Weaver Dunn Technique for AC Joint Repair

Matt Wallace

Weaver Dunn Technique for AC Joint Repair

Matt Wallace

Indications for Surgery

1. Failure of conservative treatment after 6-12 months of activity modification

2. Localized tenderness with positive lidocaine injection test

3. Positive radiographs4. Unacceptable deformity of the joint5. Unbalanced appearance of the shoulder

1. Failure of conservative treatment after 6-12 months of activity modification

2. Localized tenderness with positive lidocaine injection test

3. Positive radiographs4. Unacceptable deformity of the joint5. Unbalanced appearance of the shoulder

Surgery and Severity of Injury

• Most orthopaedic surgeons agree that injury types 4-6 are best managed operatively

• Controversy on surgery for type 3 injuries• in general surgery is usually indicated• injury usually involved has extensive soft

tissue dissection and its imperative that the deltotrapezial fascia is closed

• surgical prognosis is usually favorable• some orthopaedic surgeons feel will heal on

own

• Most orthopaedic surgeons agree that injury types 4-6 are best managed operatively

• Controversy on surgery for type 3 injuries• in general surgery is usually indicated• injury usually involved has extensive soft

tissue dissection and its imperative that the deltotrapezial fascia is closed

• surgical prognosis is usually favorable• some orthopaedic surgeons feel will heal on

own

Type 3 AC Joint Injury

•Figure 1: Type III acromioclavicular injuries are defined by complete rupture of both the acromioclavicular and the coracoclavicular ligaments.

•Figure 1: Type III acromioclavicular injuries are defined by complete rupture of both the acromioclavicular and the coracoclavicular ligaments.

Goals and Risks of Surgery

• Goals1. Relieve pain2. Restore joint stability3. Return to functional ability in athletics

or place of work

• Risks1. Infection2. Loss of ROM3. Tender scars and wound healing problems

• Goals1. Relieve pain2. Restore joint stability3. Return to functional ability in athletics

or place of work

• Risks1. Infection2. Loss of ROM3. Tender scars and wound healing problems

Different Surgical Procedures

1. Coracoclavicular Suture Fixation2. Modified Phemister Technique3. Modified Bosworth Technique4. Stewart/Mumford Technique

- simplest AC joint surgery1. Weaver Dunn Technique

1. Coracoclavicular Suture Fixation2. Modified Phemister Technique3. Modified Bosworth Technique4. Stewart/Mumford Technique

- simplest AC joint surgery1. Weaver Dunn Technique

What is the Weaver-Dunn Technique?

• AC Joint repair through 2 inch incision in the shoulder

• Distal end of the clavicle is removed• Coracoclavicular ligament is transferred from

the underside of the acromion to the top of the clavicle to replace the torn ligaments

• newer addition to the procedure

• AC Joint repair through 2 inch incision in the shoulder

• Distal end of the clavicle is removed• Coracoclavicular ligament is transferred from

the underside of the acromion to the top of the clavicle to replace the torn ligaments

• newer addition to the procedure

Weaver Dunn Technique Part 1

Weaver Dunn A.gifWeaver Dunn A.gif

•Operative exposure of the ruptured coracoclavicular ligaments

•Operative exposure of the ruptured coracoclavicular ligaments

Weaver Dunn Technique Part 2

•The coracoacromial ligament is isolated for transfer.

•The coracoacromial ligament is isolated for transfer.

Weaver Dunn Technique Part 3

•Suture anchors are used to secure the coracoid to the clavicle. The coracoacromial ligament is transferred to the clavicle.

•Suture anchors are used to secure the coracoid to the clavicle. The coracoacromial ligament is transferred to the clavicle.

Weaver Dunn Finished Product

•Post-operative radiograph demonstrating restoration of stable, anatomic alignment. The distal clavicle was excised. •http://www.mgh.harvard.edu/depts/hoj/html/articles18.html

•Post-operative radiograph demonstrating restoration of stable, anatomic alignment. The distal clavicle was excised. •http://www.mgh.harvard.edu/depts/hoj/html/articles18.html

History of The Weaver Dunn Technique

• First reported ORIF for AC dislocations performed by Cooper in 1861• 1972, two people last names Weaver and Dunn first described an

open technique for treatment of acute and chronic AC dislocations• Advantages in its development:

1) Avoided AC fixation which may result in the development of symptomatic AC arthritis

2) Reconstitutes the coracoclavicular ligament with the transferred coracoclavicular ligament

• Modifications since- addition of coracoclavicular fixation with screws or heavy sutures to protect the ligament reconstruction

• First reported ORIF for AC dislocations performed by Cooper in 1861• 1972, two people last names Weaver and Dunn first described an

open technique for treatment of acute and chronic AC dislocations• Advantages in its development:

1) Avoided AC fixation which may result in the development of symptomatic AC arthritis

2) Reconstitutes the coracoclavicular ligament with the transferred coracoclavicular ligament

• Modifications since- addition of coracoclavicular fixation with screws or heavy sutures to protect the ligament reconstruction

Weaver Dunn Surgical Procedure

• Position of patient• beach chair position• lateral decubitus

• Interscalene regional block anesthesia• Skin incision just posterior to the AC Joint to the coracoid in

the direction of the skin creases• longitudinal incision made in the condensed deltotrapezial

fascia overlying the reduced position of the clavicle• meniscus removed or detached if torn• distal clavicle exposed for 5cm medial to the AC Joint

• Position of patient• beach chair position• lateral decubitus

• Interscalene regional block anesthesia• Skin incision just posterior to the AC Joint to the coracoid in

the direction of the skin creases• longitudinal incision made in the condensed deltotrapezial

fascia overlying the reduced position of the clavicle• meniscus removed or detached if torn• distal clavicle exposed for 5cm medial to the AC Joint

Surgical Procedure cont

• May split 3cm of ant deltoid if needed to expose coracoid process

• 2 nonabsorbable sutures passed around the base of the coracoid using a curved clamp

• 2 small drill holes placed in the middle of the clavicle superior to the coracoid an the sutures are passed through the holes

• distal clavicle reduced against the acromion and the sutures are tied down

• distal clavicle resection performed if needed• coracoacromial ligament transferred to the resected distal

surface• deltotrapezial fascia repaired and routine closure performed

• May split 3cm of ant deltoid if needed to expose coracoid process

• 2 nonabsorbable sutures passed around the base of the coracoid using a curved clamp

• 2 small drill holes placed in the middle of the clavicle superior to the coracoid an the sutures are passed through the holes

• distal clavicle reduced against the acromion and the sutures are tied down

• distal clavicle resection performed if needed• coracoacromial ligament transferred to the resected distal

surface• deltotrapezial fascia repaired and routine closure performed

Modifications to the Weaver-Dunn

• No lateral clavicular end resection• coracoacromial ligament graft sutured to the

inferior part of the clavicle by transosseal sutures• Bosworth coracoclavicular screw used to protect

the graft for 8 wks. post-op• used more for young patients because of post-

traumatic arthrosis that occurs more frequently in elderly patients making clavicular end resection necessary

• Arthroscopic distal clavicle excision

• No lateral clavicular end resection• coracoacromial ligament graft sutured to the

inferior part of the clavicle by transosseal sutures• Bosworth coracoclavicular screw used to protect

the graft for 8 wks. post-op• used more for young patients because of post-

traumatic arthrosis that occurs more frequently in elderly patients making clavicular end resection necessary

• Arthroscopic distal clavicle excision

Post Operative Treatment

• Shoulder immobilized w/ sling • motion allowed at the wrist and elbow

• Shoulder motion begun at 4-6 wks.• PRE added at next 6-8 wks.or after ROM returns• Avoid contact activities till 9 mo. post-surgery

• Shoulder immobilized w/ sling • motion allowed at the wrist and elbow

• Shoulder motion begun at 4-6 wks.• PRE added at next 6-8 wks.or after ROM returns• Avoid contact activities till 9 mo. post-surgery

Studies on Weaver-Dunn

• Minnesota Orthopaedics: Does the Weaver-Dunn AC reconstruction recreate normal passive AC Joint motion

• Yes• Creates more inferior location of the clavicle with

respect to the medial acromion• Weistein & McCann

• ORIF gives patient the best chance to obtain normal shoulder function due to the restoration of the normal anatomy

• 93% success rate in returning ath. to activity• Oxford texbook describes an estimated complication rate of

only 10%

• Minnesota Orthopaedics: Does the Weaver-Dunn AC reconstruction recreate normal passive AC Joint motion

• Yes• Creates more inferior location of the clavicle with

respect to the medial acromion• Weistein & McCann

• ORIF gives patient the best chance to obtain normal shoulder function due to the restoration of the normal anatomy

• 93% success rate in returning ath. to activity• Oxford texbook describes an estimated complication rate of

only 10%

Hot Discussion Topic

• When is best time to have surgery after injury?

• Little info. known • trend towards better results with early repair

• early repair tends to show less chance for loss of reduction after surgery

• age not a factor

• When is best time to have surgery after injury?

• Little info. known • trend towards better results with early repair

• early repair tends to show less chance for loss of reduction after surgery

• age not a factor

Conclusions

• Weaver-Dunn or other surgical intervention not necessary treatment for all AC dislocations

• when surgery is indicated for AC dislocations Weaver-Dunn tends to be surgery of choice due to consistent satisfactory results for patients

• decision to operate should be made before 3 months after surgery

• after this point less favorable results are achieved

• Weaver-Dunn or other surgical intervention not necessary treatment for all AC dislocations

• when surgery is indicated for AC dislocations Weaver-Dunn tends to be surgery of choice due to consistent satisfactory results for patients

• decision to operate should be made before 3 months after surgery

• after this point less favorable results are achieved

References

• Acromioclavicular Joint Arhroscopy Distal Clavicle Excision. Arhroscopy Association of America [Online]. Available: http://www.aana.org./concepts/aricles/acromion.html

• Deshmukh, A., et al. (1998). Biomechanics of Acromioclavicular Instability. Harvard Orthopaedic Journal. 12(4). 1-7.

• Http://www.genufix.com/ac_joint.html• Injuries to the Acromioclavicular Joint (AC Joint). Sports Medicine Clinic of

North Texas. [Online]. Available: http://www.smcnt.net/AC_Joint.html• Magee, David J. (1997). Orthopedic Physical Assessment 3rd edition. • Paulik, A., Dezso, C., & Hidas, P. (1998). Surgical Treatment of Chronic

Acromioclavicular Joint Dislocation by Modified Weaver-Dunn Procedure. National Institute for Sports Medicine, Department of Sports Surgery. 48(1). 1123.

• Weistein, D.M., McCann, P.D. (1995). Surgical Treatment of Complete Acromioclavicular Dislocations. American Journal of Sports Medicine. 23(3). 324-332.

• Acromioclavicular Joint Arhroscopy Distal Clavicle Excision. Arhroscopy Association of America [Online]. Available: http://www.aana.org./concepts/aricles/acromion.html

• Deshmukh, A., et al. (1998). Biomechanics of Acromioclavicular Instability. Harvard Orthopaedic Journal. 12(4). 1-7.

• Http://www.genufix.com/ac_joint.html• Injuries to the Acromioclavicular Joint (AC Joint). Sports Medicine Clinic of

North Texas. [Online]. Available: http://www.smcnt.net/AC_Joint.html• Magee, David J. (1997). Orthopedic Physical Assessment 3rd edition. • Paulik, A., Dezso, C., & Hidas, P. (1998). Surgical Treatment of Chronic

Acromioclavicular Joint Dislocation by Modified Weaver-Dunn Procedure. National Institute for Sports Medicine, Department of Sports Surgery. 48(1). 1123.

• Weistein, D.M., McCann, P.D. (1995). Surgical Treatment of Complete Acromioclavicular Dislocations. American Journal of Sports Medicine. 23(3). 324-332.

The End

•AC joint Injury ??

•Thank you

•AC joint Injury ??

•Thank you