclavicular ligament complex. Am J Sports Med 28:103–108

    Article  CAS  PubMed  Google Scholar 

  21. Grutter PW, Petersen SA (2005) Anatomical acromioclavicular ligament reconstruction: A biomechanical comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 33:1723–1728

    Article  PubMed  Google Scholar 

  22. LaPrade RF, Hilger B (2005) Coracoclavicular ligament reconstruction using a semitendinosus graft for failed acromioclavicular separation surgery. Arthroscopy 21:1277

    Article  PubMed  Google Scholar 

  23. Lee SJ, Nicholas SJ, Akizuki KH et al (2003) Reconstruction of the coracoclavicular ligaments with tendon grafts: A comparative biomechanical study. Am J Sports Med 31:648–655

    Article  PubMed  Google Scholar 

  24. Mazzocca AD, Santangelo SA, Johnson ST et al (2006) A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 34:236–246

    Article  PubMed  Google Scholar 

  25. Tauber M, Eppel M, Resch H (2007) Acromioclavicular reconstruction using autogenous semitendinosus tendon graft: results of revision surgery in chronic cases. J Shoulder Elbow Surg 16:429–433

    Article  PubMed  Google Scholar 

  26. Erak S, Pelletier MH, Woods KR et al (2008) Acromioclavicular reconstructions with hamstring tendon grafts: A comparative biomechanical study. J Shoulder Elbow Surg 17:772–778

    Article  PubMed  Google Scholar 

  27. Guerra J, Mazzocca AD, Obopilwe MS (2008) Biomechanical testing of AC graft Rope repairs. Internet communication: whitepaper www.arthrex.com

    Google Scholar 

  28. Scheibel M, Ifesanya A, Pauly S et al (2008) Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability. Arch Orthop Trauma Surg 128:1327–1333

    Article  PubMed  Google Scholar 

  29. Hosseini H, Friedmann S, Troger M et al (2009) Arthroscopic reconstruction of chronic AC joint dislocations by transposition of the coracoacromial ligament augmented by the Tight Rope device: a technical note. Knee Surg Sports Traumatol Arthrosc 17:92–97

    Article  PubMed  Google Scholar 

  30. Lafosse L, Baier GP, Leuzinger J (2005) Arthroscopic treatment of acute and chronic acromioclavicular joint dislocation. Arthroscopy 21:1017

    Article  PubMed  Google Scholar 

  31. LaPrade RF, Wickum DJ, Griffith CJ et al (2008) Kinematic evaluation of the modified weaver-dunn acromioclavicular joint reconstruction. Am J Sports Med 36:2216–2221

    Article  PubMed  PubMed Central  Google Scholar 

  32. Wellmann M, Lodde I, Schanz S et al (2008) Biomechanical evaluation of an augmented coracoacromial ligament transfer for acromioclavicular joint instability. Arthroscopy 24:1395–1401

    Article  PubMed  Google Scholar 

  33. Wilson DR, Moses JM, Zilberfarb JL et al (2005) Mechanics of coracoacromial ligament transfer augmentation for acromioclavicular joint injuries. J Biomech38:615–619

    Google Scholar 

  34. Edelson JG, Luchs J (1995) Aspects of coracoacromial ligament anatomy of interest to the arthroscopic surgeon. Arthroscopy 11:715–719

    Article  CAS  PubMed  Google Scholar 

  35. Soslowsky LJ, An CH, Johnston SP et al (1994) Geometric and mechanical properties of the coracoacromial ligament and their relationship to rotator cuff disease. Clin Orthop Relat Res:10–17

    Google Scholar 

  36. Corteen DP, Teitge RA (2005) Stabilization of the clavicle after distal resection: A biomechanical study. Am J Sports Med 33:61–67

    Article  PubMed  Google Scholar 

  37. Tienen TG, Oyen JF, Eggen PJ (2003) A modified technique of reconstruction for complete acromioclavicular dislocation: A prospective study. Am J Sports Med 31:655–659

    Article  PubMed  Google Scholar 

  38. Costic RS, Labriola JE, Rodosky MW et al (2004) Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 32:1929–1936

    Article  PubMed  Google Scholar 

  39. Nicholas SJ, Lee SJ, Mullaney MJ et al (2007) Clinical outcomes of coracoclavicular ligament reconstructions using tendon grafts. Am J Sports Med 35:1912–1917

    Article  PubMed  Google Scholar 

  40. Tauber M, Gordon K, Koller H et al (2009) Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: A prospective comparative study. Am J Sports Med 37:181–190

    Article  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Klinik für Orthopädie, Medizinische Hochschule, Anna von Borries Str. 1-6, 30625, Hannover, Deutschland

    M. Wellmann, H. Waizy, M. Bohnsack & H. Windhagen

  2. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum, Münster, Deutschland

    T. Zantop

  3. Abteilung für Unfallchirurgie, Martin-Luther-Krankenhaus, Berlin, Deutschland

    W. Petersen

Authors
  1. M. Wellmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. T. Zantop
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. H. Waizy
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. M. Bohnsack
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. H. Windhagen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. W. Petersen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to M. Wellmann.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wellmann, M., Zantop, T., Waizy, H. et al. Aktuelle operative Therapiestrategien bei chronischer Akromioklavikularsgelenkinstabilität. Obere Extremität 4, 39–45 (2009). https://doi.org/10.1007/s11678-009-0017-9

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11678-009-0017-9

Schlüsselwörter

Keywords

Search

Navigation