AC plate on the treatment of fractures and dislocation of acromio-clavicular

joint – an Overview

J. Schmidt, A. Witt

Department for Accident-, Hand – and Reconstructive Surgery with Emergency

Department

HELIOS Klinikum Berlin-Buch

Correspondending Author

Dr. med. Jörg Schmidt

Klinik für Unfall-, Hand- und Wiederherstellungschirurgie

mit Rettungsstelle

HELIOS Klinikum Berlin-Buch

Schwanebecker Chaussee 50

13125 Berlin

Tel.: 0049 30 9401 52400

e-mail: joerg.schmidt@helios-kliniken.de
Summary

A number of treatment methods have been developed for the treatment of

ligamentous and osseous injuries of the lateral clavicle. Recently the hook plate in its

varied designs and lengths has proved to be a very appropriate implant for the

treatment of different types of injuries. This implant is both appropriate as a small-

scale procedure for the reconstruction of the acromioclavicular dislocation and for

temporary osteosynthesis of lateral fractures. In this paper the different applications

are depicted and the state-of-the-art development is presented by means of broad

range of relevant literature.

Introduction

Even Hippocrates (460 to 377 BC) was familiar with the acromioclavicular joint injury

His recommended therapy was a tight bandage to press the clavicle down and to lift

up the arm or shoulder. Until the beginning of the last century the therapy of this

injury was tight immobilisation with a corresponding loss of comfort for the patient

and subsequent restricted mobility in the shoulder joint. As early as 1861

Cooper performed the first wire cerclage of an acromioclavicular joint injury. In 1941

Bosworth began to use coracoclavicular fixation in the therapy of acromioclavicular

joint injuries. A classification of the injury was first performed by Tossy et al. in 1963

and was specified by Rockwood. In the meantime more than 150 different operative

techniques have been described. The concept of surgical treatment of the

acromioclavicular joint injury with a hook plate was introduced by Balser in 1976. In

the continuation of this concept, several plate forms were developed, which serve to

temporarily fix the clavicle against the acromion until the ruptured ligament structures

have healed. As a result of the original large size of the plate (Balser plate),

osteolyses occurred on the subacromial surface. At the beginning of the 1990s a

narrower hook plate for treatment of the acromioclavicular joint injury and lateral

clavicular fractures. In addition to the short plate body and thus the small approach

as well as the extra-articular placement of the hooks, the shallow hook depth and the

bent hooks, which allow an anatomical adaptation to the subacromial surface and

should thus prevent a subacromial impingement, are considered to be advantages.

Metal removal in cases of ligamentous injuries should occur after 8 to 12 weeks.

Lateral clavicular fractures represent a frequent trauma sequela in cases involvingt a

fall on the extended arm or a direct impact of the shoulder. Their incidence is

approximately 6 to 12% of all fractures in adulthood. They require differentiated

consideration with regard to their therapy; the reason for this is the multitude of

fracture forms with differing capsular ligament involvement. The consequent

malunion, and in some cases chronic instability in the AC joint, can result in arthrosis

of the latter and/or in an impingement syndrome due to a change in the position of

the glenoids In the relevant literature there are a number of different methods with

regard to the implant used and the operative techniques. Among them are

intramedullary and extramedullary implants, such as Kirschner wire tension banding

(both trans-articular and extra-articular), the reconstruction plate, the T plate, the one

third tubular plate, the Basler plate, and Kirschner wire fixation and AO screw fixation,

but more recently primarily hook plate osteosynthesis.

The fracture classification of the lateral clavicular fracture according to Jäger and

Breitner manages the multitude of fracture variants and the concomitant ligament

injuries well; it divides them into five fracture types.

Operative methods

The operation for both injuries occurs under standardised conditions. After induction

of the narcosis, the patient is positioned in a half-sitting position (beach chair

position). The approach to the acromioclavicular joint (ACJ) is performed through a

sagittal skin incision (a so-called sabre-cut approach) which is 5 to 6 cm long on

average and approximately 2 cm medial to the ACJ. After transection of the muscle

fascias of the deltoid muscle and the trapezius muscle, the preparation of the ACJ

and the lateral clavicle is performed. After careful removal of the soft tissue/parts

from the subacromial surface behind the ACJ, the insertion of the hook plate’s hooks

under the acromion and the repositioning of the joint is performed with the positioning

of the plate body on the lateral clavicle end. After controlling the position with the aid

of the image converter, the plate is attached to the clavicle fragment closest to the

body with three cortical screws.

Subsequent to brief immobilisation of the shoulder joint postoperatively for pain

treatment in a shoulder immobilisation bandage, pain-adapted exercise with limited

abduction up to 90° is begun during the inpatient hospitalisation and is continued in

outpatient treatment. Removal of the implant with intraoperative examination of the

overall mobility of the shoulder joint is scheduled after 12 to 16 weeks

depending on the state of ossification.

Discussion

In the last few years the surgical treatment of a 3rd degree ligamentous

acromioclavicular joint injury has been increasingly discussed. The good to very good

results subsequent to conservative therapy have been pointed out in the relevant

English literature, in particular. In a meta-analysis of the English literature Phillips et

al. were able to demonstrate the equivalence of the surgical and conservative

therapy in Rockwood III injuries. However, the prospective randomised studies from

the 1980s on which the meta-analysis was based did not undertake any comparison

of conservative therapy and surgical treatment with a hook plate because the authors
chose other operative procedures (e.g. Bosworth screw, Phemister operation).

Another meta-analysis on the therapy of acromioclavicular joint injuries under the

criteria of evidence based medicine, which was published by Bäthis et al. in 2000,

also referred to the three studies mentioned above. We feel that surgical treatment

with the hook plate was underrepresented in the additionally referenced, non-

randomised studies. Similar to Phillips, Bäthis comes to the conclusion

that the operative treatment of 3rd degree acromioclavicular joint injury does not

provide any advantages compared to conservative therapy. A survey on the daily

practice of surgical treatment of acromioclavicular joint injuries, which was also

conducted by Bäthis et al. in German accident surgery clinics comes to a contrary

conclusion. In the evaluation of this anonymous questionnaire, they report that 84%

of the clinics treated Tossy III injuries primarily surgically. Unanimity also exists

in the predominantly conservative treatment of Tossy I and II injuries, as in the nearly

exceptionless operation of Rockwood IV to VI injuries. Overall, 22% of the clinics

would primarily treat a Tossy III injury with a hook plate. There are, however, only

very few studies in the literature which consider the results of acromioclavicular

joint injuries that have been treated with hook plates. In a comparative

study between hook plate, transfixation and PDS cerclage, Göhring et al. found a

definite movement restriction in 50% of the cases treated with hook plates. However,

this study was conducted using an implant that is no longer customary and

considered only a small number of cases.

In an possible conservative treatment of the acromioclavicular joint injury, the aspect

of remaining subluxation should have to be pointed out explicitly.

With regard to the sonographic examination of ligamentous injuries, Folwaczany et

al. assess sonography without and with stress as an appropriate and adequate

instrument for the assessment of postoperative stability of the ACJ and of

subacromial structures.

The objective of surgical therapy of the lateral clavicular fracture in cases of

corresponding indication and under consideration of the fracture type classification

according to Jäger and Breitner is the ossification of the fracture line in a nearly

normal axis orientation as well as consolidation of the ligaments involved, which are

nearly always concomitantly injured.

A functional physiotherapeutic aftertreatment is essential for a satisfactory outcome.

The discussion of the different osteosynthesis procedures is still unabatedly and

actively continuing.

There is at least far-reaching unity with regard to the surgical indication in fractures of

Type I with extensive fragment dislocation, in Type IIa and displaced Type IIb

fractures due to the high pseudarthrosis rate or the formation of early AC joint

arthrosis in conservative treatment.

The advantages of hook plate osteosynthesis are in the normal axis position of the

fracture and the temporary transfixation of the AC joint in cases involving concomitant

ligamentous injury.

As a result of the high primary stability of the implant, the bridging possibility in larger

debris zones and the fixation possibility of even small bone fragments, early exercise

of the shoulder joint can be allowed.

In cases with normal course, functional aftertreatment is conducted and abduction up

to 90° is allowed.

Based on our existing experience, the results support the use of the hook plate in

cases of lateral clavicular fracture if the operation indication was correctly diagnosed

according to the Jäger/Breitner classification of instable Type I, Type IIa or displaced

Type IIb fractures.

Requirements for the implant

In principle the implants are distinguished in the shape of their hooks. A philosophy

with stable but applied hooks at a 90° position requires 3 different hook lengths.

Despite this, there is a risk that the subacromial surface will be arroded by punctiform

stresses if one does not bend the hooks in advance. This together with the various

required shaft lengths makes a extensive stock-keeping necessary.

Alternatively, one can manage with one hook shape for right and left if the hook is

adapted to the shape of the subacromial surface with an angle of 15°. But even in

this model different shaft lengths are required to treat ligamentous injuries and

bridging osteosyntheses in cases of lateral clavicular fractures. With increasing age

of the population to be treated, options for angularly stable screw-plate connection

are necessary.

Characteristic for both models is that the hooks lie behind the AC joint subacromially

and thus do not disturb either the AC joint or the shoulder joint in its functioning.

Hook plates which have a transosseus orientation are no longer state-of-the-art.

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1194
Fig 1a and 1b: Position oft hook plate behind AC-joint
Fig 2: Anatomical position of hook from ACRO-Plate® (aap)
Fig 3: Next development: ACRO-Plate fracture®