Posted: Jan 30 2023 #(C102134)

Acromioclavicular Separation in 75M

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HPI

This is a 75-year-old male, RHD, bus driver who sustained an injury of the left acromioclavicular joint 8 months ago. Patient had a direct fall onto his left shoulder after a hit-and-run. He admits that pain gets worse with any movement. Patient had extensive non-op management including PT, rest, and Nsaids. Persistent pain and disability from the AC separation were affecting his QOL. He is very active and pain was 5-8/10.

PMH

No significant medical history.

There is a prominence of the distal clavicle that is reducible to manual pressure. There is no winging or psuedo-winging. Full passive and active ROM of the shoulder. There is full range of motion to the elbow, wrist, and hand. Tender to palpation at the AC joint. Abduction in the plane of the scapula (Supraspinatus): 5/5 ER with the arm at the side (Infraspinatus)- 5/5 IR (Subscapularis)- 5/5 ER Strength at 90 deg of abduction (Teres Minor): 5/5 Deltoid: Ant: 5/5 Mid: 5/5 Post: 5/5 Patient is neurovascularly intact.

Poll

1 of 1

1. If you choose Operative management, what type of fixation would you perform to hold your AC reduction?

I would not choose Operative management

30/809

Fixation across AC joint (AC fixation) Alone

12%

98/809

Fixation to the Coracoid (CC fixation) Alone

34%

281/809

AC fixation + CC fixation

46%

374/809

Outside my area of expertise - best if I don't vote

26/809

Intra-procedure P1

8 weeks after

Post-procedure P1

Would you obtain additional imaging studies to guide management?

No - current radiographs are sufficient

How would you classify this injury with the Rockwood Classification?

Rockwood type III

How would you manage this injury at this time?

Operative

If you choose Operative management, what type of fixation would you perform to hold your AC reduction?

AC fixation + CC fixation

It you choose Fixation across AC joint Alone, what fixation technique would you use?

I would not choose Fixation across AC joint only

If you choose Fixation to the Coracoid (+/- fixation across AC joint), what type would you use?

Ligament reconstruction (allograft, autograft)

If you choose Fixation to the Coracoid with a Synthetic implant, what fixation type would you use on the Coracoid?

Trans-bicortical device (Dogbone, Cortical button, Juggernaut))

If you choose Ligament reconstruction, what surgical approach would you use?

Open only

If you choose Ligament reconstruction, what type of graft would you use?

Allograft

If you choose Ligament reconstruction, what fixation techniques would you use on the Coracoid and Clavicle?

Coracoid loop + Clavicle bone tunnel(s)

If you choose Ligament reconstruction, in addition to graft fixation on the coracoid and clavicle, would you extend fixation of the graft to the acromium?

Yes

If you choose Ligament reconstruction, would you include a distal clavicle resection?

Yes - only if irreducible

If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Active ROM (ex. pendulums)?

>6 weeks post-op (>42 days)

If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Strengthening exercises?

3 months

If you choose Ligament reconstruction and obtained the fixation seen below, when would you allow Unrestricted Activity (ex. skiing)?

6 months

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