Acromioclavicular Joint Approach

ACROMIOCLAVICULAR JOINT APPROACH

USES

This approach is used only to access the acromioclavicular joint for lateral clavicle resection or for acromioclavicular joint repair.

ADVANTAGES

The approach comes directly down on the area of interest through an area that has no significant neurovascular structures.

DISADVANTAGES

This is a limited-exposure approach that is difficult to extend in a medial direction, if that is needed.

STRUCTURES AT RISK

There are no significant structures at risk if this approach is done properly. If you are operating too inferior to the joint, the deltoid muscle and its attachment to the clavicle could be damaged.

TECHNIQUE

A 4-cm incision is made starting approximately 1 cm posterior to the acromioclavicular joint and coming anteriorly, paralleling the joint surface and directed toward the coracoid. It is carried through the subcutaneous tissue. The deltoid fibers will be seen approaching the clavicle. At that point, the transverse fibers of the capsule should be visible and the location of the joint can be identified. If the goal of surgery is to resect the lateral clavicle, there is no need for any further anterior dissection. Split the capsule fibers in line with their fibers along the superior clavicle and strip subperiosteally off the lateral clavicle so that it can be resected for a distance of 1 cm. This will create a flap of periosteum attached to the trapezius and another to the deltoid, simplifying closure.

If there is an acromioclavicular joint separation and the goal is to repair that, then the first structure identified will usually be the lateral end of the clavicle because it is protruding superiorly. In this case also the capsule will be torn. For these patients, you need to strip the deltoid off of the anterior clavicle for a distance of approximately 3 cm, which then allows you to see the coracoacromial ligament, which in turn should lead you to the coracoid. In these patients, the coracoclavicular ligaments will be torn, but they would normally be coming off of the superior medial side of the coracoid. If your repair includes some ligature under the coracoid and around the clavicle, then the deltoid needs to be stripped off the clavicle for a distance of 1 or 2 cm medial to the coracoid. The coracoid should be approached directly and you should stay subperiosteal on the coracoid and be very cautious anytime you are on the medial side of the coracoid. This exposure will also allow you to resect the coracoacromial ligament off the acromion if it is going to be used in the repair of the acromioclavicular joint.

TRICKS

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