AC Joint Reconstruction Surgery

Surgery to Repair a Separated Shoulder

shoulder
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A separated shoulder is a condition that causes the collarbone (clavicle) to separate from its normal attachment from the shoulder blade. Often confused with a shoulder dislocation, a shoulder separation is a different injury. Typically caused by falling on the outside of your arm or shoulder, people who have a shoulder separation will notice a bump and pain on top of their shoulder. The bump is actually caused by the end of the collarbone pushing up against the skin.

Many people with a separated shoulder can manage the injury with noninvasive treatments. In fact, most orthopedic surgeons agree that all type I and type II separations can be managed without surgery. Type I and II shoulder separations are by far the most common, therefore, surgical intervention is considered only in a small fraction of these injuries. 

There is controversy about the management of type III shoulder separations, while most type IV, V, and VI shoulder separations do better with surgery. The bottom line is, most people will do fine without surgery; it's only the most severe types of separated shoulders that end up needing a surgery for treatment.

Surgical Treatment Options

The goal of all surgical treatments for a shoulder separation are to restore the normal alignment of the end of the collarbone with the outer edge of the shoulder blade (the acromion). Ultimately, the hope is to restore the alignment of these bones, have them held in a stable position, and relieve pain at the acromioclavicular joint.

The primary surgical options include:

Repairing the AC Joint: Repair of the acromioclavicular joint makes a lot of sense. The most noticeable aspect of this injury is the disruption of the joint, and aligning and holding the joint in proper position makes a lot of sense. The AC joint is typically held in place with metal plates or pins called Kirschner wires (k-wires).

The downside of this surgery is that it fails to address the ligament damage to the strong ligaments that hold the end of the clavicle down. In addition, these metal implants used to hold the joint in position can cause pain, they may need to be removed, and even more concerning is the possibility that these implants can migrate. This means they can move within the body, and there are frightening reports of k-wires placed in the clavicle ending up inside the chest cavity over time.

Holding the Collarbone Down: There are several techniques to address AC joint injuries that hold the collarbone down, some using metal, others using heavy sutures. Most often the collarbone is held to the coracoid process, a hook of bone in the front of the shoulder that is just below the collarbone. Either a screw can be put from the collarbone into the corocoid, or the two bones can be wrapped together tightly with sutures. The downside of these techniques are that screws generally have to be removed, and sutures can cut through and fracture the bone.

Reconstructing Ligaments: The final category of options is to reconstruct the ligaments that hold the end of the clavicle in proper position. There are a number of options for this procedure, either using a patient's own tissue or donor tissue. One of the most commonly performed procedures, called a Weaver-Dunn surgery, shifts one of the major ligaments that attaches to the acromion over to the end of the clavicle. This holds the clavicle in its normal position. Other options include reconstruction of the coracoclavicular ligaments (that were torn when the shoulder separation injury occurred) with either a tendon from your leg or a tendon from a donor. The tendon graft is wrapped around the hooked coracoid and then into the clavicle.

My Preferred Treatment

In most situations, I prefer to reconstruct the damaged ligaments. Metal implant migration (movement) from the clavicle is concerning, and most patients don't want a second surgery for routine removal of an implant. Furthermore, the reconstructive procedure is the only one that addresses the primary problem--the torn ligaments that hold down the end of the clavicle. I use donor tissue that wraps around the coracoid and is held in the collarbone with screws that are absorbed by the body over time. While it is also possible to use an individuals own tissue, rather than donor tissue, most people don't want to have simultaneous surgery on their shoulder and on one of their legs! Therefore, the donor tendon is a good option and has worked well in my experience.

All that said, other surgeons have success with other treatment options. Just because one surgeon prefers a particular treatment does not mean it is the best. Very well regarded surgeons argue over these very issues, and may disagree about which option is the best. Make sure you find a surgeon who has experience with surgical treatment of a separated shoulder when you make your decision.

Sources:

Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ. "Acromioclavicular joint injuries: diagnosis and management" J Am Acad Orthop Surg. 2009 Apr;17(4):207-19. Review.

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