AC Joint Separation

AC Joint injury,shoulder separation , treatment - Everything You Need To Know - Dr. Nabil Ebraheim

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Background:

• an acromioclavicular joint injury, otherwise known as a shoulder separation, is a traumatic injury to the acromioclavicular (AC) joint with disruption of the acromioclavicular ligaments and/or coracoclavicular (CC) ligaments
  • treatment is immobilization or surgical reconstruction depending on the degree of separation and ligament injury.

Epidemiology

• incidence
  • common injury making up 9% of shoulder girdle injuries
• demographics
  • more common in males and athletes

Pathophysiology

• mechanism
  • direct blow to the shoulder
  • often sustained while falling onto the shoulder

Dr. Garcia demonstrates his cutting edge technique for revision AC reconstruction surgery

Anatomy:

• Stability
  • static
    • joint capsule
    • acromioclavicular (AC) ligaments
      • controls horizontal motion and anterior-posterior stability
      • has superior, inferior, anterior and posterior components
        • posterior and superior AC ligaments are most important for stability
    • coracoclavicular (CC) ligaments
      • controls vertical motion and superior-inferior stability
      • two ligaments
        • conoid
          • medial
          • inserts on clavicle 4.5cm medial to lateral edge
          • most important for vertical stability
        • trapezoid
          • lateral
          • inserts on clavicle 3cm medial to lateral edge
  • dynamic
    • anterior deltoid
    • trapezius

Presentation:

• Symptoms
  • pain
    • usually over AC joint
    • can also be referred to the trapezius

• Physical exam
  • lateral clavicle or AC joint tenderness
  • abnormal contour of the shoulder compared to contralateral side
  • stability assessment
    • horizontal (anterior-posterior) stability evaluates AC ligaments
      • cross-body adduction
      • horizontal instability (ISAKOS type 3B) may indicate need for more aggressive treatment
    • vertical (superior-inferior) stability evaluates CC ligaments

Check out Dr. Garcia’s minimally invasive and arthroscopic assisted AC joint reconstruction.

Treatment Options:

• Nonoperative
  • brief sling immobilization, rest, ice, physical therapy
    • indications
      • type I and II
      • type III in most individuals
        • good results when clavicle displaced < 2cm
    • rehab
      • early shoulder range of motion
      • regain functional motion by 6 weeks
      • return to normal activity at 12 weeks
      • consider corticosteroid injections
    • outcomes
      • type III treated non-op had higher DASH scores at 6 weeks and 3 months, and equal function at 1 year with lower rate of secondary surgery (removal of hardware) compared to those treated operatively
    • complications
      • AC joint arthritis
      • chronic subluxation and instability

Check out Dr. Garcia’s new innovative technique for AC joint reconstruction.

Operative

• CC interval restoration (ORIF vs. Ligament Reconstruction)
  • indications
    • acute type IV, V or VI injuries
      • recent studies suggest no difference in functional outcomes between operative and nonoperative interventions for high grade injuries
    • acute type III injuries in laborers, elite athletes, patients with cosmetic concerns
    • chronic type III injuries that failed non-op treatment
      • historically it was thought acute injuries were treated with ORIF and chronic injuries were treated with CC ligment reconstruction
        • however, new studies have shown no difference in outcomes in types III injuries treated surgically after 6 weeks non-op treatment versus immediate surgery
  • contraindications
    • patient unlikely to comply with postoperative rehabilitation
    • skin problems over fixation approach site
  • techniques
    • ligament reconstruction with soft tissue graft
      • Modified Weaver-Dunn
        • distal clavicle excision with transfer of coracoacromial ligament to the distal clavicle to recreate CC ligament
      • autograft
      • allograft
    • fixation
      • suture
      • hook plate
      • CC screw (Bosworth)
      • cortical flip button (e.g Dog Bone)(+/- arthroscopic assistance)
      • K-wire
  • rehabilitation
    • sling immobilization for 6 weeks, no shoulder range of motion
    • return to full activity after 6 months

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