AOSSM/AANA Specialty Day 2020-Handout 1 - The Unstable AC Joint-Fixing and Avoiding Complications

Handout 1 - The Unstable AC Joint-Fixing and Avoiding Complications

Pdf Summary

This presentation by Dr. Stephen F. Brockmeier from UVA Orthopaedics addresses the challenges and strategies in managing “unstable” acromioclavicular (AC) joint injuries. AC separations are common shoulder injuries, and key treatment dilemmas include when to operate, how best to reconstruct, and how to minimize complications. The AC joint's complex forces, anatomy, and biomechanics must guide surgical planning.<br /><br />Treatment typically depends on injury grade: Grades 1-2 are managed nonoperatively, Grades 4-5 surgically, while Grade 3 injuries remain controversial. Evidence comparing early versus delayed surgery is limited but suggests some benefit to early repair, though outcomes are not conclusively superior. Several studies report no clear functional advantage of surgery versus nonoperative care for certain types (III, possibly IV and V), with surgery providing better reduction and cosmesis at the expense of higher cost and complications, while nonoperative care may allow faster return to activity.<br /><br />Dr. Brockmeier emphasized critical surgical principles: avoid drilling into the coracoid, minimize clavicular holes, always use a graft secured around the clavicle (e.g., FiberTape with Dogbone device or Lockdown system), and repair or reconstruct the AC capsule with internal bracing for stability. Case examples illustrate these techniques in active patients.<br /><br />Postoperative management is crucial, involving strict sling immobilization for six weeks followed by staged rehabilitation progressing from passive motion to strengthening and sport-specific activities, with gradual timelines for returning to weights, cycling, and contact sports.<br /><br />A UVA clinical series comparing combined AC/CC reconstruction versus CC reconstruction alone showed superior radiographic outcomes and fewer complications with the combined approach. Final recommendations highlight the toughness of these injuries, the lack of robust evidence for timing of surgery, initial nonoperative treatment for almost all Grade III injuries, and favoring anatomic reconstruction with graft and capsule repair for unstable Grade III, IV, V injuries or failed nonoperative cases. Conservative, closely monitored post-op care is essential for success.

Keywords

acromioclavicular joint injuries

AC separations

shoulder injury management

surgical treatment of AC injuries

nonoperative care for AC injuries

AC joint biomechanics

graft reconstruction techniques

postoperative rehabilitation

combined AC/CC reconstruction

clinical outcomes in AC injury treatment