acromion - os-acromiale fractures and insufficiency

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Os acromiale, Acromial # and acromial insufficiency James Wilson ST8 Trainee T&O Upper Limb Fellow Wrightington Hospital

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  1. 1. Os acromiale, Acromial # and acromial insufficiency James Wilson ST8 Trainee T&O Upper Limb Fellow Wrightington Hospital
  2. 2. Scapula ossified from 9 or more centres Body - 8 weeks Middle Coracoid 15-18 months Base coracoid Base acromion Inferior angle Tip of acromion Vertebral border Embryology
  3. 3. 1 Flat 2 Curved 3 Hooked 4 Convex Morphology
  4. 4. PA = Pre-acromion MSA = Meso-acromion MTA = Meta-acromion Meso and Meta-acromion junction most common Nomenclature Os Acromiale
  5. 5. Incidence 1.4-30% 33-62% bilateral Types - 1: between meso and meta acromion (typical) 2: between pre and meso acromion 3: between pre and meso as well as meta acromion 4: between all three ossification centres Os Acromiale
  6. 6. Presentation Signs and symptoms of impingement Night Pain Tenderness Indirect - Cuff tear Diagnosis Best seen on axillary view Os Acromiale
  7. 7. Nothing (if asymptomatic) Non operative Physiotherapy Injections Subacromial space intra-lesional Surgical Excision Acromioplasty Fixation Treatment
  8. 8. Arthroscopic vs Open excision Theoretically arthroscopic preserves the deltoid attachment No comparative studies Pagnani - Arthroscopic excision 11 Mesoacromiales (18-25yrs) return to sport and full strength by 14 weeks Wright - Arthroscopic excision 13 Mesoacromiales (Mean age 36) - full strength 26 weeks 85% satisfaction (11/13) Boehm et al and Warner et al performed open excision with deltoid reattachment. (4 pre and 5 meso) Boehm - similar outcomes to acomioplasty and fixation. Warner - good outcomes with pre-os excision, poor outcomes for meso-os excisions Excision
  9. 9. Abbound - mixture of open (5) and arthroscopic (6) acromioplasty of patients with a stable mess-os. Retrospective comparison with mixture of K-wire (5) and cannulated screw fixations (3) - no significant difference. Boehm - Open acromioplasty retrospectively compared with k- wire fixation - equivalent satisfaction and Constant scores Acromioplasty
  10. 10. Review found Cannulated screw fixation 96% (23/24) K-wire 63% (31/49) Union correlated with outcome and satisfaction scores Removal of metalware Cann screw 38% K-wire 88% Complications Deep infection - Open excision (1), Open acromioplasty (2), ORIF (1) all had I&D Superficial infection - ORIF (2) settled with ABx Fixation
  11. 11. Rare Mechanism Direct blow Avulsion due to deltoid Overuse Complication of reverse TSR Indications for fixation Symptomatic non-union Subacromial Impingement >1cm displacement Open injuries Multiple disruptions of the SSSC Acromion fractures
  12. 12. Posterior approach Lateral decubitous position Incision over posterior border of acromion and along spine Fixation Technique
  13. 13. Deltoid elevated off with infraspinatus to expose fracture Laminar spreader used to distract fragments to facilitate cleaning and reduction Fixation technique
  14. 14. Fixation Technique
  15. 15. Smaller lateral fractures can be fixed with a similar technique 2.7 screw with 2mm mini-fragment plate Fixation Technique
  16. 16. 457 RSA 5 centres 40 shoulders identified with acromial pathology Os Acromiale (23) Aquired acromial lesions (17) Non union scapula spine (1) Post operative scapula spine fracture (4) No acromial pathology (416) Insufficiency