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AC Joint Reconstruction

Evaluation of a New Surgical Technique

RELEVANT LINKS:
Shoulder - General Information
Acromioclavicular Joint Reconstruction - Rehabilitation

Acromioclavicular Joint Reconstruction Using Gore-Tex Tape
Evaluation Of A New Surgical Technique
And Rehabilitation Protocol

Kevin R. Stone, M.D.

Angelo De Carli, M.D.

Robert Day, A.T.C.
Mike Mullin, A.T.C.

N.B. We no longer use GORE-TEX^®; we now use allograft tendon.

ABSTRACT

Surgical repair of the grade III acromioclavicular joint with Gore-Tex tape can lead to a rapid recovery and early return to activity and sports. The new technique avoids the placement of metal screws and anatomically repairs the disrupted joint. An aggressive postoperative rehabilitation program is permitted and leads to an early return of muscle strength. However the technique has specific pitfalls that may lead to early failures. The surgical technique and rehabilitation program are described and illustrated.

Introduction

Injuries to the acromioclavicular (AC) joint are common. Although most of the injuries are treated without surgical repair, surgical intervention is often preferred for throwing athletes with severe dislocations. The surgical techniques have had many complications and require significant recovery periods prior to return to full sports. To diminish the complication rate and to speed the return to full throwing sports a new technique of permanent tape fixation and rapid rehabilitation is described with its own benefits and potential problems.

Mechanism of Injury and Classification

The AC joint is formed by the lateral end of the clavicle and acromion process of the scapula, and has a cartilaginous intraarticular disc. The joint provides a connection between the trunk and upper extremity through the sternoclavicular joint, clavicle and acromioclavicular joint. The AC joint is stabilized by two separate ligamentous structures: the AC ligament and the scapuloclavicular ligaments. The much stronger stabilizing system consists of the conoid and trapezoid ligaments, which run obliquely from the coracoid to the clavicle in opposing directions and are analogous to the cruciate ligaments of the knee, preventing anterior-posterior and upward displacement of the clavicle and acting as a rotational guide. The acromioclavicular capsule is relatively more lax and is reinforced by a superior AC ligament. The most frequent mechanism of injury to the AC joint is a fall or a sharp blow on the acromion process which forces the scapula and the arm downward while the clavicle, locked by the ribs, is then pushed upward. According to Rockwood (1) these lesions are classified in six different types:

Figure 1

Type I: partial tear of the acromioclavicular ligament without real change in position of the distal clavicle in relation to the acromion.
Type II: Rupture of the acromioclavicular ligament with a partial tear of the coracoclavicular ligaments. The distal end of the clavicle is displaced in relation to the acromion less than the full width of the clavicle itself.
Type III: Rupture of the AC ligament and the coracoclavicular ligaments, with displacement of the distal clavicle more than its full width (Figure 1).
Type IV: posterior displacement of the distal clavicle through the muscle aponeuroses of trapezius. Deltoid and trapezius muscles are detached from the distal clavicle.
Type V: The distal clavicle is severely displaced upward toward the base of the neck, covered only by skin and subcutaneous tissue, with a complete rupture of the deltoid- trapezius musculature.
Type VI: Inferior dislocation of the clavicle under either the acromion or the coracoid process. Coracoclavicular ligaments and muscles are intact or disrupted.

"The multiplicity of procedures available is clear evidence that none is totally satisfactory; thus the search for more satisfactory methods continues" (2). However almost all authors note excellent or good results either with conservative or with surgical treatment (references 3-20). More than fifty different bandaging techniques and more than thirty different operations have been suggested for the treatment of complete AC joint dislocation. Surgical repairs fall into two general categories: those that attempt to restore the normal anatomy and those that alter the anatomy in order to achieve reduction and stability. Today most surgeons use various combinations of the techniques described as shown in Table I.

Surgical Indications

The management for acute dislocations of the acromioclavicular joint is controversial. Most of orthopaedists have agreed that Type I and II injuries require a conservative treatment; however the debate in 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. The trend in management of AC type III dislocations in young active people is suggested by results of a questionnaire sent by Cox (20) to the chairmen of all orthopaedic residency training programs in North America and to a group of orthopaedic surgeons active in sports medicine. Eighty-six per cent of physicians involved in care of collegiate and professional athletes and seventy-two per cent of the chairmen preferred non-surgical treatment. Among the physicians that were choosing a conservative treatment, 33% and 28% respectively (team physicians and chairmen) were using manual reduction of the dislocation and maintenance of that reduction by an acromioclavicular immobilizer. However, the questionnaire failed to ask whether the athlete was male or female, a thrower or not, or whether the dominant arm was injured (20). 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.

Surgical Procedure

Our preferred approach for all 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. 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 (Figure 2). 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 (Figure 3). 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 (Figure 4). 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 (Figure 5). Two further #1 Ethibond sutures are passed through the vertical strands of the Gore-Tex tape, effecting final locking of the tape onto itself (Figure 6). 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 suture with 3-0 nylon in the skin. Marcaine is instilled in the incision to afford postoperative pain relief and a standard ABD dressing is applied to the superior aspect of the shoulder with a shoulder sling. An Aircast Cryo Cuff is applied to the shoulder and left in place until the dressing is changed on the first post operative day.

Figure 2	Figure 3	Figure 4

Figure 5	Figure 6

CASE REPORTS

Case Report 1:

A 22 year old female was involved in a side impact auto accident where she hit her right shoulder on the dash board. She suffered a grade 3 AC joint separation. Shortly after the accident she was repaired surgically. Approximately 4 months later she noticed that her clavicle was elevated although she does not recall any post operative complications. She did not like the appearance of the shoulder and requested a second reconstruction. On physical examination she had full range of motion with equal strength bilaterally except for a slight loss of supraspinatus strength on the involved side. The second surgery (AC joint reconstruction using Gore-Tex Tape) was performed approximately 5 months after the first.

The day following the surgery she was started on icing and pendulum exercises. A sling was used for comfort. Two weeks later shoulder pulley range of motion exercises and biceps and triceps strengthening were started. Six weeks after surgery she started active range of motion exercises for the shoulder in all planes. Strengthening of the internal and external rotators of the shoulder and upper back as described earlier were started, also. Eight weeks after surgery she had full range of motion with only a slight loss of strength. She was allowed to begin returning to her normal activities. Sixteen weeks following surgery she had no complaints about her shoulder and she returned to work.

Case Report 2:

A 32 year old highly active male suffered a third degree AC joint separation while snowboarding. The patient fell face first onto the hard snow and tried to somersault back to his feet. Upon rolling to his right shoulder he felt a pop in the shoulder. On physical examination he had a Grade III AC joint separation. One week later surgery was performed to reconstruct the AC joint using Gore-Tex tape. The day following surgery the patient was started on icing, pendulum exercises and active and isometric internal and external rotation exercises. Four days later the exercise program continued and he was started on the AC joint taping program.

One month after surgery the patient was started on the rehabilitation program described above. He progressed as he tolerated the exercises and additional weight.

Five months after surgery the patient had regained his full range of motion and strength and resumed his full activity level which includes windsurfing, road and off road bicycling, running and snowboarding.

Case Report 3:

A 42 year old active female suffered a third degree AC joint separation and possible shoulder subluxation when she landed on her right shoulder during a bicycle accident. On physical examination she had a Grade III AC joint separation as well as a possible anterior subluxation. One week later her AC joint was reconstructed using Gore-Tex tape. The day following surgery she was started on icing, pendulum exercises and isometric internal and external rotation shoulder strengthening.

Two weeks later she was started on biceps and triceps strengthening. Three weeks after surgery she had full passive range of motion of the shoulder and active range of motion to 90 degrees. Shoulder and scapular strengthening exercises as described earlier were started one month after surgery. She regained full range of motion eight weeks after surgery.

Fourteen weeks after surgery she felt a pop in the shoulder area and noticed that her clavicle was slightly elevated. At the time she began to have mild pain with her normal upper body exercise program. Upon physical examination a Grade I AC joint elevation was found. She had full range of motion with decreased strength due to pain. She also complained of left trapezius pain and left arm weakness. Her exercise program was decreased to pain free levels for two weeks then progressed as tolerated.

Eleven months after surgery she had increased elevation of the right AC joint. She complained of aching in the AC joint as well as general upper body weakness. She contributed most of the weakness to her decreased activity following a diagnosis of cervical disc disease and spurring on the left side. However, prominence of the joint suggested failure of the reconstruction.

Case Report 4:

A 43 year old male was horseback riding when he fell from his horse and landed on his right shoulder. Upon physical examination a Grade III AC joint separation was found. This was repaired using Gore-Tex tape three weeks after the injury. Icing and pendulum exercises were started the day following surgery.

Three weeks following surgery he was started in a formal physical therapy program. At four weeks after surgery he had active and passive shoulder flexion to 145 degrees and active and passive abduction to 135 degrees. At this time he was started on the exercise program described earlier.

Three months after surgery he had full range of motion with mild tenderness at the surgical site. He was continuing to increase his exercise program. Four months after surgery he had full range of motion with near normal strength. His only complaint was daily aching but this stopped with exercise.

Five months after surgery he had full range of motion, normal strength, no complaints of pain or aching, and had returned to his normal activity level.

Preferred Post-Operative Protocol On day one post surgery, the dressing is changed, an ABD pad is placed on the superior surface of the wound and cross taping performed in order to reinforce the clavicular reduction. The patient is advised to use the Cryo Cuff icing unit as much as possible over the next 2-3 weeks. An optional sling is used for comfort and support. Isometric internal and external rotation exercises in standing are started. Immediate range of motion exercises with pendulum and biceps and triceps strengthening exercises are permitted. A nerf ball or hand strengthening ball is used to strengthen the grip and forearm muscles. All of the exercises are performed 2-3 times per day for the next two weeks.

On the fifth post operative day the patient returns to the office and the dressing is removed. Supportive taping for the AC joint is applied using dressing retention tape on the skin and rigid strapping tape for support (Figure 7). The patient is taught how to change and apply the tape. Active internal and external rotation exercises are started. The exercises are begun in standing and progressed to side lying as pain and range of motion permit.

Figure 7

After four weeks the patient is started on a more aggressive home rehabilitation program. The shoulder exercises performed are flexion to 90 degrees, abduction to 90 degrees, bent over extension, bent over horizontal abduction, and side lying external rotation. The patient performs 3 sets of 10-15 repetitions with 3 pounds for the first four exercises. The patient is allowed to increase the weight when able to perform 3 sets of 15 repetitions. Side lying external rotation is started at 2 pounds and the weight is increased in 1 pound increments as the patient is able to perform 3 sets of 25 repetitions. The primary emphasis of this phase is to concentrate on the rotator cuff endurance without compromising the AC joint. These exercises are done on a 5 times per week basis for two weeks.

At the sixth post operative week the range of motion of flexion and abduction are increased to 180 degrees as tolerated by the patient. The patient continues to increase the weight to 5 pounds as he is able to complete 3 sets of 15 with each exercise. A maximum of 5 pounds is used for any of these exercises.

Additionally a scapular strengthening program is started with 3 sets of 10-15 repetitions using the SPORT Cord system. The first exercise is seated rowing with the resistance from overhead (Figure 8). The patient is instructed to pull down and back to the belt line. The second exercise is seated middle rowing with the resistance at the chest level (Figure 9). The patient is instructed to pull straight into the chest at a level below the nipple line. Third, is standing rowing with the resistance from below (Figure 10). The patient is instructed to pull the cord under the chin but not to allow the upper arms to abduct more than 90 degrees. The final exercise is the standing punch for the serratus anterior. The patient is instructed to put the cord at shoulder level. A straddled stance with the arm extended at the shoulder level perpendicular to the trunk is used (Figure 11). With the elbow extended the patient thrusts the arm forward while keeping the trunk still and not bending the elbow.

Figure 8	Figure 9

Figure 10	Figure 11

The exercise program is performed on a three times per week basis for each group. The patient is given the option to do all of the exercises in one day or to alternate days with each group. The goal for the patient is to be able to complete 3 sets of 25 repetitions with side lying external rotation using 5 pounds, 3 sets of 15 repetitions using 5 pounds with the shoulder flexion, abduction, extension, and horizontal abduction, and 3 sets of 15 repetitions with the SPORT Cord program. Once the patient is able to achieve these goals a progressive return to sporting activities is planned.

SUMMARY

AC joint dislocations can be safely and solidly repaired without the use of metal or screws. The repair technique with the Gore-Tex tape has lead to a stable shoulder that could be exercised promptly in three of the four patients described in this report. Early return of muscle strength and sporting activities are achieved by following a disciplined shoulder exercise program. Long term complications as a result of Gore-Tex Tape use remain to be evaluated, however one patient appears to have failed fourteen weeks after reconstruction. Most likely, weakness at the suture Gore-Tex interface is the cause. To correct this weakness, a crimp mechanism, securing the Gore-Tex without suture use is under development. At this time, Gore-Tex reconstruction of Grade III AC joint reconstructions may be useful but would benefit from an improved closure technique prior to widespread use.

References:

Rockwood C, Green D: Fractures in Adults, pp 870-2. Lippencott, 1984.
Kappakas G, McMaster J: Repair of acromioclavicular separation using a dacron prosthesis graft. Clin Orthop, 131:247-251, 1978.
O'Carroll P, Sheehan J: Open reduction and percutaneous kirschner wire fixation in complete disruption of the acromioclavicular joint injury, Journal of Accident Surgery 13(4):299-301, 1982.
Copeland S, Kessel L: Disruption of the acromioclavicular joint: surgical anatomy and biological reconstruction. Injury, 11:208-214, 1980.
Warren-Smith C, Ward M: Operation for acromioclavicular dislocation. J Bone Joint Surg. 69B(5):715-718, 1987.
Berson B, Gilbert M, Green S: Acromioclavicular dislocations; treatment by transfer of the conjoined tendon and distal end of the coracoid process to the clavicle. Clin Orthop, 135:157-164, 1978.
Nelson C: Repair of acromio-clavicular separations with knitted dacron graft. Clin Orthop, 143:289, 1979.
Bosworth B: Acromioclavicular separation: new method of repair. Surg Gynecol Obstet, 73:866-871, 1941.
Vargus L: Repair of complete acromioclavicular dislocation, utilizing the short head of the biceps. J Bone Joint Surg, 24(4):772-773, 1942.
Tyler G: Acromioclavicular dislocation fixed by a vitallium screw through the joint. Bosworth Surg Gynec Obst, 245, 1941.
Roper B, Levack B: The surgical treatment of acromioclavicular dislocations. J Bone Joint Surg, 64B(5):597-598, 1982.
Zaricznyj B: Treatment of the acromioclavicular joint. Orthop Rev, 10(4):41-51, 1981.
Bargen J, Erlanger S, Dick H: Biomechanics and comparison of two operative methods of treatment of complete acromioclavicular separation. Clin Orthop, 130:267-269, 1978.
Taft T, Wilson F, Oglesby J: Dislocation of the acromioclavicular joint. J Bone Joint Surg, 69A(7):1045, 1987.
Imantani R, Hanlon J, Cady G: Acute complete acromioclavicular separation. J Bone Joint Surg, 57A(3):328-332, 1975.
Larsen E, Bjerg-Nielsen A, Christensen P: Conservative or surgical treatment of acromioclavicular dislocation. J Bone Joint Surg, 68A(4):552-555, 1986.
Wojtys E, Nelson G: Conservative treatment of grade III acromioclavicular dislocations. Clin Orthop, 268:112-119, 1991.
Varney J, Coker J, Cawley J: Treatment of acromioclavicular dislocation by means of a harness. J Bone Joint Surg, 34A(1):232-233, 1952.
Moneim M, Balduini C: Coracoid fracture as a complication of surgical treatment by coracoclavicular tape fixation. Clin Orthop, 800:133, 1982.
Cox J: Current method of treatment of acromioclavicular joint dislocations. Orthop, 15:1041-1044, 1992.

TABLE 1 Sample of Acromioclavicular Joint Reconstruction Techniques

AUTHORS TECHNIQUE

#
STAGE FOLLOW RESULTS COMPLICATIONS X-RAYS

O'CARROL P.F.

A-C JOINT REPAIR (PERCUTANEOUS KIRSCHNER WIRE)

35
35 ACUTE 30 MO 33 GOOD 2 SUBLUXATION 1 INFECTION 1 LOOSE OF FIXATION I BREAKAGE OF WIRE 19 OSSIFICATION AC JOINT

COPELAND S.

CORACOACROMIAL LIG. + BONE TO THE CLAVICLE + BOSWSORTH SCREW

9
9 CHRONIC 9 MO 7 GOOD 2 SUBLUXATION 1 SEVERE CHANGES TIP OF CLAVICLE

WARREN- SMITH

C.D. EXCISION OF THE DISTAL CLAVICLE + C.A. LIG. IN TO THE CUT END OF THE REMAINING CLAVICLE

29 9 ACUTE
20 CHRONIC 38 MO 17 EXCELLENT 11 GOOD 1 POOR 1 CALCIFICATION C-A LIG.

KAPPAKAS G.S.

C.A. LIG. RECONSTRUCTION WITH A DACRON PROSTHESIS GRAFT 20

20 ACUTE 13 MO 18 SATISFACTORY 2 UNSATISFATORY 1 INFECTION 4 EROSION OF THE GRAFT 10 CALICIFICATIONS C.A. REGION

BERSON B.L.

TRANSFER OF CONJOINED TENDON AND DISTAL END OF CORACOID TO THE CLAVICLE 29

23 ACUTE 6 CHRONIC 47 MO 14 EXCELLENT 14 GOOD 1 FAIR 1 FRACTURE 2 INFECTIONS 1 TRANSIENT FROZEN S. 40% CALCIFICATIONS

NELSON

CA. RECONSTRUCTION WITH UNITED DACRON GRAFT

43
27 MO 98/100 POINTS MEAN 1 INFECTION 2 DEGENERATIVE CHANGES AC JOINT

BOSWORTH A.B.

CORACO-CLAVICULAR FIXATION WITH BOSWORTH SCREW

4
ACUTE 2 EXCELLENT 2 POOR 1 PARTIAL REDISLOCATION 2 SCREW BENDING 1 CALCIFICATION

ZARICZNYJ B.

AC AND CA RECONSTRUCTION WITH AUTOGENOUS TENDON (PALH. LONGUS OR EXT. 5TH TOE)

16
1-18 YRS 16 SATISFACTORY

BARGEN J.H.

AC JOINT REDUCTION + WITH FIXATION WITH WIRE OR DACRON / C-C LOOP

44
12 14/12 15/4 3/10 9/1 18 AC WIRES BROKE. BENT OR BACKED 3 INFECTIONS

IMATANI, R.J.

AJ JOINT RED. + FIXATION WITH STEINMANN PINS OR BONSWORTH 15 ACUTE >10

INCREASING OF THE AC JOINT IN FOLLOW UP

LARSON E. AC JOINT FIXATION (KIRSCHNER WIRES) 39 ACUTE

39 MO 36 EXCELLENT 2 GOOD 0 FAIR 1 POOR 6 INFECTIONS 2 K.W. MIGRATION 6 K.W. BREAKAGE

UNDARAM N. CORACO-CLAVICULAR FIXATION (MODIFIED BOSWORTH TECH.)

31 ACUTE 12 YRS 24 EXCELLENT OR GOOD 7 FAIR NO CORRELA- TION BETWEEN X-RAY & CLIMCAL RESULTS

STAM L.

CORACO CLAVICULAR FIXATION WITH DACRON LIGAMENT

20
4 YRS 19 EXCELLENT OR GOOD 1 POOR

BAKALIM G.

CORACO CLAVICULAR REPAIR + AC JOINT FIXATION (KIRSCHNER)

19 ACUTE 4 YRS 14 GOOD 5 POOR 2 PARTIAL DISLOCATIONS 1 COMPLETE DISLOCATION 13 OSSIFICATIONS C-A LIG.

SAGE F.P.

A-C JOINT FIXATION (K-WIRES, STEINMANN KNOWLES PINS...)

33 ACUTE/CHRONIC 17 MO 22 EXCELLENT 8 GOOD 3 POOR 4 EXTRUSION OF PINS OR INFECTION 43 CALCIFICATIONS

NEVIASER J.S

AC JOINT FIXATION (KIRSCHNER) + CORACO ACROMIAL LIG. TRANSFERENCE

112 ACUTE/CHRONIC 10 YRS 103 EXCELLENT 5 FAIR 4 POOR 4 RECURRENCE
1 INFECTION 1 BROKEN KIRSCHNER 22 CALCIFICATIONS CORACO CLAVICLE
16 CALCIFICATIONS AC JOINT

ENS W.D.

AC JOINT FIXATION + DELTOID TRAREZIUS IMBRICATION

7
6-2 MO 7 EXCELLENT NONE