w w w . r b o . o r g . b r
Original
Article
Acromioclavicular
dislocation:
treatment
and
rehabilitation.
Current
perspectives
and
trends
among
Brazilian
orthopedists
夽
Gustavo
Gonc¸alves
Arliani
∗,
Artur
Yudi
Utino,
Eduardo
Misao
Nishimura,
Bernardo
Barcellos
Terra,
Paulo
Santoro
Belangero,
Diego
Costa
Astur
CentrodeTraumatologiadoEsporte(Cete),DepartamentodeOrtopediaeTraumatologia,UniversidadeFederaldeSãoPaulo(Unifesp), SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received29July2014 Accepted15September2014 Availableonline18August2015
Keywords:
Acromioclavicularjoint Shoulderdislocation Rehabilitation
a
b
s
t
r
a
c
t
Objective:ToevaluatetheapproachesandproceduresusedbyBrazilianorthopedicsurgeons intreatmentandrehabilitationofacromioclaviculardislocationoftheshoulder.
Methods:Aquestionnairecomprisingeightclosedquestionsthataddressedtopicsrelating totreatmentandrehabilitationofacromioclaviculardislocationwasappliedtoBrazilian orthopedicsurgeonsoverthethreedaysofthe45thBrazilianCongressofOrthopedicsand Traumatology,in2013.
Results:Atotalof122surgeonscompletelyfilledoutthequestionnaireandformedpart ofthesampleanalyzed.Mostofthemcamefromthesoutheasternregionofthecountry. Inthissample,67%oftheparticipantswouldchoosesurgicaltreatmentforpatientswith grade3acromioclaviculardislocation.Regardingthepreferredtechniqueforsurgical treat-mentofacuteacromioclaviculardislocation,amajorityofthesurgeonsusedsubcoracoid ligaturewithacromioclavicularfixationandtransferofthecoracoacromialligament(25.4%). Regardingcomplicationsfoundaftersurgeryhadbeenperformed,43.4%and32.8%ofthe participants,respectively,statedthatresidualdeformityoftheoperatedjointandpainwere thecomplicationsmostseenduringthepostoperativeperiod.
Conclusions: Althoughtherewasnoconsensusregardingthetreatmentandrehabilitation ofacromioclaviculardislocation,evolutionhadoccurredinsomeofthetopicsanalyzedin thisquestionnaireappliedtoBrazilianorthopedists.However,furthercontrolledprospective studiesareneededinordertoevaluatetheclinicalandscientificbenefitofthesetrends.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
夽
WorkdevelopedattheCentrodeTraumatologiadoEsporte(CETE),DepartmentofOrthopedicsandTraumatology,UniversidadeFederal deSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](G.G.Arliani).
http://dx.doi.org/10.1016/j.rboe.2015.08.003
Luxac¸ão
acromioclavicular:
tratamento
e
reabilitac¸ão.
Perspectivas
e
tendências
atuais
do
ortopedista
brasileiro
Palavras-chave:
Articulac¸ãoacromioclavicular Luxac¸ãodoombro
Reabilitac¸ão
r
e
s
u
m
o
Objetivo:AvaliarascondutaseosprocedimentosfeitospeloscirurgiõesortopédicosdoBrasil notratamentoenareabilitac¸ãodasluxac¸õesacromioclavicularesdoombro.
Métodos: Foiaplicadoumquestionáriodeoitoquestõesfechadasqueabordavamtópicos relacionadosaotratamentoeàreabilitac¸ãodasluxac¸õesacromioclavicularesaoscirurgiões ortopédicosbrasileirosnostrêsdiasdo45◦CongressoBrasileirodeOrtopediae
Traumatolo-giade2013.
Resultados: Preencheramcompletamenteoquestionárioefizerampartedaamostra anal-isada122cirurgiões.AmaiorparteeraprovenientedaRegiãoSudeste.Naamostra,67% dosparticipantesoptariampelotratamentocirúrgicoempacientescomluxac¸ão acromio-claviculargrau3.Emrelac¸ãoàtécnicapreferidaparatratamentocirúrgicodasluxac¸ões acromioclaviculares agudas, a maioriados cirurgiões usa amarrilhosubcoracoide com fixac¸ão acromioclavicularetransferência doligamentocoracoacromial(25,4%). Quando perguntadossobrecomplicac¸õesencontradasapósacirurgia,43,4%e32,8%dos partici-pantes,respectivamente,responderamquedeformidaderesidualnaarticulac¸ãooperadae dorforamascomplicac¸õesmaisvistasnoperíodopós-operatório.
Conclusões: Apesardenãohaverconsensonotratamentoenareabilitac¸ãodasluxac¸ões acromioclaviculares,háevoluc¸ãoemalgunstópicosanalisadosnoquestionárioaplicado paraosortopedistas nacionais.Noentanto,maisestudosprospectivoscontroladossão necessáriosparaavaliarobenefícioclínicoecientíficodessastendências.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Theacromioclavicularjointisadiarthrodialjointthatinvolves themedialjointfacetoftheacromionandthedistalportion oftheclavicle.Itconnectsthescapularbelttotheaxial skele-ton.Stabilization ofthis jointis achievedbymeans ofthe jointcapsuleandtheacromioclavicularandcoracoclavicular ligaments.
Acromioclavicular dislocation is one ofthe commonest injuriesoftheshoulderandaccountsfor9%ofallinjuries.1 Itoccursmainlyinsportsactivitiesthatinvolvecontactand intrafficaccidents.Apreviousstudydemonstratedthatthe incidencewas1.8casesofacromioclaviculardislocationper 10,000 inhabitants per year, and that these cases mostly occurredamongmenaged20–39years.2 Overrecentyears, severalstudieshavebeenconductedwithaviewtoimproving thetreatmentandrehabilitationofthisinjury.However,there isstillnoconsensusonthissubjectintheliterature.3
Thehighincidenceoftheseinjuriesandthegreat impor-tanceofsocialandeconomicfactorsrelatingtothem,along with the enormous divergences in the literature on this subject, makeit extremelypertinent to assess the current approachesandtrendsrelatingtothismatterinBrazil.
The aim of this study was to evaluate the approaches andproceduresfollowedbyBrazilianorthopedicsurgeonsin treatmentandrehabilitationofcasesofacromioclavicular dis-location.Theresultsfromthisstudywouldmakeitpossible todelimitthenationaltrendsregardingthissubjectand to provideguidanceforfuturegood-qualitystudies.
Material
and
methods
Thiswas adescriptivestudy inwhichaquestionnairewas appliedtoasampleoforthopedicsurgeonsinBrazil.The ques-tionnairewasdrawnupandapprovedbythepresentauthors insuchawaythatitwouldbeverysimpleandeasyto under-stand.Itconsistedofeightclosedquestionsthataddressed topicssuchasthesurgeons’numbersofyearsofexperience andtheircurrentnumbersofsurgicalproceduresperformed, along witha varietyofother mattersrelatingto the treat-mentand torehabilitationsubsequenttoacromioclavicular dislocationoftheshoulder(AppendixA).
ThequestionnairewasappliedtoBrazilianorthopedic sur-geons duringthethreedaysofthe 45thBrazilianCongress ofOrthopedicsandTraumatology,in2013.Participantsonly filled outthequestionnairesiftheyhad concludedmedical residencyinorthopedicsandwereperformingsurgical proce-durestotreatacromioclaviculardislocation.Inthismanner, 130 questionnaireswere filled out and eightofthese were excluded: three because the surgeon belonged to another country(Bolivia,ColombiaandPeru)andfivebecausetheyhad beenincompletelyfilledout.Thus,122questionnaireswere completelyfilledout.Toresolveanyqueriesthatemergewhile the questionnaires were being answered, two researchers wereathandthroughouttheperiodinwhichthe question-naireswereapplied.
ThedatawereanalyzedusingtheSPSSforWindows soft-ware,version16.0,andthesignificancelevelusedwas5%.
Results
Atotalof122orthopedicsurgeonscompletelyfilledoutthe questionnaireandformedpartofthesampleanalyzed.The distributionofthesurgeonsasafunctionoftheirregionof originandnumbersofyearsofexperiencearepresentedin
Table1.Inrelationtothesurgeons’lengthofexperienceof
shouldersurgery, 69% had less than 5years ofexperience (whichwasdefinedaccordingtothedateonwhichtheywere awarded the title of specialist in orthopedicsand trauma-tology).Therelationship betweenthesurgeons’ experience ofsurgeryrelatingtoacromioclaviculardislocationandtheir fieldoforthopedicactivityisshowninTable2.Whenasked about their approach toward a patient presenting grade 3 acromioclaviculardislocation,67%oftheparticipantsstated thattheywouldchoosesurgicaltreatment.Thisapproachwas morecommonlyfound amongsurgeons withmore than 5 yearsofexperience.Inrelationtothepreferredtechniquefor surgicaltreatmentofacuteacromioclaviculardislocation,the largestproportionofthesurgeonsstatedthattheyused sub-coracoidligaturewithacromioclavicularfixationandtransfer ofthe coracoacromialligament(25.4%)or subcoracoid liga-turewithacromioclavicularfixationalone (24.6%)(Table 3). However,whensurgeryisnecessaryforchronic acromioclav-iculardislocation(injurieslastingformorethan6weeks),2,3 theparticipants’preferencewasmuchmorepredominantly forthesurgicaltechniqueconsistingofsubcoracoidligature withacromioclavicularfixationandtransferofthe coracoacro-mialligament(41%)(Table4).Regardingthedurationofuse ofimmobilizationafterthesurgicalprocedure,themajority
ofthesurgeons(67.2%)usedthisafterthesurgeryforthree to6weeks.Inrelationtoathletes returningtotheir sports activityafterconservativetreatmentofacromioclavicular dis-location,41.8%consideredthataperiodof3monthswasideal.
Table5showsthattheprofessionalswithmorethan10years
ofexperiencesuggestedthatthereturntosportsafter conser-vativetreatmentoughttobelater(p=0.004).Table6presents the lengthsof time untilthe return tosports, subsequent to surgical treatment ofacromioclavicular dislocation, and theircorrelationwiththesurgeon’sexperience.Whenasked aboutcomplicationsencounteredafterthesurgery,43.4%and 32.8%oftheparticipants,respectively,respondedthat resid-ualdeformityinthejointthatwasoperatedandpainwerethe complicationsthatweremostseen.Therewasasignificant correlationbetweenprofessionalswithlesslengthofsurgical experienceandpresenceofmorelocalpainandlessresidual deformity(p=0.032).
Discussion
Thissurvey,whichwasconductedduringtheprincipal ortho-pedicscongressofBrazil,demonstratesthatthereisstillno consensusamongBrazilianorthopedistsregarding manage-mentofacromioclaviculardislocation.
Theuncertaintyregardingtheidealtreatmentfor acromio-claviculardislocationcanbeseeneveninthemostancient medicaldescriptionsfromthetimeofHippocratesandGalen.4 Historically, although acromioclavicular dislocation can be consideredconceptuallytobeasimpleinjury,anenormous variety of surgical techniques has been described, which makesitmoredifficulttodefinewhichtechniqueorapproach wouldprovideabetterresultfortheseinjuries.
Table1–Distributionofthesurgeonsasafunctionoftheirregionoforiginandnumberofyearsofexperience.
Region Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
North 2 2.4 1 5.0 0 0.0 3 2.5 0.79
Northeast 4 4.8 1 5.0 2 11.1 7 5.7
Center-west 13 15.5 1 5.0 4 22.2 18 14.8
Southeast 54 64.3 13 65.0 9 50.0 76 62.3
South 11 13.1 4 20.0 3 16.7 18 14.8
Total 84 100.0 20 100.0 18 100.0 122 100.0
Table2–Relationshipbetweensurgicalexperienceandsurgeons’orthopedicspecialty.
Specialty Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
Shoulder 21 25.0 14 70.0 9 50.0 44 36.1 0.005
Knee 7 8.3 1 5.0 2 11.1 10 8.2
Spine 2 2.4 0 0.0 0 0.0 2 1.6
Hand 2 2.4 2 10.0 2 11.1 6 4.9
Foot 2 2.4 0 0.0 0 0.0 2 1.6
General 28 33.3 2 10.0 4 22.2 34 27.9
Hip 3 3.6 1 5.0 0 0.0 4 3.3
Others 19 22.6 0 0.0 1 5.6 20 16.4
Table3–Techniquespreferredforsurgicaltreatmentofacuteacromioclaviculardislocationandrelationshipwith
surgicalexperience.
Acuteacromioclaviculardislocation Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
Phemister(acromioclavicularfixation) 13 15.5 1 5.0 2 11.1 16 13.1 0.422
Bosworth(coracoclavicularfixation) 4 4.8 1 5.0 1 5.6 6 4.9
Subcoracoidligature+acromioclavicularfixation 20 23.8 6 30.0 4 22.2 30 24.6
Subcoracoidligature;+acromioclavicular fixation+;transferofcoracoacromialligament
22 26.2 3 15.0 6 33.3 31 25.4
Fixationusinganchors+acromioclavicularfixation 18 21.4 3 15.0 2 11.1 23 18.9
Fixationusingopenbutton(tightrope) 4 4.8 2 10.0 3 16.7 9 7.4
Otherarthroscopictechniques 1 1.2 1 5.0 0 0.0 2 1.6
Otheropentechniques 2 2.4 3 15.0 0 0.0 5 4.1
Total 84 100.0 20 100.0 18 100.0 122 100.0
Table4–Techniquespreferredforsurgicaltreatmentofchronicacromioclaviculardislocationandrelationshipwith
surgicalexperience.
Chronicacromioclaviculardislocation Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
Phemister(acromioclavicularfixation) 5 6.0 0 0.0 0 0.0 5 4.1 0.289
Bosworth(coracoclavicularfixation) 8 9.5 0 0.0 1 5.6 9 7.4
Subcoracoidligature+acromioclavicularfixation 19 22.6 5 25.0 4 22.2 28 23.0
Subcoracoidligature+acromioclavicular fixation+transferofcoracoacromialligament
31 36.9 9 45 10 55.6 50 41.0
Fixationusinganchors+acromioclavicularfixation 11 13.1 1 5 0 0 12 9.8
Reconstructionusingflexortendons 3 3.6 1 5.0 1 5.6 5 4.1
Fixationusingopenbutton(tightrope) 1 1.2 0 0.0 1 5.6 2 1.6
Otherarthroscopictechniques 1 1.2 1 5.0 0 0.0 2 1.6
Otheropentechniques 5 6.0 3 15.0 1 5.6 9 7.4
Total 84 100.0 20 100.0 18 100.0 122 100.0
Table5–Returntosportafterconservativetreatmentofacromioclaviculardislocation.
Sport–conservative Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
1month 0 0.0 1 5.0 0 0.0 1 0.8 0.004
2months 12 14.3 4 20.0 0 0.0 16 13.1
3months 30 35.7 11 55.0 10 55.6 51 41.8
4months 17 20.2 1 5.0 0 0.0 18 14.8
>4months 25 29.8 3 15.0 8 44.4 36 29.5
Total 84 100.0 20 100.0 18 100.0 122 100.0
Table6–Returntosportaftersurgicaltreatmentofacromioclaviculardislocation.
Sport–surgical Yearsofexperience p
<5years 5–10years 10years Total
n % n % n % n %
1month 2 2.4 2 10.0 0 0.0 4 3.3 0.019
2months 9 10.7 1 5.0 0 0.0 10 8.2
3months 26 31.0 3 15.0 3 16.7 32 26.2
4months 17 20.2 6 30.0 1 5.6 24 19.7
>4months 30 35.7 8 40.0 14 77.8 52 42.6
Thefirstmodernprocedurewasperformedin1860. Dur-ing the 1930s and 1940s, avariety oftypes ofnonsurgical treatmentweredescribed.In1941,Bosworth5describedthe techniqueoffixationoftheclavicletothecoracoidprocess, usingascrewthatwaspassedthrough“blindly”.Duringthat sameperiod,Mumford6describedresectionofthemostdistal 2cmoftheclavicle.In1972,Weaver–Dunndescribeda tech-niqueforresection ofthe distalextremity ofthe clavicle.7 Since then,surgeons have agreed that high-grade injuries shouldbetreatedsurgically,and injuriesofgradesI andII conservatively.Inourstudy,70%oftheorthopedistshadmore than5yearsofexperienceandstatedthattheytreatedgrade IandgradeIIinjuriesconservatively.
AccordingtothesystematicreviewofBeitzeletal.,8 the mostacceptedmethodforinjuriesofgradesIandIIconsists ofabriefperiodofimmobilizationusinganAmericanor func-tionalslingtosupporttheweightoftheupperlimbandlimit thestressonthecoracoclavicularligaments.Thisperiodof immobilizationmaybeassociatedwithlocalmeasures(gelor topicalanti-inflammatoryagents)andtreatmentsfor symp-toms. Patients are encouraged to start to perform passive movementsattheendofthefirstweek,inordertoreducethe painandavoidthemorbidityrelatingtolongperiodsof immo-bilization.Scapularstabilizationandcoreexercisesarestarted inthethirdweek.Contactsportsandweightliftingareavoided forupto4months.Inthequestionnaireofthisstudy,41.8%of theorthopedistsstatedthattheyreleasedtheirpatientsfor sportsactivities 3monthsafterthe surgery,but the ortho-pedistswithmoreexperiencesuggestedthatpatientsshould returntosportslateron.
UnlikeinrelationtothetreatmentfortypeIandIIinjuries, therewasacertaindegreeofdiscrepancyanddivergenceof opinions regardingthe best treatmentfor type IIIinjuries, althoughinitialconservativetreatmentfortheseinjurieswas saidtobewelltolerated.Somerecentstudieshave demon-stratedthatconservativetreatmentforgradeIIIinjuriesalters the kinematicsof the scapula.9 In treatments forathletes, individualfactorsneedtobetakenintoaccount,suchasthe typeofsport,time duringthe championship seasonwhen theinjuryoccurred,levelofactivity,playingpositioninteam sports and type of ball-throwing activity. In our opinion, patientswho are notathletes and present typeIII injuries shouldinitiallybemanagednonsurgically,focusingon appro-priaterehabilitation.Ifthepainpersistsandtheiractivities arelimited,surgicaltreatmentisindicated.Incasesof con-tactorcollisionsports,inwhichthereisariskthatgradeIII injuriescouldevolvetogradeVinjuries,initialsurgical treat-mentisindicated.Althoughsurgicaltreatmentisthetypeof treatmentmostindicatedforinjuriesofgradesIV,VandVI, twolevelIIstudiesshowedthattheresultsfromnonsurgical treatmentweresuperiortothosefromsurgicaltreatment.10,11 However,thesestudieswereconductedinthe1980s,whenthe surgicaltechniqueswerenotasrefinedastheyaretoday.In thepresentstudy,67%oftheorthopedistssaidthattheywould indicatesurgicaltreatmentforcasesofgradeIII acromioclav-iculardislocation.
Thereisacertainscarcityofstudiesreportingonthebest time fortreating acromioclavicular dislocation.In cases of gradeIII injuries, waiting for3–4 weeks initially and then reassessing the patient seems to be the approach most
indicated.12Insomecases,ifthepainpersists,togetherwith significant functional limitation of the limb, surgical tech-niquesthatdonotinvolvegraftsorotherbiologicalmaterials shouldbeused,sincebringingtheclavicleclosertothescapula gives rise to good healing because of the friable recently injuredtissues.
Morethan200surgicaltechniqueshavebeendescribedfor treatingacromioclaviculardislocation.3Itisunusualtofind studies demonstrating that onetechnique presents results thataresuperiortothoseofanotherfixationtechnique.For proceduresinwhichtheaimistoreconstructthe coracoclav-icularligamentusinglocalorfreegrafts,useofthisligament togetherwithaportionoftheconjoint,semitendinosusorlong palmartendon,amongothers,hasbeenwelldescribed.13–18 Transferofthe coracoacromialligament,whichwas gener-ically described as the Weaver–Dunn procedure, remains popularforreconstructionofthecoracoclavicularligaments. Thetechniqueincludestransferofthecoracoacromial liga-ment and its insertionin theacromion, tothe distalthird oftheclavicle,withmodificationsinvolvingligaturesaround the clavicle.Although excellentresults havebeen reported throughusingthistechnique,acertaindegreeofsubluxation andcomplicationsoffixationhasbeendescribed.Oneofthe causesthatprovideanexplanationisthattheresistanceof thecoracoacromialligamentisaround25%oftheresistance of the coracoclavicular ligament,as shown through recent biomechanical studies.19–22 Moreover, this non-anatomical reconstruction onlyensures coronal stability and does not correcttheinstabilityinthetransverseoraxialplane.
Inrelationtoanatomicalandnon-anatomicalsurgical pro-cedures,thereisnoconsensusregardingthebesttechnique. Franchini etal.23 and Tauber et al.15 used asynthetic and the semitendinosusligament, respectively, incomparisons with non-anatomical procedures (modified Weaver–Dunn) andreportedthatthefunctionalscoreswereslightlyhigher in thegroup withanatomical reconstruction.However, the studybyFranchiniwasaprospectivecaseseriesandthestudy byTauberetal.15wasaretrospectivestudy.Temporary fixa-tionwithwiresintheacromioclavicularjointremainsoneof the directrepairmethodsmostusedbecauseofitseaseof useandrapidity.Variationsinthistechnique,throughusing themeniscustoreinforcethesuperioracromioclavicular lig-ament were described bySage and Salvatore.24 Zaricznyj25 addedtheextensortendonofthefifthfingertothisfixation, inordertoreinforcethecoracoclavicularligaments.Bundens andCook26emphasizedtheimportanceofsuturingthefascia ofthetrapeziusandthedeltoidovertheclavicle.Wefound thatthetechniquemostusedfortreatingacuteandchronic acromioclaviculardislocationconsistedofacromioclavicular fixation in association withsubcoracoid ligature and cora-coacromialtransfer.
treatedforgradeIIIandIVchronicacromioclavicular disloca-tionandshowedgoodresults.Inthepresentstudy,veryfew orthopedistsreportedhavingexperienceofthearthroscopic technique.
ComplicationssuchasmigrationofwiresofEndobuttons, breakageofmaterials,infection,painand/orresidual sublux-ation,reactiontosuturingwiresandrecurrenceshavebeen described.Whenaskedaboutthepostoperativecomplications thattheymostfrequentlyobserved,independentofthetime, 43.4%and32.8%oftheparticipants,respectively,responded thatresidualdeformityofthejointthathadbeen operated andlocalpainwerethemostprevalentcomplicationsduring thepostoperativeperiod.Thisshowsthattherewasa signifi-cantcorrelationbetweenprofessionalswithshorterlengthsof surgicalexperienceandpresenceofmorelocalpainandless residualdeformity.
Conclusion
Inourstudy,wesoughttoshowthetherapeuticmanagement usedbyBrazilianorthopedistsinrelationto acromioclavicu-lardislocation.Althoughthisisaconceptuallysimpleinjury, itstreatmentissurroundedbyadiversityofapproachesand divergentsurgicaltechniques.Nonetheless,thereisacertain degreeofconsensusthatgradeIandIIacromioclavicular dis-locations should be treatedconservatively. Moreover,there waslowerincidenceofsurgicalcomplicationsamong orthope-distswithmorethan5yearsofexperienceofshouldersurgery.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Appendix
A.
Questionnaire
on
surgery
for
acromioclavicular
dislocation
Cidade/Estado:______________________________________________________________
ESPECIALIDADE:
OMBRO JOELHO COLUNA MÃO PÉ TUMOR GERAL QUADRIL OUTROS
1 - Anos de experiência em cirurgia do Ombro:: ___________________________anos.
2 - Qual sua conduta no paciente com LAC III?
CIRÚRGICO NÃO CIRÚRGICO
3 - No tratamento cirurgico de LAC agudos (cirurgicos), qual sua tecnica preferida?
Phenister(fixação acromioclavicular)
Bosworth(fixação claviculo-coracoide com parafuso)
Amarrilho subcoracoide + fixação acromioclavicular
Amarrilho subcoracoide + fixação acromioclavicular + transferencia de ligamento coracoacromial
Fixação com ancoras + fixação acromioclavicular
Reconstrução com tendoes flexores
Fixação com botão(tight-rope) aberto
Fixação com botão(tight-rope) artroscopico
Outras tecnicas artroscopicas
Outras tecnicas abertas
4 - No tratamento cirurgico das LAC crônicas (cirurgicos), qual sua tecnica preferida?
Phenister(fixação acromioclavicular)
Bosworth(fixação claviculo-coracoide com parafuso)
Amarrilho subcoracoide + fixação acromioclavicular
Fixação com ancoras + fixação acromioclavicular
Reconstrução com tendoes flexores
Fixação com botão(tight-rope) aberto
Fixação com botão(tight-rope) artroscopico
Outras tecnicas artroscopicas
Outras tecnicas abertas
5 – Quanto tempo de imobilização você recomenda:
< 3 SEMANAS 3-6 SEMANAS
> 6 SEMANAS NÃO IMOBILIZA
6 - Quanto tempo você considera ideal para o retorno ao esporte no tratamento conservador:
1 MESES 2 MESES
3 MESES 4 MESES
> 4 MESES
7 - Quanto tempo você considera ideal para o retorno ao esporte no tratamento cirúrgico:
1 MESES 2 MESES
3 MESES 4 MESES
> 4 MESES
8 – Principal complicação observada:
SEM COMPLICAÇÕES
INFECÇÃO
DEFORMIDADE RESIDUAL
DOR LOCAL
RESTRIÇÃO DE ADM
r
e
f
e
r
e
n
c
e
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