Acromioclavicular Dislocation Surgery

Acromioclavicular (AC) Joint and Stabilization

The acromioclavicular (AC) joint is a small but important joint between the outer end of the collarbone (clavicle) and the projection of the shoulder blade (scapula) called the acromion. This joint plays an important role in movements such as raising the arm overhead. Joint stability is provided primarily by two groups of ligaments:

1. Acromioclavicular (AC) Ligaments: These form the joint capsule and contribute to the anterior-posterior stability of the joint.
2. Coracoclavicular (CC) Ligaments: These are two much stronger ligaments (the conoid and trapezoid ligaments) that extend between the collarbone and the coracoid process of the shoulder blade. These ligaments are the main stabilizers that prevent the collarbone from displacing upward.

AC Joint Dislocation/Separation: This is the loss of the collarbone’s normal position relative to the acromion, causing it to displace upward or backward, as a result of injury to one or both of these ligaments.

What Causes AC Joint Dislocation? Risk Factors

The overwhelming majority of AC joint dislocations occur as a result of direct trauma:

• Falling Onto the Shoulder: This is the most common mechanism. Falling directly onto the top of the shoulder while the arm is held close to the body pushes the collarbone downward while pushing the shoulder blade and acromion upward, causing the ligaments to stretch or tear.
• Direct Blow: A hard blow to the top of the shoulder.

This type of trauma commonly occurs in situations such as contact sports (football, rugby, ice hockey), cycling accidents, and skiing falls.

Classification of AC Joint Dislocations (Rockwood)

Determining the severity of the injury is very important in deciding on treatment for AC joint dislocations. The Rockwood Classification is most commonly used for this purpose. This classification is based on which ligaments are damaged and to what extent, and how much the collarbone has displaced:

• Type I: There is only a mild sprain of the AC ligaments. The CC ligaments are intact. There is no visible separation or upward displacement of the bone. Pain and tenderness are minimal.
• Type II: The AC ligaments are completely torn, and the CC ligaments are sprained. The collarbone has displaced slightly upward (by 25-50% of its own thickness). Mild swelling or a bump may be noticeable at the shoulder.
• Type III: Both the AC and CC ligaments are completely torn. The collarbone has displaced markedly upward (more than 100% of its own thickness). A clear deformity (bump) is visible at the top of the shoulder. Its treatment is controversial (conservative vs. surgical).
• Type IV: The AC and CC ligaments are torn, and the collarbone displaces posteriorly, becoming buttonholed into the trapezius muscle. Surgical treatment is required.
• Type V: Similar to Type III, all ligaments are torn, but the upward displacement of the collarbone is much more severe (100-300% of its own thickness). Surgical treatment is required.
• Type VI: This is a very rare condition. The collarbone displaces downward and becomes lodged beneath the coracoid process. Surgical treatment is required.

Treatment Approach: In general, Type I and II injuries are treated non-surgically (conservatively). Type IV, V, and VI injuries usually require surgical treatment. Treatment of Type III injuries is individualized according to the patient’s age, activity level, occupation, and expectations; both conservative and surgical treatment options are available.

What Are the Symptoms of AC Joint Dislocation?

• Pain: Localized at the very top of the shoulder, over the AC joint. It increases with arm movement.
• Tenderness: Marked tenderness on palpation of the AC joint.
• Deformity: Particularly in Type III and higher-grade injuries, there is noticeable swelling or a step-off bump on the top of the shoulder (the “piano key” sign: the bump depresses when pressed and springs back up when released, although this sign is not always reliable).
• Restricted Motion: Difficulty raising the arm or moving it across the body (cross-body adduction) due to pain.
• Swelling and Bruising: Swelling and bruising due to subcutaneous bleeding may be seen at the site of injury.

How Is AC Joint Dislocation Diagnosed?

Diagnosis is usually made based on the patient’s history, physical examination, and X-ray:

• Patient History: Details of how the injury occurred (e.g., falling onto the shoulder) are obtained.
• Physical Examination: The AC joint is checked for tenderness and deformity. The stability of the collarbone (up-down, anterior-posterior) is carefully assessed. Shoulder range of motion is checked. Comparison with the opposite shoulder is always performed.
• X-ray: This is the most important method for diagnosis and classification.
  
  • Comparative anteroposterior (AP) views of both shoulders are usually obtained.
  • Zanca View: A special AP view taken with the X-ray tube tilted 10-15 degrees cephalad to better visualize the AC joint.
  • On X-rays, the position of the collarbone relative to the acromion and coracoid process is assessed to determine the type of injury (Rockwood I-VI).
  • Stress Views: These are X-rays taken while the patient holds weights in both hands, formerly used to differentiate Type II from Type III or to assess the stability of a Type III injury. However, they are used less often today because they are painful and do not always provide additional diagnostic value.
• Other Imaging Methods (CT/MRI): These are generally not necessary for the diagnosis of AC joint dislocation. However, they may be requested if a fracture is suspected, in chronic cases, or if other associated injuries are being considered.

Treatment Options: Conservative or Surgical?

The treatment decision is made based on the Rockwood type of the injury and the patient’s individual factors:

Non-Surgical (Conservative) Treatment:

• Who Is It For? It is the standard treatment for Type I and Type II injuries. It is also the initially preferred approach for many Type III injuries (particularly in patients with lower activity levels and minimal overhead activities).
• Methods:
  
  • Arm Sling: Usually used for 1-3 weeks to reduce pain and rest the joint.
  • RICE: Rest, ice application, bandaging, and elevation of the arm for the first few days.
  • Pain Control: NSAIDs or simple analgesics.
  • Early Mobilization: Shoulder exercises (pendulum exercises, passive/active-assisted movements) are started early, as soon as pain allows.
  • Physical Therapy: Important for regaining range of motion, strengthening the muscles around the shoulder and shoulder blade, and returning to normal function.
• Outcome: Good functional results are generally achieved. However, a mild permanent bump (cosmetic deformity) may remain at the shoulder, especially after Type II and III injuries.

Surgical Treatment:

• When Is It Needed?
  
  • Absolute Indications: Rockwood Type IV, V, and VI injuries (due to severe displacement).
  • Controversial Indication (Type III): Type III patients with persistent pain or functional limitation despite conservative treatment; young, active Type III patients who are overhead athletes or perform heavy labor; those bothered by a noticeable cosmetic deformity (cosmetic concerns alone should not be the main reason). A shared decision between the patient and surgeon is important for Type III cases.
  • Chronic AC Joint Instability/Pain: Patients who previously had a conservatively treated injury but continue to experience pain or instability symptoms afterward.
• Goal of Surgery: To reduce the upwardly displaced collarbone back to its normal anatomical position (reduction) and to repair or reconstruct the torn ligaments (particularly the CC ligaments) so that it remains in this position.
• Surgical Techniques: Many different techniques have been described to date. Modern approaches generally focus on anatomic reconstruction of the Coracoclavicular (CC) ligaments:
  
  • CC Ligament Reconstruction (with Graft or Synthetic Material): This is the most commonly used method. The torn CC ligaments are mimicked by passing the patient’s own tendon (autograft – e.g., hamstring), a cadaveric tendon (allograft), or very strong synthetic suture materials/tapes (or a combination of these) between the coracoid process of the shoulder blade and the collarbone, and the collarbone is pulled down and secured. Bone tunnels, special buttons, or screws may be used for fixation. This procedure can be performed arthroscopically assisted (supported by a closed technique) or via open surgery.
  • AC Ligament Repair/Reconstruction: Sometimes, in addition to CC ligament reconstruction, repair or reconstruction of the AC ligaments may also be performed.
  • Distal Clavicle Resection (Mumford Procedure): This procedure is performed in patients with chronic AC joint pain or osteoarthritis; it is not a treatment for acute dislocation. It involves removing the outermost end of the collarbone (approximately 0.5-1 cm). It may sometimes be combined with ligament reconstruction if pain is present along with chronic instability.
  • Older Techniques: Older methods such as hook plates and Kirschner wires are less commonly preferred today due to high complication rates.

Prof. Dr. Murat Bozkurt carefully classifies AC joint injuries, understands the limits of conservative treatment, and successfully applies modern CC ligament reconstruction techniques when surgery is required.

AC Joint Surgery: Risks, Benefits, and Recovery Process

• Benefits (Surgery): Restoration of the joint’s anatomical position and stability, relief of pain related to instability, improvement of shoulder function (particularly overhead strength), and potentially better cosmetic appearance.
• Risks:
  
  • General surgical risks: Infection, bleeding, nerve injury (particularly cutaneous nerves), and anesthesia risks.
  • Specific risks: Loss of reduction (the collarbone displacing upward again), loosening or failure of the fixation materials (button, screw, graft) or discomfort from them under the skin, bone fracture (of the clavicle or coracoid during surgery), persistent pain, shoulder stiffness, and the need for repeat surgery (e.g., hardware removal).
• Recovery Process (Post-Surgery):
  
  • Arm Sling Use: An arm sling must generally be worn for 4 to 6 weeks after surgery to protect the repair or reconstruction. Active elevation of the shoulder is not allowed during this period.
  • Rehabilitation: A physical therapy program is important. After the sling is removed, treatment begins with passive and active-assisted movements. Patients gradually progress to active movements and shoulder-strengthening exercises.
  • Timeline: Recovery may take somewhat longer if bone tunnels were created or a graft was used. Return to normal daily activities may take a few months. Return to heavy lifting, pushing/pulling, and contact sports usually takes 4 to 6 months or longer.

Acromioclavicular Joint Dislocation Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

AC joint dislocations are conditions frequently seen in Ankara, particularly as a result of sports injuries and falls, and they can lead to chronic pain and functional loss if not treated correctly. In his approach to AC joint injuries, Prof. Dr. Murat Bozkurt:

• Accurate Diagnosis and Classification: Accurately determines the type of injury (Rockwood I-VI) using X-ray.
• Priority on Conservative Treatment (For Suitable Cases): For Type I, II, and most Type III injuries, he first recommends non-surgical treatment methods (arm sling, physical therapy) and monitors the results.
• Individualized Surgical Decision (Especially for Type III): For Type III injuries, he makes the surgical decision together with the patient, taking into account the patient’s age, activity level, occupation, expectations, and clinical findings.
• Modern Surgical Techniques: When surgery is required (Type IV, V, VI, or selected Type III), he applies current and effective surgical techniques (arthroscopically assisted or open), such as anatomic Coracoclavicular (CC) ligament reconstruction, to best restore joint stability.
• Rehabilitation Follow-up: Emphasizes the importance of the post-surgical rehabilitation process for a successful functional outcome and guides the patient accordingly.

Acromioclavicular (AC) joint dislocations are common shoulder injuries that require accurate diagnosis and classification. While most cases can be successfully treated with non-surgical methods, modern surgical techniques applied in severe separations or selected patients are effective at restoring joint stability and function. For an AC joint injury you have experienced in Ankara, you can obtain the most appropriate treatment by consulting Prof. Dr. Murat Bozkurt’s expertise.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt at 0312 502 70 74.