Surgical techniques: General

Historically, the recommended resection length has varied from 0.5 to 2.5 cm, although the precise amount to resect is unknown. Based on cadaveric studies, 5 mm is suggested to adequately prevent bony abutment in both rotationally and axially loaded shoulders if the CC and AC ligaments are intact. This recommendation was confirmed in an arthroscopic cadaveric study demonstrating that, if the resection was 2.5 mm or less, abutment was likely to occur between the acromion and the clavicle, particularly inferiorly and posteriorly, and that joint stiffness diminished with the amount of bone resected. Furthermore, a resection of greater than 0.8 cm in women and 1.0 cm in men may result in detachment of some portion of the trapezoid ligament. A resection of less than 11.0 mm may not violate any portion of the trapezoid ligament in 98% of men or women, and resection of less than 24.0 mm should not violate the conoid ligament. To prevent the abutment of the acromion and clavicle during adduction of the arm, Neer advocated the removal of 1.5 to 2.0 cm, resecting more superiorly and posteriorly than inferiorly and anteriorly.

When performing AC joint resection, symmetric resection of both the medial acromion and lateral clavicle is recommended as anterior-to-posterior peak load to failure is significantly higher compared with distal clavicle excision (DCE) alone. However, when biomechanically examining horizontal translations of the clavicle after DCE, progressively increased anterior-to-posterior excursions are noted compared with the native joint with inferior capsule excision and 10-mm bone excisions, even when the superior and posterior AC capsular ligaments and the CC ligaments remained intact. Furthermore, with open techniques for DCE, meticulous closure of the superior capsule and investing AC ligaments is extremely important. However, when performing lateral clavicle excision, it must be noted that persistent pain can occur due to inadequate resection or when performed for the wrong indication.

Procedure

The patient is placed in the beach chair position with the head supported on an adjustable well-padded headrest to allow free access to the superior aspect of the shoulder. The skin incision is made in the relaxed skin tension lines approximately 1 cm medial to the AC joint, extending for 3 to 4 cm ( Fig. 22.1 ). A small, straight Gelpi retractor is placed into the subcutaneous tissue, which is gently elevated from the underlying fascia.

A superior incision in the relaxed skin tension lines is made slightly medial to the acromioclavicular joint for a distance of 3 to 4 cm.

(Courtesy Steven B. Lippitt, MD.)

Beginning 2.0 to 2.5 cm medial to the AC joint, electrocautery is used to incise the soft tissue overlying the superior aspect of the clavicle ( Fig. 22.2 ). The incision should be carefully placed to avoid the trapezius and deltoid muscles from their respective insertions. The incision is continued laterally through the capsule of the AC joint onto the acromion process for a distance of approximately 0.5 to 1 cm. Subperiosteal dissection of the distal clavicle is carried out with electrocautery to create anterior and posterior soft tissue flaps that include the capsule, the superior ligaments of the AC joint, and the adjacent muscles. Complete soft tissue dissection is confirmed with a 0.25-inch key elevator enabling the placement of two small Chandler retractors bent to 90 degrees anterior and posterior to the distal clavicle. The arm is then moved into adduction to avoid any abutment. With the help of a mobile C-arm (fluoroscopy), a length of 5 to 8 mm of the distal clavicle is measured, marked, and resected using a microsagittal saw ( Fig. 22.3 ). The resected fragment is grasped with a towel clip or pointed bone reduction forceps and manipulated to allow access for the release of the remaining soft tissue attachments inferiorly.

In line with the clavicle, the deltotrapezius fascia and underlying acromioclavicular joint capsule are divided and reflected from the distal clavicle.

(Courtesy Steven B. Lippitt, MD.)

The surrounding soft tissues are protected as the lateral clavicle is excised with a microsagittal saw.

(Courtesy Steven B. Lippitt, MD.)

Upon removal of the resected lateral clavicle, the wound is thoroughly irrigated with normal saline. The resected clavicular surface is inspected, palpated, and smoothed, if needed, using a pinecone bur, rasp, or file. Proliferative synovium and abnormal intra-articular disk material are excised. By placing a fingertip into the area of resection and performing extremity adduction, contact between the acromion and the residual distal clavicle is recognized and corrected by additional resection.

The surrounding soft tissues are infiltrated with a local anesthetic solution consisting of equal parts of 0.5% Marcaine with epinephrine and 1% lidocaine. With the medial subcutaneous flap retracted with a bent Army-Navy retractor, a 6-D Mayo trocar needle delivers No. 2 nonabsorbable sutures through the anterior and posterior soft tissue flaps ( Fig. 22.4 ). No more than three sutures placed with a figure-of-eight technique are usually necessary. The sutures are tied with four rows to limit the likelihood of palpable and potentially painful knots beneath the skin at the surgical site. For extremely thin patients, absorbable sutures are preferred. The subcutaneous tissue is closed with 2-0 absorbable sutures using a buried technique, capturing the dermal layer to ensure excellent superficial soft tissue apposition. Strips of 0.5-inch adhesive-backed paper tape cut in half are applied to the skin. A sterile dressing covers the wound, and the arm is placed in a sling.

The residual defect is closed by careful repair of the deltotrapezius fascia and acromioclavicular joint capsule. No more than three sutures placed with a figure-of-eight technique are usually necessary. The sutures are tied with four throws to limit the likelihood of palpable and potentially painful knots beneath the skin at the surgical site. Leaving a small tag further reduces the possibility of palpable suture.

(Courtesy Steven B. Lippitt, MD.)

Postoperative rehabilitation

Patients are discouraged from active arm elevation without the assistance of the opposite limb for 3 to 4 weeks to protect the deep soft tissue repair. Heavy use of the extremity is not recommended for 6 to 8 weeks to ensure that sufficient preliminary healing of the AC ligaments has taken place and that the residual void created at the time of DCE has been filled with scar. Hydrotherapy to obtain range of motion is suitable as soon as the wound has healed. Return of full strength, range of motion, and full function can be expected in most cases by 12 weeks.

Technical pearls and pitfalls

Cosmetically unappealing scars may be avoided by carefully placing the incision in the relaxed skin tension lines. Placing the skin incision approximately 1 cm medial to the palpable prominence of the distal clavicle enables optimum and safe placement of the saw. The angle of resection favors removing slightly more bone superiorly and posteriorly than inferiorly and anteriorly ( Fig. 22.5 A). This orientation of the plane of resection prevents contact between the remaining clavicle and the acromion when the arm is placed in cross-body adduction (see Fig. 22.5 B). In addition, it may be important to smooth the lateral corner of the clavicle, especially in patients with prominent bony structures. A saw is preferred to the use of either a bur, which creates more bone debris, or an osteotome, which can shatter the bone.

(A), The plane of resection favors slightly more bone removal superiorly and posteriorly to prevent abutment of the acromion process on the clavicle during extremity adduction. (B) A proposed mechanism for painful instability after distal clavicle excision is abutment of the remaining posterolateral clavicle against the posteromedial acromion

(Courtesy Steven B. Lippitt, MD.)

The soft tissue sleeve that includes the AC joint capsule and its supporting ligaments is carefully closed side to side without an attempt to obliterate the dead space formed by the absence of the lateral clavicle. It is important that the repair suture engage the entirety of the reflected soft tissue, not just its most superior/superficial portion. This effectively repairs the superior AC ligaments and capsule, which reduces the possibility of iatrogenic AC joint instability. In patients with joint laxity, open DCE should be preferred over an arthroscopic-assisted technique, to avoid horizontal or rotational instability. The temptation to create an interposition arthroplasty using the soft tissues adjacent to the joint should be resisted. Their relative immobility risks a closure under tension that can lead to dehiscence of the tissues at the repair site. Overtightening the trapezius or deltoid muscle at the resection site can contribute to focal discomfort. Likewise, an insufficient closure can be painful, cosmetically unappealing, and functionally compromising.

Heterotopic ossification (HO) can develop at the surgical site. Preventive measures include (1) subperiosteal dissection with electrocautery rather than sharp or blunt elevation of the soft tissue from the bone, (2) thorough irrigation of the surgical site to remove residual bone debris, and (3) prophylactic administration of pharmacologic agents such as indomethacin.

Outcomes and complications

DCE, regardless of method, following trauma to the AC joint produces fewer excellent and good results than when it is performed for nontraumatic conditions. ^{, , ,} Cheung et al. reported expectedly improved clinical outcomes at a mean follow-up of 8.3 years. Eskola found that patients with a resection of more than 1.0 cm have more pain than patients with less than 1 cm of resection.

According to a systematic review performed in 2007, there is little argument that excision of the lateral clavicle successfully addresses the majority of the pathologic entities encountered at the AC joint. However, there are unsatisfactory outcomes because of cosmesis, pain, and dysfunction that are typically mechanical in nature. The factors are often interrelated and include improper surgical technique and resection, instability, loss of soft tissue integrity, HO, scars, and neuromas. Failure to resect enough distal clavicle can result in continued, symptomatic abutment of the acromion and the clavicle (see Fig. 22.5 ). The problem is usually secondary to inadequate visualization or underestimation of the amount of resection when DCE is performed arthroscopically.

Overresection, which is most often accompanied by manifestations of instability, is a far more challenging problem, nearly always resulting in more significant pain and dysfunction than underresection. Different degrees of overresection and extent and directions of instability are possible. Exceedingly generous resections, usually radiographically apparent, place the important CC ligaments at risk, especially the most lateral trapezoid. Refractory symptoms usually necessitate a formal reconstructive stabilizing procedure to specifically address the instability pattern. The more subtle but nevertheless disabling symptoms are probably attributable to translational microinstability in the anteroposterior plane.

Several studies have compared the results of arthroscopic and open excision of the lateral clavicle with confirmation of the benefits of each method. ^, In a 2007 systematic review, Rabalais and McCarty demonstrated that arthroscopic distal clavicle resection provided better results than the open procedure, but this observation is mostly comprised of low-level evidence. Flatow et al. reported earlier recovery of comfort with an arthroscopic method. Using validated outcome measurement tools, Freedman et al. failed to demonstrate significant differences 1 year postoperatively between arthroscopic and open procedures, with the exception of significant improvements in visual analog scale (VAS) scores in the arthroscopic group but not the open group. With the arthroscopic method, there is opportunity to diagnose and treat intra-articular lesions that would otherwise go undetected with open methods. Elhassan’s group revealed comparable results in both arthroscopic and open groups, although 90% of the arthroscopic group underwent subacromial decompression as well as many other additional procedures compared with the open group. Patient dissatisfaction, regrowth of the distal clavicle, and revision surgery were more frequent in the arthroscopic group, although pain directly over the AC joint was less frequent. In another comparative study, the only difference between open and arthroscopic DCE at the 4- to 5-year follow-up was less residual pain in the arthroscopic group.

Complication rates after DCE are noted to be high, with up to 64% of the cases being reported. Residual tenderness of the AC joint (55%), incisional scar sensitivity (55%), postoperative stiffness (29%), hypertrophic incisional scar (14%), and infections (10%) are among the most common reported complications. ^, Motion limitation after an appropriate period of healing is occasionally reported, with undetected stiffness existing at the time of the index procedure likely being the most common precipitating factor. ^{, ,} HO and calcification can occur after an AC joint injury or following excision of the lateral clavicle. ^{, , , ,} Symptomatic HO or calcification is quite uncommon, although it may be an offending lesion when the outcome of DCE by either open or arthroscopic methods is not considered satisfactory ( Fig. 22.6 ). ^{, ,} Patients at high risk for developing HO, such as those with a previous history of the lesion or patients with either hypertrophic pulmonary osteoarthropathy, diabetes mellitus, or spondylitic arthropathy, may be candidates for pharmacologic prophylaxis. The formation of mechanically significant heterotopic bone at the site of DCE is rare. Miscellaneous conditions reported to confound the results of DCE include preexisting psychiatric illness, suprascapular neuropathy, infection, and osseous bridging of the AC joint. ^{, , ,}

An extreme example of heterotopic ossification with nearly complete restoration of the lateral clavicle following open excision.

Other atraumatic indications

An open approach to the AC joint may be needed in the event of septic arthritis, painful cysts, or local or metastatic disease including primary bone tumors such as multiple myeloma. Open techniques are rarely indicated for crystalline arthropathy.

Nonoperative versus operative treatment: General considerations

When compared with nonoperative treatment, operative treatment can result in less pain and better endurance, especially during overhead work. Operative treatment has resulted in improved pain and patient satisfaction in both short- and long-term follow-up studies. ^{, ,} In contrast, no differences between operative and nonoperative treatment have been observed in shoulder strength, pain relief, throwing ability, or osteoarthritis (OA) according to a 2011 meta-analysis from Smith et al.; however, better cosmesis and increased time lost from work occurred with operative treatment. In another systematic review in 2014, Korsten et al. recognized that both subjective and objective outcomes were better with operative treatment, although radiographic abnormalities were more common. Although subjective and radiographic outcomes were better with operative treatment, objective parameters (University of California at Los Angeles [UCLA] score, Constant-Murley [C-M] score, American Shoulder and Elbow Surgeons [ASES] score, ACJI scores) were not significantly different. In high-performance overhead athletes, complete pain relief and return to “normal” was achieved more predictably with operative treatment (92% vs. 80%). Return to professional football required nearly 60 days following those that underwent surgical management for high-grade injuries. Cardone et al. reported a trend toward earlier return to football (i.e., Australian rules) with a more satisfactory outcome following operative treatment.

Historical perspective

A plethora of literature has been published describing surgical techniques to reconstruct the AC joint. Historically, Sage and Salvatore reported primary AC ligament repair with internal fixation or CC reinforcement more than 50 years ago. Even recently, direct ligament repair backed up with a temporary CC screw has been described ( Fig. 22.7 ). Rushton et al. stabilized the AC joint via two pairs of transosseous tunnels between the acromion and distal clavicle and biologic tendon augmentation. Sandmann et al. reported a triple cerclage technique whereby one AC and two CC sutures maintained joint reduction. Sobhy used a single nylon tape around the coracoid, through the clavicle, and across the AC joint.

Acromioclavicular, trapezoid, and conoid ligament suture repair protected with a coracoclavicular screw.

(Modified from Assaghir YM. Outcome of exact anatomic repair and coracoclavicular cortical lag screw in acute acromioclavicular dislocations. J Trauma . 2011;71[3]:E50–E54.)

The AC joint may be reduced by closed or open techniques and stabilized with metallic wires or pins that temporarily cross the joint. ^{, , ,} The importance of supplemental techniques performed in conjunction with internal fixation has been emphasized by some authors. These techniques include additional repair of the AC and CC ligaments, AC and CC ligament repair reinforcement with the intra-articular disk, repair or imbrication of the deltoid and trapezius attachments, adjacent soft tissue transfers (coracoacromial ligament [CAL], short head of the biceps tendon), DCE, autologous fascia lata suspension, CC suture augmentation, and clavicle osteotomy. *

* References , , , , , , , , , , , , , .

Coracoacromial ligament and tendon transfer

Transposing the CAL into the resected distal clavicle was first suggested in 1917 by Cadenet, then advocated by Neviaser in the early 1950s, and finally modified by Weaver and Dunn in 1972, who used the technique for both acute and chronic type III injuries. ^{, , ,} Other authors have used the CAL in the same or a similar manner ^{, , ,} or have modified the previously described Weaver-Dunn method. ^, The CAL, with or without an accompanying fragment of bone, may be transferred to the clavicle with or without supplementary fixation. Augmentation of the CC ligaments in conjunction with the Weaver-Dunn operation have been supported by the results of experimental studies. In 2014, Cerciello et al. described a modified Cadenet procedure with an additional CC cerclage, CC ligament remnant suturing, and transarticular dual K-wire fixation of the reduced AC joint.

Another method for incorporating the CAL was originally described by Vukov. It differs in that the ligament is left intact, and the reduced distal clavicle, having undergone a limited distal resection, is “elastically” affixed with sutures passed through transosseous tunnels in the clavicle.

In 1965, muscle transfers were first suggested as a reasonable treatment for type III injuries. ^, The tip of the coracoid process, including the coracobrachialis and the short head of the biceps tendon, was osteotomized and attached to the clavicle. Scattered reports appeared later, some with slight modifications of the technique. ^, Transposition of the long head of the biceps or a slip of the conjoined tendon have been described as substitution methods for the CC ligaments. Jiang et al. additionally described a reconstruction technique with a proximally based conjoined tendon transfer supplemented with transclavicular sutures anchored in the coracoid process. ^,

Bosworth screw

In 1941, Bosworth was the first to describe the use of a screw between the clavicle and the coracoid process to achieve AC joint stability. Since then, several authors have modified the technique to treat AC joint separations ( Fig. 22.8 ). ^{, , ,} Garrigues et al. described an intraoperative fluoroscopically aided method for the proper identification of the base of the coracoid process to facilitate the placement and security of purchase of a percutaneously placed CC fixation device. This method is applicable to more recent CC devices that incorporate cortical suture buttons (described later).

Excellent reduction with restoration of a normal coracoclavicular interval with a coracoclavicular screw. (A) Anteroposterior stress radiograph of the right shoulder in a patient with a type III acromioclavicular dislocation. (B) A stress film of the left shoulder revealed it to be normal. (C) Postoperative radiograph showing the acromioclavicular joint reduced and held temporarily in place with a special modified coracoclavicular lag screw.

(From Rockwood CA, Green DP, eds. Fractures . 2nd ed. Philadelphia: JB Lippincott; 1984.)

When using the Bosworth procedure, the exploration and debridement of the AC joint has been advocated, ^{, , ,} but some authors do not consider this an essential component of treatment. ^{, ,} In the setting of CC stabilization, the necessity for the direct repair of the CC ligaments remains uncertain. ^{, , , ,} However, some authors have emphasized the importance of supplemental CC ligament repair at the time of CC stabilization. Repair of the trapezius and deltoid fascial attachments can contribute to the overall strength of the repair and has been emphasized by several authors. ^{, , , ,}

There are significant variations in the recommendations for postoperative immobilization, restrictions, rehabilitation, the necessity for implant removal, and the timing of implant removal. ^{, , , ,}

Acromioclavicular joint reconstruction with hook plates

The first account of the use of a hook plate was published by Balser et al. almost 40 years ago. The principles of the hook plate are based on open reduction and internal fixation with a precontoured hook plate affording rigid internal fixation and sparing the articular surfaces of the joint ( Fig. 22.9 A and B). ^{, ,} The device has the advantage of simultaneously stabilizing the CC (superior-inferior) and the AC (anterior-posterior) ligaments. With no other means of fixation augmentation, stability is afforded by scar that accompanies healing of the surrounding soft tissues. Several authors have described the use of supplemental fixation, including CC fixation with polydioxanone sulfate (PDS) sutures, direct CC ligament repair, suturing the capsuloligamentous sleeve of the AC joint, additional screw fixation through the plate, and transposition of the CAL as per Weaver and Dunn. ^{, , , ,} Some authors have advised early range of motion within a day of the operation. ^{, , , ,} Others limit motion after a brief period of protection. ^{, , , ,} Implant removal is reported between 4 and 24 weeks; infrequently, the duration of implant retention is as long as 7 to 13 months. ^, Some authors do not routinely remove the device, ^{, ,} whereas asymptomatic patients may occasionally refuse a secondary operation to remove the plate. Immediately after plate removal, vigorous efforts toward motion and strength recovery are initiated.

(A) Acroplate (aap Implantate AG). (B) Hook plate for type III injury enabling excellent restoration of anatomy.

(A, From Cîrstoiu C, Rădulescu R, Popescu D, et al. Acroplate—a modern solution for the treatment of acromioclavicular joint dislocation. J Med Life . 2009;2[2]: 173–175.)

In the past decade, different hook plate designs have been presented. Although the appearance of the plates may vary, the principles since inception of the concept have not changed. Liu et al. designed and used the articulated micromovable and anatomic AC plate ( Fig. 22.10 ), and Ryhanen et al. described the use of a CC nitinol C-shaped hook implant (tifix AC-Hakenplatte; Fig. 22.11 ). Moreover, arthroscopic-assisted insertions have been described.

Articulated hook plate applied across the acromioclavicular joint to permit some joint motion.

(From Liu Q, Miao J, Lin B, et al. Clinical effect of acute complete acromioclavicular joint dislocation treated with micromovable and anatomic acromioclavicular plate. Int J Med Sci . 2012;9[8]:725–729.)

Tifix AC-hakenplatte.

(From Kienast B, Thietje R, Queitsch C, et al. Mid-term results after operative treatment of Rockwood grade III-V acromioclavicular joint dislocations with an AC-hook-plate. Eur J Med Res . 2011;16[2]:52–56.)

Suture augmentation and synthetic devices

The extraosseous, intraosseous, and transosseous placement of absorbable sutures, nonabsorbable sutures, wires, cables, anchors, and synthetic ligaments have been used for indirect AC joint stabilization ( Fig. 22.12 ). *

* References , , , , , , , , , , .

† References , , , , , , , , , , .

Acute type III injury. (A) Preoperative. (B) Final postoperative treatment using encircling permanent sutures with distal clavicle resection.

Method of coracoclavicular reconstruction with loops passing through a prepared hole in the clavicle.

(Modified from Dimakopoulos P, Panagopoulos A. Functional coracoclavicular stabilization for acute acromioclavicular joint disruption. Orthopedics. 2007;30[2]:103–108.)

Various types of synthetic ligaments have been used for AC joint reconstruction, ^{, ,} with the first reconstruction techniques using CC sutures dating back to 1996. Such methods theoretically pose less risk to adjacent neurovascular structures, have comparable strength of the native ligaments, and are minimally invasive. ^{, ,} Additional advantages include less blood loss, shorter operative time, and no secondary incision or hardware to remove. ^{, ,} The relatively simple suspension method of Huang et al. incorporated subcoracoid and transclavicular passage of large, nonabsorbable sutures through tunnels at the sites of the conoid and trapezoid ligament footprints. Concomitant CC ligament repair can be performed and is noted to be one of the most important components of the repair technique. ^, The potentially less invasive aspects of some newer implants, such as high-tensile sutures with EndoButton fixation, has been recently advocated. ^{, ,}

Anatomic coracoclavicular ligament reconstruction

In the past decade, there has been a significant trend to seek a more anatomic and biologic solution for CC ligament reconstruction. The notion is that reliable restoration of function and comfort is dependent on the durable restoration of anatomic parameters, including the congruency and stability of the AC joint. The method often includes substituting synthetic and/or biologic material for each CC ligament separately entering the clavicle and coracoid as close as possible to the footprints of the native ligaments.

Early biomechanical investigations followed the initial report of Jones et al., who described a surgical technique using an autologous semitendinosus tendon, and applied the method in a revision case. ^{, , , , ,} Mazzocca et al. were among the earliest advocates for so-called anatomic coracoclavicular ligament reconstruction (ACCR) using autograft or allograft tendon to replicate the CC ligaments at their anatomic location ( Fig. 22.14 ). Biomechanically, this has been shown to be more effective in mimicking the properties of the native CC ligaments compared with ligament transfers. Moreover, using the ACCR technique, high subjective satisfaction scores and rates with favorable clinical outcomes have been reported. ^{, , , ,}

A coracoclavicular reconstruction that is considered anatomic uses autograft or allograft tendon.

(Modified from Mazzocca AD, Conway J, Johnson S, et al. The anatomic coracoclavicular ligament reconstruction. Oper Tech Sports Med . 2004;12:56–61.)

Additional biomechanical work by Lee et al. led to the first clinical application and report of the use of autologous hamstring tendon by Nicholas et al. ^, Subsequently, anatomic reconstruction techniques using autogenous or allogenous tendon have been reported as a preferred method of treatment. ^{, ,} Historically, a similar method was eloquently described in 1928 by Bunnell, who incorporated a fascial graft weave that offered stability between the clavicle and the scapula at both sites.

Authors’ preferred surgical method for acromioclavicular joint injuries type III to VI

Our preferred method for type III to VI injuries is the ACCR technique. ^{, , ,} At our institution, patients presenting with acute or chronic type III to VI injuries undergo minimum 6 weeks of nonoperative management, which includes physical therapy. Thus patients who do not respond to a trial of conservative management are indicated for conversion to the ACCR technique. For both groups, good function and clinical outcomes may be expected ^{, , ,} ; however, time from injury to surgery may have an influence on postoperative clinical or radiographic complications such as HO, loss of reduction, or clinical failure. ^, Moreover, Muench et al. and Berthold et al. demonstrated that greater complications for patients with longer time from injury to surgery (>6 months) may be expected. ^,

Surgery starts with the patient in the beach chair position. An incision is made starting at the posterior edge of the clavicle, 3.5 cm medial to the AC joint, and extending inferiorly toward the coracoid process. The incision can be placed obliquely to have full visualization of the AC joint laterally and the coracoid process medially. Dissection is performed down to the deltotrapezial fascia with electrocautery. Full-thickness fascioperiosteal flaps are elevated off the clavicle. All soft tissues preventing proper joint reduction are resected and a trial reduction is performed. This includes upward displacement of the scapulohumeral complex combined with the use of a reduction forceps placed on the posterosuperior clavicle and on the undersurface of the coracoid process. The most distal end of the clavicle should be freed from trapezius muscle, hypertrophic scar tissue, and/or capsular remnants ( Figs. 22.15 and 22.16 ). Care is taken not to damage the distal clavicle.

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Tumors and Related Conditions Throwing athletes Epidemiology, evaluation, and nonoperative management of acromioclavicular joint disorders Anterior instability: Arthroscopic surgery and outcomes Multidirectional instability—open inferior capsular shift Evaluation of rotator cuff pathology: History, examination, and imaging

Stay updated, free articles. Join our Telegram channel

Join