Chapter 34

Anatomic Acromioclavicular Joint Reconstruction

Knut Beitzel, Simone Cerciello and Augustus D. Mazzocca

Chapter Synopsis

• Acromioclavicular joint injuries are among the most common shoulder injuries. Classification and indication for surgical or nonsurgical treatment are based on clinical and radiologic findings. Recent surgical techniques allow for anatomic reconstruction of the instable joint.

Important Points

• Classification is based on both clinical and radiologic examination findings.

• High-grade injuries—typically types IV, V, and VI, with greater than 100% displacement in either a posterior or inferior direction—are typically treated surgically.

• Surgical techniques should aim toward anatomic reconstruction of the acromioclavicular and coracoclavicular ligaments.

Clinical and Surgical Pearls

• Include the sternoclavicular joint in the operative field to allow wide exposure.

• Place a small towel bump under the medial scapular edge.

• Perform glenohumeral arthroscopy to evaluate for possible associated glenohumeral lesions.

• Instead of repositioning of the head, the clavicle can be displaced anteriorly with a towel clip to allow access for conoid tunnel drilling.

• The skin incision is over the coracoid process, more medial than usual (not over the acromioclavicular joint).

• The medial skin incision allows direct visualization of the coracoclavicular ligament and coracoid.

• Tag the deltoid and trapezial fascia for good repair.

• If sutures are passed laterally to medially, make sure the medial coracoid base is exposed and position a Darrach retractor on the medial base to “catch” the passing device.

• Do not power-spin the reamer out to avoid tunnel widening.

• The 5.5 × 8 mm polyetheretherketone (PEEK) screws are inserted into a 5.5-mm bone tunnel (line to line).

• Insert the screw anterior to the graft to adequately recreate the posteriorly positioned coracoclavicular ligaments.

• A postoperative platform brace (Lehrman) is prescribed for 6 weeks.

Clinical and Surgical Pitfalls

• Nonanatomic tunnel placement resulting from improper patient positioning and surgical exposure

• Difficult graft passage because of improper graft preparation

• Insufficient repositioning of the joint in chronic cases because of soft tissue or scar tissue interposition

Acromioclavicular (AC) joint separation represents one of the most common shoulder injuries in general orthopedic practice. The most common mechanism of this injury is a fall with a direct force to the lateral aspect of the shoulder and with the arm in an abducted position.

Depending on the magnitude of injury to the AC joint capsule and ligaments as well as to the coracoclavicular (CC) ligaments, these injuries can be classified by increasing severity as type I through type VI. Typically, the first- and second-degree sprains of the AC joint, otherwise known as type I and type II injuries, are treated conservatively; most affected patients return to preinjury status.

No overall consensus exists on treatment for type III dislocations according to Rockwood’s classification, although a trend toward initial nonoperative treatment is presently favored in most cases. Some of these conservatively treated patients will have persistent pain and an inability to return to their sport or job. Subsequent surgical stabilization, albeit delayed, has still allowed return to sport or work in such cases. However, consideration of other factors, such as type of sport, timing of injury relative to athletic season, position in which the athlete competes, or throwing demands, may alter the procedure. In light of the controversy and clear lack of evidence supporting acute surgical management of grade III AC separations, we recommend that all patients be treated initially with 3 to 4 weeks of nonoperative management. A patient with a grade III AC separation qualifies for surgical reconstruction after a failed short course of nonoperative management as defined by persistent symptoms.

High-grade injuries—typically types IV, V, and VI—with greater than 100% displacement in either a posterior or inferior direction are typically treated surgically.

Currently a wide range of procedures aimed at a permanent reduction of AC joint dislocations exists. However, none of these has been shown to be the overall gold standard. Most of the current techniques focus on reconstruction of the CC ligaments in reference to anatomic studies emphasizing the biomechanical importance of the CC ligaments for vertical stability of repairs of the AC joint. From a biomechanical perspective, the importance of the CC ligaments and AC ligaments in controlling superior and horizontal translation of the distal clavicle has been elucidated. Open and arthroscopically assisted procedures are currently known. Of these, anatomic techniques focus on reconstruction of both the conoid and trapezoid ligaments. However, improved horizontal stability may further be facilitated by a reconstruction of the CC ligaments in an early stage after injury with an approach of clavicle and acromion, allowing subsequent healing of the torn AC and CC ligaments. Alternatively, an additional reconstruction of the AC ligaments could be performed, which is seen as advantageous especially in chronic instabilities with decreased healing potential of the AC ligaments.

We advocate use of a separate, more robust graft source, semitendinosus tendon rather than the coracoacromial ligament, and an anatomic procedure to achieve optimal postoperative results. The anatomic coracoclavicular reconstruction (ACCR) enables simultaneous reconstruction of the CC ligaments (trapezoid and conoid) and the AC ligaments for optimized restoration of biomechanical function. This technique restores function of both the CC ligaments and the AC ligaments in an anatomic procedure with the use of an allogenic or autologous tendon graft (semitendinosus).

Preoperative Considerations

The pain associated with AC joint injury may be difficult to localize because of the complex sensory innervation of the joint. An acute injury as described earlier is an important indicator in the diagnosis. Conversely, the lack of a discrete injury with AC joint pain and joint separation is more consistent with a degenerative condition. Given an acute injury, it is important to determine the level of perceived pain, its location, and any history of previous shoulder injuries. During examination, the patient should be upright so that the weight of the arm helps exaggerate any deformities. If a patient has more pain than is expected for a simple AC joint injury, then there should be high suspicion for a coronoid fracture or a type IV injury with displacement of the clavicle through the trapezial fascia. An examination for neural injuries, vascular injuries, or additional injuries of the adjoining joints should always be completed.

History

• Acute traumatic event versus chronic instability

• Current pain, physical limitations, and disability

• Failure of at least 3 months of conservative treatment

• Age of the patient (physeal fractures)

• Prior surgical procedures (distal clavicle resection)

• Status post–distal clavicular fracture (not always obvious)

• Posterior headache (nuchae)

Physical Examination

• AC joint examination

– Inspection (Fig. 34-1)

Figure 34-1 High-grade (type V) acromioclavicular separation. A, Anteroposterior view. B, Lateral view.

– Tenderness to palpation

– Anterior-posterior translation or mobility

– Superior-inferior translation or mobility

– Reduction of the distal clavicle with shoulder shrug differentiates type III from type V (distal clavicle buttonhole through deltotrapezial fascia)

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