AC Joint Reconstruction Overview
Although most injuries are treated without surgical repair, surgical intervention is often preferred for throwing athletes with severe dislocations. The management for acute dislocations of the acromioclavicular joint is controversial. Most orthopaedists agree that Type I and II injuries require conservative treatment; however, the debate in the case of Type II injury concerns which type of non-surgical treatment to employ; either symptomatic only or bandaging in order to attempt an external reduction of the AC joint dislocation. Grade III injuries may be managed either with surgery or non-operatively. In our experience, throwers and other overhead athletes playing tennis, volleyball, and squash are significantly weakened by the Grade III joint dislocation for up to a year after injury. In these athletes, and with patients concerned about the cosmetic appearance of the dislocation, we recommend prompt repair and rapid return to training.
AC Joint Reconstruction Surgical Technique
Our preferred approach for shoulder surgery, both arthroscopic and open, is with the patient in the “beach chair position.” The arm is draped free and gravity provides a safe level of traction. The AC joint is exposed through a vertical longitudinal incision directly over the AC joint extending down just superior to the coracoid in Langer's lines. A sharp dissection is carried down to the superior surface of the clavicle.
The torn superior ligamentous connection between the clavicle and the acromion is carefully identified and preserved. Using sharp dissection, the remaining fascial fibers are dissected from the superior surface of the clavicle. Using blunt dissection, the tip of the coracoid is identified. A 4.5 millimeter AO drill and guide is brought into place. A Darrach retractor is placed inferior to the clavicle and a vertical 4.5 millimeter drill hole is placed from superior to inferior, directly in the mid-body of the clavicle one centimeter from the distal clavicular end. A second 4.5 millimeter drill hole is then placed from superior to inferior through the distal tip of the coracoid process, taking care not to break through the distal tip of the coracoid; again, one centimeter from the distal tip. Careful identification of the coracoclavicular ligaments is then performed.
|Rupture of the AC ligament and the coracoclavicular ligaments, with displacement of the distal clavicle more than its full width.|
|If the ligaments are of sufficient quality, a #1 Ethibond suture is woven into the remaining coracoclavicular ligaments and passed through the periosteum of the clavicle, performing a primary repair of the coracoclavicular ligaments. A flexible Richard's suture passer is then passed through the clavicle, carrying a #1 Ethibond suture and through the distal tip of the coracoid from superior to inferior. The suture is then passed with a sharp needle through the end of a 4 millimeter Gore-Tex tape. The suture and tape are then pulled through from superior to inferior of the clavicle and the coracoid.|
|The loop of the Gore-Tex tape is left on the superior surface of the clavicle and the Gore-Tex tape is looped over the distal tip of the coracoid back up to the loop on the superior surface of the clavicle and folded down over itself in a belt loop fashion.|
|Using a large Kocher clamp, the distal end of the Gore-Tex is clamped and tension applied, reducing the clavicle to the level of the acromion.|
|A #1 Ethibond suture is passed through the looped ends of the Gore-Tex tape, securing the vertical strands to each other, effectively stopping any further slippage of the Gore-Tex tape onto itself. The tape is then wound around itself in a candy-stick fashion.|
|Two further #1 Ethibond sutures are passed through the vertical strands of the Gore-Tex tape, effecting final locking of the tape onto itself.|
This step defines the ultimate failure strength of the procedure. If the tape shreds or is weakened during needle passage, failure may occur by early rupture of the suture-tape construct. Closure is then undertaken by primarily repairing the superior ligamentous tissues overlying the clavicle and acromion. Soft-tissue closure is performed by using 0 and 2-0 absorbable sutures with 3-0 nylon in the skin. Marcaine is instilled in the incision to afford post-operative pain relief and a standard ABD dressing is applied to the superior aspect of the shoulder along with a shoulder sling. A Breg cryo cuff is applied to the shoulder and left in place until the dressing is changed on the first post-operative day.
AC Joint Reconstruction Rehabilitation Protocol
The Stone Clinic
Building Better Joints Through Advanced Techniques in Cartilage Replacement, Regeneration and Repair