Acromioclavicular Separation Repair
When is repair for an acromioclavicular separation needed?
Repair of collarbone joint separations in the acute setting (shortly after injury) is not routinely required. In fact, well designed studies support nonsurgical management for many acute acromioclavicular separations, with equivalent outcomes at 2 years(1). There are some patterns of injury to the acromioclavicular joint, particularly those that are more severe and displaced, that do not fare as well with nonsurgical treatment(2), and therefore surgical stabilization is an option in selected patients with high activity demands, and those concerned about the permanent cosmetic defect that will persist at the top of the shoulder. Nonsurgical management of these injuries not only causes an unsightly bump at the top of the shoulder, but may accompany low-grade symptoms including pain, popping, clicking, and easy fatiguability, and therefore surgery may be appropriate for some of these more active individuals.
How is repair performed for an acromioclavicular separation?
The general strategy of repairing acute separations involves surgical reduction (realigning) of the acromioclavicular joint followed by placement of a device to hold the joint in the correct position while the injured ligaments heal in their anatomical position. The device that is placed is either removed in a second procedure or retained in the shoulder. While some chronic injuries require replacement (called reconstruction) of the ligaments with supplementation of tissue (“graft”), this may not be required in the acute setting. Graft augmentation has recently been shown to improve functional outcomes and maintenance of joint alignment even with acute acromioclavicular separations, however(3).
The first and commonly utilized technique for repair of these injuries involves arthroscopically-assisted coracoclavicular fixation (with or without graft augmentation). This technique utilizes strong suture tensioned between two titanium buttons, one on the clavicle and one on the coracoid process, to hold the acromioclavicular joint back in position. This technique is performed arthroscopically through tiny portals and a small inch-long incision at the clavicle. In this approach, a graft can be added in more severe injury patterns to enhance fixation and to improve joint alignment at long term follow up(3).
An alternative technique, and the one historically studied in the traditional literature(1) uses a rigid and secure plate, called the “hook” secondary to the portion of the implant deployed underneath the acromion. This device mechanically holds the collarbone down in the correct position during healing but uses a metal implant in the subacromial space and therefore needs to be removed. Because of the requirement for a second procedure and the slight delay of functional recovery with this approach(1), this procedure may be less favored currently than in the past.
What are the possible complications from surgery for acromioclavicular separation repair and what is recovery like?
Surgery for acromioclavicular separation repair is performed as an outpatient, where the patient leaves the facility the same day. A numbing block is administered followed by a light general anesthetic for the procedure which takes approximately one hour to perform. Showering and hygiene is permitted after a few days when bandages are removed and a sling is worn for six weeks, during which time simple activities are permitted with the hand and elbow. Once the sling is discontinued, activities of daily living are resumed, and stretches and strengthening exercises are incorporated. Between 10 and 12 weeks is the time point recommended for removal of a retained implant if required, such as the hook plate, followed by resumption of activities as tolerated including overhead and heavy use.
Complications from repair of acromioclavicular separations are similar as those with any surgical procedure, and although rare, include infection, injury to surrounding structures, failure of the repair, need for revision surgery. With appropriate surgical indications and technique, you can expect success of the repair and resumption of full preinjury activities without restrictions.
- Canadian Orthopaedic Trauma Society. Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation. J Orthop Trauma. 2015 Nov;29(11):479-87. doi: 10.1097/BOT.0000000000000437. PMID: 26489055.
- Dunphy TR, Damodar D, Heckmann ND, Sivasundaram L, Omid R, Hatch GF 3rd. Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment. J Am Acad Orthop Surg. 2016 Oct;24(10):728-34. doi: 10.5435/JAAOS-D-16-00176. PMID: 27579816.
- Bi AS, Robinson J, Anil U, Hurley ET, Klifto CS, Gonzalez-Lomas G, Alaia MJ, Strauss EJ, Jazrawi LM. Treatment options for acute Rockwood type III-V acromioclavicular dislocations: a network meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023 Jun;32(6):1146-1158. doi: 10.1016/j.jse.2023.01.039. Epub 2023 Mar 5. PMID: 36871607.
At a Glance
Dr. Thomas Obermeyer
- 15+ years of training and experience treating complex shoulder and sports medicine conditions
- Expert subspecialized and board-certified orthopedic care
- Award-winning outstanding patient satisfaction scores
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