AOSSM/AANA Specialty Day 2020-Handout 2 - The Unstable AC Joint-Fixing and Avoiding Complications

Handout 2 - The Unstable AC Joint-Fixing and Avoiding Complications

Pdf Summary

The presentation by Dr. Stephen F. Brockmeier from UVA Orthopaedics addresses the complex management of unstable acromioclavicular (AC) joint injuries, commonly known as "AC separations." These injuries are frequent but challenging due to uncertainties in surgical indications, timing, techniques, and complication avoidance. The decision to operate depends on factors like injury grade, patient age, activity, scapular kinematics, and cosmetic concerns. Generally, nonoperative treatment is accepted for Grade 1 and 2 injuries, surgery favored for Grades 4 and 5, and Grade 3 injuries remain controversial.<br /><br />A key debate centers on acute versus delayed surgical repair. A systematic review found limited evidence supporting early versus delayed intervention, with some studies showing better anatomical reduction and outcomes with early repair, but overall no definitive consensus due to lack of high-level evidence. Nonoperative and operative treatments for Type III and higher AC injuries yield similar patient-reported outcomes; surgery offers better reduction and cosmesis but involves longer recovery and higher costs.<br /><br />Current preferred surgical technique emphasizes a strong construct without coracoid drilling, limited clavicle holes, consistent use of grafts (wrapped and sutured), and addressing the AC joint capsule with repair or internal brace to improve stability and reduce failures. Postoperative protocol includes strict sling immobilization for 6 weeks, gradual rehabilitation from passive motion to strengthening over 12 weeks, and return to sport/contact activities in 4-6 months.<br /><br />UVA’s series comparing combined coracoclavicular (CC) and AC reconstructions to CC-only showed better radiographic outcomes, fewer complications, and lower reoperation rates when AC repair was included.<br /><br />In conclusion, AC joint injuries remain challenging with no clear high-level evidence guiding management. Most Grade III injuries may start nonoperative, while Grade IV, V, and unstable Grade III injuries or failed conservative cases benefit from open or arthroscopic-assisted anatomic reconstruction focused on strong fixation, AC capsule repair, and careful postop management. Surgical judgment and patient-specific factors remain crucial in treatment choice.

Keywords

Acromioclavicular joint injuries

AC separations

Unstable AC joint

Surgical indications AC injury

Nonoperative treatment AC injury

Grade III AC injury controversy

Acute vs delayed AC repair

Coracoclavicular reconstruction

AC joint capsule repair

Postoperative rehabilitation AC injury