Acromioclavicular Separation, Surgery for

Indications: who needs surgery, when and why, and goals

• Athletes with some types of severe sprains require surgery to restore the normal relationship of the collarbone to the shoulder and to reduce the drooping of the shoulder.

• Surgery soon after injury is sometimes recommended in heavy laborers and throwing athletes.

• Contact athletes are usually treated nonoperatively with a sling until the pain recedes, allowing for a more rapid return to sports. This is due to the prolonged convalescence and rehabilitation after surgery and the likelihood of recurrent injury with contact sports.

• Patients with continued pain after nonoperative management—including 3 months or more of physical therapy, antiinflammatory medications, and activity modification—are also candidates for surgery.

• The goal of the operation is to bring the shoulder up to the height of the collarbone to maintain their normal height relationship.

Contraindications: reasons not to operate

• Because synthetic material or screws may be used to temporarily or permanently hold the collarbone while the ligament grows into it, infection is a contraindication to surgery.

• Previous surgery in which a large amount of the end of the collarbone has been removed may make it impossible to perform the surgery.

• Surgery for acromioclavicular (AC) separation often uses the ligament between the acromion and coracoid process; thus anyone who has had previous surgery to this ligament, such as for a subacromial decompression or rotator cuff surgery, and anyone who has had previous surgery to the AC joint may not be a candidate for this operation.

Risks and complications of surgery

• Infection, bleeding, injury to nerves (numbness, weakness, paralysis) of the shoulder, arm, forearm, and hand

• Recurrence of the deformity or continued pain

• Breakage of a screw or early breakage of synthetic material

• Erosion or fracture of the collarbone

• Shoulder stiffness (uncommon)

Technique: what is done

A variety of options are available to restore the normal relationship between the collarbone and shoulder. These include repairing the ligaments that were torn, using a graft or synthetic material as a loop around the coracoid and collarbone, or transferring a ligament from the coracoid process to the acromion (the CA ligament) to replace the torn ligament. Your surgeon will discuss which procedure will work best for you. If the surgery is performed soon after the injury, the torn ligaments can occasionally also be repaired. The second operation includes removing about 1 inch from the end of the collarbone and moving the CA ligament from the acromion to the end of the collarbone. This replaces the torn ligaments that previously held the collarbone to the coracoid process; this ligament is held to the end of the collarbone with stitches.

Another option is to use a tendon, either from your leg or from a cadaver, called an allograft, to replace the torn ligaments. The tendon is usually looped around the coracoid process and is either brought around or through the collarbone or sometimes sewn or screwed into the collarbone.

Sutures or threadlike materials, wires, pins, and screws are often used to hold the collarbone to the coracoid process or acromion, while the ligament heals or grows into the end of the collarbone. If screws or pins are used to hold the collarbone in the appropriate position, these are usually removed about 6 weeks after the surgery.

Postoperative course

• Keep the wound clean and dry for the first 10 to 14 days after surgery.

• You may feel more comfortable sleeping sitting up on a couch or recliner for the first 1 to 2 weeks after surgery.

• Your physician will prescribe pain medications for you.

• Keep your arm in a sling, usually for 6 weeks or until after the screw or pin is removed from the shoulder.

• Physical therapy is used to regain motion and then strength.

Return to sports

• Return to sports depends on the type of sport, position played, and the arm injured (dominant versus nondominant).

• A minimum of 4 months is necessary after surgery before returning to sports.

• Full shoulder motion and strength are necessary before returning to sports.

When to call your doctor

• You experience pain, numbness, or coldness in the arm.

• A blue, gray, or dusky color appears in the fingernails.

• Any of the following occur after surgery: increased pain, swelling, redness, drainage, or bleeding in the surgical area.

• Signs of infection appear, such as headache, muscle aches, dizziness, or a general ill feeling with fever.

• New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

Do not eat or drink anything 8 hours before surgery. Anything in the stomach makes general anesthesia more hazardous.

Range of Motion and Stretching Exercises

Surgery for Acromioclavicular Separation

These are some of the initial exercises you may use to start your rehabilitation program, until you see your physician, physical therapist, or athletic trainer again, or until your symptoms resolve. Please remember:

• Flexible tissue is more tolerant of the stresses placed on it during activities.

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