AcromioClavicular Joint Injury

Courtesy: Ali Noorani, Shoulder Surgeon, London, UK

ACROMIOCLAVICULAR JOINT INJURIES

Objectives

ACJ Joint Anatomy & Stability
Classification of ACJ Instability
Management of Acute Injuries
Management of Chronic Injuries
Techniques for fixation

Stability

STATIC

Every joint relies on Ligaments – acromioclavicular and coracoclavicular, bony Congruency and muscles around it in addition to a good functioning neurological system
CC ligaments constitutes of conoid and trapezoid parts

DYNAMIC
– Deltotrapezial Fascia

Anatomy

AC Joint Anatomy
– Diarthrodal Joint – Variety of Movements
– Intra-articular Disc (meniscus)
– Surrounded by capsule
– Thickest superiorly
– Thinnest inferiorly

Age & Diagnosis of Shoulder Pathologies

– 10 to 30 years
Instability ( Glenohumeral Joint & AC Joint )
Internal & Secondary Impingement

– 30 to 50 years
Primary Impingement Syndrome
Frozen Shoulder
AC Joint Pain

– 50 to 80 years
Full Thickness Cuff Tears
Arthritis

AC Separations

Prevalence of Type 3 or higher- 14.5/100k per year
Incidence depends on activity: 32% of professional Rugby players, 9% to 12% of traumatic shoulder injuries
Associated intra-articular pathology> 15 %

Classification of AC Joint Separation

Type I
Sprain of the joint

Type II

Some disruption of the AC ligaments
Non-surgical injury’s only requiring rest and NSAIDs

Type III

Superior dislocation of the AC joint with ruptured AC and CC ligaments
TO FIX OR NOT TO FIX?
Remains Controversial

Type IV

Posterior displacement

Type V

Highly Elevated

Type VI

Inferior displacement
All require surgical intervention

Treatment:

1 & 2 – These are stable and may be treated conservatively
3 Usually Non Operative initially. Consider Operative for Sports ( Throwers/Contact)
4/5 – these are unstable and require surgical management
6 Rare but Fix it

Surgical Considerations for type 3

Two different approaches

1.Fix Acutely

Heavy Laborers
High level athletes
Patients not willing to accept cosmetic deformity
Trade bump for Scar

2. Conservative approach

Rest
Ice
Anti-inflammatories
Continued pain or fatigue for > 3months = Surgery
Usually done with addition of biologic graft

Classification

Flawed. Not a linear deformity but 3D Rotational Deformity
X-rays can show dynamic improvement
4/5 is probably the same
Examination more important than the X-ray in decision making
Low intra and inter observer reliability for the Rockwood classification

Acute or Chronic ACJ

Acute 6 weeks
Aim for Reconstruction
Allograft, Autograft or Synthetic Ligament +/- Additional Stability
e.g Dog-Bone or Hook Plate

Surgical Treatment for Acute Injuries

Address All Stabilisers of the Joint
Periosteal sleeve avulsion of CC ligaments.
Reduce Clavicle and hold it
Stable e.g Dog Bone or Hook plate
Repair Posterior Capsule of Joint
Avoid resection of lateral end of clavicle. Remove IA Disc.
Avoid further damage to Deltoid and Trapezius
Mason-Allen repair of Deltotrapezial fascia

Surgical Treatment for Chronic Injuries

Address All Stabilisers of the Joint
Reconstruction of CC +/- AC ligaments & hold it stable e.g Dog Bone or Hook plate
Repair Posterior Capsule of Joint
Avoid resection of lateral end of clavicle. Remove IA Disc.
Avoid further damage to Deltoid and Trapezius
Mason-Allen repair of Deltotrapezial fascia

AC Joint Reconstruction

Important Considerations:

Arthroscopic Technique (address associated pathology- 18% to 50% in reports)
Open Technique Repairs the Deltotrapezial fascia and capsule
Consider Combination
Strength of construct
Potential Complications

AC Joint Surgery

Bosworth screw
Weaver-Dunn
Hook plate
Tightrope
Surgilig/Lockdown/Synthetic Ligament
Auto or Allograft
Arthrex Dog-Bone

ACCR Technique

Anatomic Coracoclavicular Reconstruction
“Mazzocca” technique
Open technique for chronic AC reconstruction
Graft under coracoid using fibre wires and screws

Current Challenges in AC Joint Repair