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Traumatic Injuries

It has been well accepted that type I and II AC separations should initially be treated nonoperatively. However, it should be noted that not all patients will fully recover following these seemingly benign injuries. Bergfeld et al9 reported that 9% of type I and 23% of type II AC separations will have difficulties following nonoperative treatment. Similarly, it has been standard of care to treat type IV V and VI injuries operatively. Due to the severity of soft-tissue injury in these higher grade separations, nonoperative management has resulted in poor outcomes.9 The treatment of grade III AC separations remains controversial. Historically, the argument against nonoperative treatment has been based on retrospective studies that claim poor long-term results. Several authors claim that operative intervention is superior to nonoperative management due to findings indicating that surgical reduction of the joint will improve the subjective and objective long-term results.10,11 These reports condemn nonoperative management (citing factors such as persistent deformity, AC arthritis, and residual weakness) as inadequate treatment of this injury.12,13 For grade III AC separations, we generally recommend nonoperative management.14 In a prospective evaluation of patients treated nonoperatively for AC separations, we followed a small group of recreational athletes

Athletes Acromioclavicular
Figure 26-5 Anteroposterior view radiograph taken at 15 degrees cephalad.

Figure 26-6 Cross-arm adduction view radiograph.

Table 26-1 Injury Classification of Acromioclavicular Joint Injuries

Type I

Acromioclavicular joint

AC ligament: strained CC ligament: strained

Type II

Acromioclavicular joint

AC ligament: ruptured CC ligament: strained <25% displacement of CC distance.

Type III

Acromioclavicular ligament

Acromioclavicular ligament

Coracoclavicular Interspace
. Coracoclavicular ligament

AC ligament: ruptured CC ligament: ruptured

25%-100% displacement of CC interspace.

Type IV

Coracoclavicular ligament

Acromioclavicular ligament

Acromioclavicular ligament

Deltotrapezial Fascia Image

Coracoacromial ligament


„Supraspinatus Acromioclavicular ligament

Coracoclavicular ligament

AC ligament: ruptured CC ligament: ruptured

Clavicle displaced posteriorly into trapezius. 25%-100% displacement of CC interspace.

Type V

Acromioclavicular ligament

Acromioclavicular ligament

Coracoclavicular ligament

Type VI

Acromioclavicular ligament Coracoclavicular ligament

Coracoclavicular ligament

AC ligament: ruptured CC ligament: ruptured >100% displacement of CC interspace. Deltotrapezial fascia often disrupted.

AC ligament: ruptured CC ligament: ruptured

Inferior displacement of clavicle beneath coracoid. Likely mechanism is severe hyperadduction with external rotation.

AC, acromioclavicular; CC, coracoclavicular.

with type III AC separations and found that the majority had acceptable results.14 Patients were not given a specific treatment regimen other than rest, ice, and the use of nonsteroidal antiinflammatory drugs. Patients demonstrated no limitation in range of motion or loss in rotational strength. However, there was, on average, a 17% deficit in bench press strength compared to the uninvolved extremity. Twenty percent believed their results were suboptimal, but none were severe enough to warrant surgery. Of these individuals, the perceived disability was fatigue with maximal overhead activities, such as lifting and climbing.

There is still considerable controversy regarding the management of high-grade AC separations in overhead athletes. There are very few studies in the literature that address this topic, particularly for the high-level thrower. Lemos15 suggested operative management for high-level pitchers after a retrospective review of patients. McFarland et al16 surveyed 42 orthopedic surgeons participating in the care of 28 professional baseball teams; 31% recommended immediate operative treatment. However, this same group of surgeons estimated that normal function and significant pain relief were achieved in 80% of their athletes with nonoperative management. We recently completed a retrospective review of National Football League quarterbacks with complete grade III AC separations. When the injury involved the dominant extremity, nonoperative management had variable success. If the player was treated in a Kenny-Howard sling full time for at least 3 weeks, missing an average of eight games, all were able to eventually return to play without problems. When the player was treated with a sling for comfort and early motion, the average time lost was only five games. However, a high percentage of these quarterbacks eventually underwent surgical reconstruction in the off season. In quarterbacks who had early surgery, all of them missed the remainder of the season but were able to return the following year without problems. From this review, it has been our opinion that if a quarterback has an injury to his dominant extremity early in the season, then a trial of nonoperative management is warranted. If he fails this treatment or if the injury occurs late in the season, then surgical reconstruction can be expected to result in a good outcome.

Nonoperative Treatment for Traumatic Acromioclavicular Separations

In all cases, patients are treated with ice, analgesics, and non-steroidal anti-inflammatory drugs for acute pain control. Options for immobilization for these injuries include sling,17,18 brace and harness,19-21 adhesive straps,22,23 figure-eight straps,24 and a sling strap.25 Of these, the most popular is the Kenny-Howard sling. This consists of a sling with a strap over the distal end of the clavicle, which is tightened to manually reduce the distal end of the clavicle in relationship to the acromion. However, for effective reduction, the patient is required to wear the sling continuously for the first 3 to 4 weeks. Removal of the strap leads to loss of joint reduction. The sling can also be problematic because the pressure of the strap can cause necrosis of the skin over the distal clavicle. One case of posterior interosseous nerve palsy caused by the sling has been reported in the literature.26


Open Distal Clavicle Resection

Traditionally, distal clavicle excisions have been performed using open techniques. These have been done in isolation for AC arthritis, as well as with concomitant surgeries for rotator cuff pathology. In 1941, Gurd27 and Mumford28 independently described their results of excision of the distal end of the clavicle. Mumford recommended this operation for AC instability particularly in those with arthritis of the joint.28 Gurd27 recommended his procedure in symptomatic type III AC separations. Technically speaking, excision of the distal end of the clavicle is referred to as the Mumford or Gurd operation only when this procedure is used for excision of the clavicle with associated instability. Nowadays, the distal clavicle excision is more routinely used for patients with arthritis. Patients with true AC instability are typically managed with a reconstructive procedure (described later in this chapter).

The operation is usually performed in the beach chair position. The arm is prepped and draped free. When this procedure is being done for isolated AC arthritis, a vertical incision approximately 2.5 to 3 cm in length is placed directly over the distal end of the clavicle (Fig. 26-7). An incision is made through the skin and dissection is carried out through the subcutaneous tissue. On incising the capsule by sharp dissection, a degenerative disk will often be identified along with articular cartilage changes on the distal end of the clavicle. After removing the disk and/or hypertrophic synovium, a subperiosteal dissection is then performed to expose the distal end of the clavicle. An attempt to preserve a thick fascial sleeve will be helpful at the time of closure.

A large Darrach retractor is placed underneath the clavicle to protect the underlying neurovascular structures. A sagittal saw is then used to make a perpendicular cut in order to remove approximately 1 to 1.5 cm of the distal clavicle (Fig. 26-8). Care

Clavicle Resection

Figure 26-7 Open distal clavicle resection. A, A vertical incision approximately 2.5 to 3 cm in length is placed directly over the distal end of the clavicle. B, A large Darrach retractor is placed underneath the clavicle to protect the underlying neurovascular structures. (Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

Figure 26-7 Open distal clavicle resection. A, A vertical incision approximately 2.5 to 3 cm in length is placed directly over the distal end of the clavicle. B, A large Darrach retractor is placed underneath the clavicle to protect the underlying neurovascular structures. (Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

Hawkins Shoulder Retractor Depuy
Figure 26-8 With a distal clavicle resection, approximately 1 to 1.5cm of the distal clavicle is removed. (Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

should be taken to avoid excessive resection of the distal clavicle, as this will often lead to instability if the CC ligaments are disrupted. The completion of the cut can be done using osteotomes. Following the resection, a gloved finger should be able to remain between the clavicle and the acromion as the arm is brought into maximal adduction. This serves as a method to determine whether the distal clavicle has been sufficiently excised. It is not uncommon to find that more of the anterior portion of the clavicle has been removed, leaving more of the posterior clavicle, which can create pain from ongoing contact of the distal end of the clavicle with acromion (Fig. 26-9).

After thorough irrigation, the deltotrapezial fascia is reap-proximated using no. 1 Vicryl sutures. The deep subcutaneous tissue is closed with interrupted 3-0 absorbable sutures. The skin is either closed with a running nylon suture or staples. Postop-eratively, the patient is placed into a sling for comfort, passive range of motion is started between 0 and 2 weeks, active motion between 2 and 4 weeks, and a light strengthening program can begin at 4 weeks.

Arthroscopic Distal Clavicle Resection

With an increasing number of shoulder procedures being done completely arthroscopically, it is important for physicians treating these problems to have a method of addressing the degenerative AC joint using an all-arthroscopic technique. After performing a thorough diagnostic arthroscopy of the shoulder and addressing the associated pathology, preparations are made for distal clavicle excision.

The distal clavicle resection usually begins with the arthro-scope in the posterior portal, using the lateral accessory portal for the working instruments. This procedure is often done in conjunction with a subacromial decompression. In most cases, the bursa has been excised and the acromion has been converted to a type I morphology. This allows visualization of the AC joint. The joint can be identified either by pushing on the end of the distal clavicle and looking for movement or by placing a spinal needle in the AC joint to identify the exact location. At this point, a shaver can be used to remove the underlying joint capsule identifying the distal end of the clavicle. As noted with the open technique, there will often be a degenerative disk and/or degenerative changes of the articular cartilage overlying the clavicle.

Eventually, the working instruments will be brought to the anterior portal site to allow resection of the capsule and then bone. Synovial shavers are initially used to resect the soft tissue and then a round 4-0 bur is employed. As opposed to the open technique, the arthroscopic resection often will remove no more than a centimeter. This can be done by removing bone on both acromial and clavicular sides. Once an adequate amount of resection of the bone has been performed, the scope should be taken out of the posterior viewing portal and placed into the anterior portal. This will then allow visualization of the posterior aspect of the AC joint. A spinal needle is then used to identify the location for a direct posterior portal site, and once this is confirmed, a no. 11 scalpel blade can be used to make a skin incision. Blunt dissection is carried out to bring the shavers and bur into the posterior aspect of the AC joint. This is helpful to resect the bone posteriorly.

It is equally as problematic when using an arthroscopic technique as in the open technique if adequate posterior clavicle resection is not achieved. The other pitfall with the arthroscopic technique is often not taking enough of the soft tissue prior to bony resection, making assessment of the superior bone inadequate. This can be remedied by using an electric cautery wand to identify the end of the bone and the overlying capsule, particularly superiorly. Once an adequate resection has been performed, it is then possible to remove the scope from the anterior portal and place it in the direct posterior portal site to view the amount of anterior resection. An instrument such as an arthro-scopic osteotome or probe can then be used to confirm an adequate amount of bony resection. Care is taken to preserve the



Joint Inflammation Recovery
Figure 26-9 Contact between the distal end of clavicle and the acromion may cause pain. (Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

dorsal AC ligaments. This is one of the advantages of the arthroscopic technique. It is often thought to result in an earlier recovery.

In cases of osteolysis, there is rarely a need to resect any bone since this disorder leads to bone loss. In this pathologic entity, the joint usually has an inflammatory process that is best treated by resection of the inflamed joint tissue.

Postoperative care involves the use of a sling for comfort. Cryotherapy is also undertaken. Patients are able to work through the active and passive range-of-motion program more quickly than what is traditionally seen with an open procedure. Once pain subsides, progressive resisted exercises are initiated.

In our experience, the greatest advantage of the arthroscopic resection is that time lost can be reduced by nearly 4 weeks. By preserving the AC joint capsule and ligaments, the recovery time can be expected to be as short as 8 weeks.

Distal Clavicle Resection Recovery Time

Acromioclavicular Reconstruction

Indications for early surgery include a grossly unstable highriding distal clavicle, fixed deformities, and occasionally in the overhead throwing athlete. Traditionally, these are addressed by performing a primary autogenous repair of the disrupted AC and CC ligaments. This is then supplemented with an absorbable no. 9 braided polydiaxone monofilament suture strand that is passed around the base of the coracoid and then through a drill hole in the anterior aspect of the clavicle, as described by Warren29 (Fig. 26-10). This creates a strong absorbable construct lasting approximately 6 to 8 weeks, which is long enough to hold the clavicle in position while the autogenous tissue heals. In acute cases, the distal end of the clavicle may be preserved if there is a normal intra-articular disk and no evidence of arthritis.

Delayed AC reconstructions are recommended in patients who have a high-riding unstable dislocation that has failed nonoperative treatment. Because of the difficulty in maintaining the

Acromioclavicular Reconstruction
Figure 26-10 Acromioclavicular reconstruction. A vertical drill hole (arrow) is made through the anterior aspect of the clavicle. (Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)
Atlas Subluxation Treatment

Figure 26-11 A and B, The reconstruction is performed using existing ligaments and supplemented with absorbable polydiaxone monofilament suture. (A, Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

Figure 26-11 A and B, The reconstruction is performed using existing ligaments and supplemented with absorbable polydiaxone monofilament suture. (A, Adapted from Hawkins RJ, Bell SB, Lippitt LH: Atlas of Shoulder Surgery. Philadelphia, Mosby, 1996.)

reduction in these situations, we have described a "three-in-one" repair (Fig. 26-1 1).30 This technique employs a modified Weaver-Dunn reconstruction supplemented with either a palmaris or hamstring tendon as an autogenous graft. In chronic cases, we always resect approximately 1.5 cm of the distal end of the clavicle. This eliminates the possibility of postoperative pain in cases of degenerative arthritis or when there is partial loss of reduction of the distal clavicle. The coracoacromial ligament is then transferred into the medullary canal of the clavicle as part of the modified Weaver-Dunn reconstruction. A 3/8-inch drill is used to make a hole in the anterior aspect of the clavicle at the level of the coracoid to eventually pass a polydi-axone monofilament suture strand and palmaris/hamstring graft. It is important to keep the drill hole anterior so to better position the clavicle in relationship to the acromion as these structures are secured. If the drill hole is placed too posteriorly, it will have a tendency to pull the clavicle anteriorly in relationship to the acromion. Once these structures are around the cora-coid, they are passed through the drill hole in the clavicle creating a figure-eight construct for both the polydiaxone monofilament suture and palmaris graft. With the clavicle reduced, it is now possible to maintain the reduction by tying the palmaris/hamstring graft using a surgeon's knot. This has been proved to be the strongest method to secure the autogenous tissue.31 As with the acute surgeries, we protect the reconstruction with an absorbable suture strand. In the past, we used to braid the suture but found this extremely difficult to handle and tie this construct. We have now modified this braided technique after being shown a new method that we have nicknamed the Skyler Scroll after Dr. Skyler DeJong from West Point. This method creates a polydiaxone monofilament suture rope by taking three individual strands of polydiaxone monofilament suture and securing them at one end while rotating the group 30 times in a clockwise manner. After each of the three strands is created, the entire group is then rotated 40 times in a counterclockwise manner. Once the AC joint is reduced, the delto-trapezial fascial flaps are reapproximated as part of the repair. The skin is then closed with a running nylon stitch.

Postoperatively these patients are protected in a sling for a total of 4 weeks without any motion. We have learned that accelerated rehabilitation programs often lead to loss of reduction. At the 4-week mark, passive range of motion is employed for 2 weeks. An active range-of-motion program with terminal stretching then follows this for 2 weeks. At the 8-week mark, a light resisted strengthening program can be instituted, with return to the weight room at 3 months. The patient is released to all activities without restriction at 4 months.


In general, patients are restricted from unlimited activities until they have a full pain-free range of motion with normal strength. With nonoperative treatment of acute AC separations, the time lost from participation depends on the grade of injury and the sport. On average, those with grade I injuries miss 1 week, those with grade II are out 2 to 4 weeks, and those with grade III AC separations can be expected to miss up to 6 weeks.

It has been our experience that in the athletic patient population, time lost can be significantly reduced when a cortico-steroid injection is used acutely as an adjunct to the nonoperative program, immediately after these injuries occur (Fig. 26-12). We

Figure 26-12 Corticosteroid injection into the acromioclavicular joint.

have had experience with this form of treatment in the professional football player population.32 With higher grade AC separations, time lost was dramatically reduced when the nonoperative program was augmented with injection. When an athlete returns to contact sports, an AC pad is helpful to limit recurrent injuries. In this select group, we have found the injections to be safe and have had no complications such as infection or progression to higher grade AC separations.


The success rate of nonoperative treatment in grade I and II AC separations and chronic disorders is high. For this reason, it is critical to exhaust all options before recommending surgery. If surgery is necessary, a distal clavicle resection performed using either open or arthroscopic techniques can lead to good results. With open surgery, Cook and Heiner33 and Tibone et al34 reported a 95% success rate in an athletic population with a painful joint secondary to degenerative arthritis or as a result of traumatic arthritis from a first- or second-degree AC separation. The only complaint following treatment was that patients often were unable to regain maximal bench press strength. Recent studies evaluating the success of arthroscopic distal clavicle resection have demonstrated equally successful outcomes.35-37 Kay et al37 reported good and excellent long-term results in 100% of their patients. Martin et al36 found no significant strength differences of the involved shoulder but did report that a small percentage of athletes had mild pain with strenuous overhead activities. Although the literature is scant on the subject, we have also found that arthroscopic debridement for osteolysis has a very high success rate.

For grade III AC separation, we have reported success in the majority of patients treated nonoperatively.38 If an AC reconstruction is necessary, as is the case with higher grade injuries, good results have been achieved in 93% of the patients undergoing a Weaver-Dunn reconstruction.39 In this series, the outcome was not affected by whether this was done acutely or in chronic injuries.40


The most frequent complication following distal clavicle resection is excess bone removal, which ultimately compromises the CC ligaments. In these situations, there is often a cosmetic deformity and pain. Although the case of pain is not fully understood, it is thought to be secondary to medial translation of the scapula in relation to the clavicle.

With AC reconstruction, loss of reduction is the most common problem. Although this leads to a deformity, it has been our experience that some of these patients still have a good functional outcome.


Successful treatment of AC disorders relies on an accurate diagnosis obtained through a detailed history, thorough physical examination, and a complete radiographic evaluation. The radiographic findings of degenerative arthritis alone are not enough to warrant treatment since this is commonly seen after the age of 40. The painful joint that is unresponsive to nonoperative management including injection will be expected to have a good outcome following a distal clavicle excision.

In traumatic AC separations, the majority of these injuries will respond to a nonoperative treatment regimen. In grade III AC separations including overhead throwers, we have recommended a trial of nonoperative management. For those with grade III separations who fail nonoperative treatment, along with high-grade AC separations (grades IV to VI), we have had success employing a "three-in-one" operative technique. The


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