Acromioclavicular Joint Repair- Orthopedics
Acromioclavicular Joint Repair
The acromioclavicular joint on the shoulder, often called the AC joint, is where two bones converge. The collarbone, or clavicle, is one of these bones. The second bone is actually a piece of the scapula, the large bone that sits behind the shoulder and is connected to the shoulder joint. The acromion refers to the area of the shoulder blade that joins the collarbone. The AC joint is, therefore, where the clavicle joins the acromion.
Arthritis, injuries, and "separations" are the most common issues affecting the AC joint. When the acromioclavicular joint is "separated", it means that the acromion and clavicle ligaments have been injured, causing the two structures to no longer align properly.
Acromioclavicular joint separations frequently develop from falls or other trauma where the acromion may shift or separate from the clavicle, and the ligaments may be strained or ripped.
While conservative therapy is frequently used to treat AC joint separations initially, more severe injuries or those that last for a long time may necessitate surgery.
Depending on how long you had the condition, a joint repair or reconstruction may be performed. After carefully assessing your condition, your surgeon will decide which type of operation is most appropriate for you.
What Is An Acromioclavicular Joint Separation?
An acromioclavicular joint separation or a separated shoulder occurs when the ligaments between the part of the shoulder blade (acromion) and the collarbone (clavicle) are torn. The rip causes the collarbone and shoulder blade to shift or separate from one another.
A separated shoulder, unlike a dislocated shoulder, does not involve damage to the primary ball-and-socket joint. The AC joint's supporting and encircling ligaments are ruptured. A hump on the shoulder results from the clavicle being pushed up and the shoulder collapsing beneath the weight of the arm in the absence of any ligament support.
Most shoulder separations are brought on by direct impact with the shoulder that is strong enough to rip ligaments. Injuries sustained in sports and car accidents also frequently result in AC joint separation.
AC separations can range in severity from minor to severe, depending on the ligaments ripped and the extent of the damage.
Grade I Injury: The least damage has been done, and the AC joint is still lined up.
Grade II injury: There is damage to the ligaments supporting the AC joint. However, these ligaments are only partially torn. Under pressure, the AC joint becomes unsteady and uncomfortable.
Grade III Injury: The AC and secondary ligaments have been completely torn, with the collarbone no longer connected to the shoulder blade and showing an obvious deformity.
The Rockwood classification of AC joint injuries ranges from type I (injury limited to an AC ligament sprain; joint still in place) to VI (severe ligament detachment and joint dislocation) injuries.
How Is An AC Joint Separation Diagnosed?
AC Joint separation results in pain at the topmost part of your shoulder. It also causes a lump at the end of the collarbone on the top of the shoulder. In addition, due to ruptured ligaments, the weight of the arm causes the shoulder blade to shift downward, which causes the top end of the collarbone to protrude up.
A separated shoulder is diagnosed in the following ways:
- A review of the injured shoulder's current signs and symptoms
- A review of the medical history
- A physical examination
Your doctor might ask you to undergo imaging procedures such as X-rays, MRIs (magnetic resonance imaging), and ultrasounds. You could be requested to bear weight in your hand during these tests to make the injury more evident in the images taken.
The doctor can assess the severity of the shoulder separation following an examination and grade the severity. This gives the patient an indication of the duration of the treatment and the long-term repercussions, as well as determining the proper medical response, including the requirement for surgery.
Treatment Of AC Joint Separation
Most patients heal from a separated shoulder without surgery in two to twelve weeks. The non-surgical procedures utilized are as follows:
- Using a sling to keep the shoulder in place while it heals.
- Placing ice packs and taking painkillers, such as ibuprofen, aspirin, naproxen, or acetaminophen, to relieve pain and discomfort.
Physical therapy or an exercise regimen to strengthen the shoulder muscles and ligaments may be necessary once the injury has healed. A doctor's approval is required before beginning a rehabilitation program. Refrain from carrying large objects for eight to twelve weeks, even after the shoulder has healed.
Surgery may be necessary when non-surgical treatments are shown to be ineffective or in more difficult situations (such as class IV, V, or VI injuries on the Rockwood scale). For example, the injury is more severe in cases where the fingers are cold or numb, the shoulder deformity is significant, or the arm muscles are weak.
Primary Acromioclavicular Joint Repair
The surgery is best carried out within two to three weeks of the injury and is used to repair an acute acromioclavicular joint separation.
How is the procedure carried out?
The surgery is performed under a combination of general and regional anesthesia. In the acute setting, an incision is made over the acromioclavicular joint, exposing the joint and the end of the collarbone. The coracoid process and the clavicle both have tunnels drilled into them.
To stabilize the coracoclavicular interval, a "tight-rope" device is positioned between the clavicle and the coracoid and tightened. Next, sutures are inserted through drill holes in the bones to repair the capsule (or sleeve) surrounding the acromioclavicular joint. After the treatment, the surrounding muscles are fixed, and the skin is stitched shut using sutures inserted deep beneath the skin.
Repairing the injury, regaining stability, and enhancing joint function are the key benefits of the surgery. Over 90% of patients experience positive outcomes from surgery.
Although surgery is generally safe, there are certain risks associated with acromioclavicular joint repair or reconstruction, such as:
Stiffness (10%) – Most of the time, it will go away as soon as you start moving the arm with the help of physiotherapy. This occasionally necessitates additional surgery to restore movement.
Pain – The shoulder may be sore for a few weeks following surgery. This is typically controlled by activity modification and using proper painkillers.
Recurrent AC joint instability - As the implant stretches, a tiny step may occasionally become visible at the AC joint. This is rarely functionally important and typically does not require revision surgery. Only a tiny minority of patients will experience recurring AC joint instability and need revision surgery.
Infection (1%) – If an infection occurs, you might require further surgery or medication to eliminate it.
Bleeding or nerve damage (<1%) Minor bleeding from the surgery site is not unusual and will often stop in a day or two. Nerve injury is possible but very rare.
Bruising - Bruising around the joint and the scar is possible and often goes away two to three weeks after surgery.
Coracoid/clavicle fracture or erosion - These narrow bones can occasionally experience erosion or, even less frequently, fracture during or after these operations.
Numbness – A little numbness next to the scar is not unusual, although it does not interfere with daily activities.
Hardware or fixation failure – Rarely, the sutures employed in the tight-rope device may fail, cut out of the bone, or become loose. It might necessitate additional surgery.
Asymmetry – The two sides may continue to be slightly asymmetrical. Typically, this does not result in functional issues.
Arthrosis – Wear and tear in the joint after an injury can cause symptoms later and necessitate follow-up treatment.
Following surgery, shower-proof bandages are applied to the surgical incision. For 14 days, the dressings should be kept as undisturbed as possible. If the dressings are taken off for any reason, they need to be replaced with plasters that are waterproof or similar dressings.
A physiotherapist will give instructions on how to care for the shoulder before hospital discharge. You will be instructed to protect the shoulder by using a sling for four weeks and occasionally moving the shoulder within certain limits.
You can discontinue using the sling and be permitted to actively move your shoulder through a wider range of motion after four weeks. After eight weeks, strengthening workouts are initiated.
You should refrain from lifting anything heavy or using your arm vigorously for three months. After that, it may be necessary to continue outpatient physical treatment for another three to six months.
After one week or once you can control your arm, you can start driving again. Depending on your line of work, you may return to work accordingly. Avoid performing manual tasks for at least three months. Both contact and non-contact sports may be resumed after three and six months, respectively.
Chronic Reconstruction of Unstable Acromioclavicular Joint
This is an open procedure that is carried out for chronic cases where reconstructing the ligaments is necessary rather than simply repairing them.
How is the procedure carried out?
An incision is made over the top of the shoulder to expose the lateral clavicle and coracoid process. The medial deltoid muscle is lifted and flipped off the lateral clavicle to expose the coracoid. A wafer of bone is removed from the injured end of the clavicle, and debris is removed. A loop of very sturdy, specifically woven polyester rope (LARS ligament) is attached with small screws via two holes in the collarbone and looped beneath the bony coracoid process of the shoulder blade. The remaining nylon rope is employed to fortify the repair even further.
A second implant (Internal Brace, a fiber tape held with two suture anchors) may occasionally be used to improve front-to-back stability.
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