Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Acromioclavicular Joint Injuries and Reconstruction Techniques

Transcript

Acromioclavicular Joint Injuries and Reconstruction Techniques · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Welcome to the Deep Dive. Today we're focusing
• 0:02
  on a specific and actually fairly common shoulder
• 0:05
  issue, the acromioclavicular joint or the AC
• 0:08
  joint. That's right. Often called a shoulder
• 0:10
  separation. Exactly. And while it might sound
• 0:13
  minor, it can really affect daily life and particularly
• 0:16
  athletic function. We often see it in high impact
• 0:19
  sports, don't we? Indeed. Rugby, cycling falls,
• 0:22
  horse riding, quite common. And the impact on
• 0:26
  function can be, well, profound. So our goal
• 0:29
  in this deep dive is to really get under the
• 0:32
  skin of AC joint injuries. We want to provide
• 0:34
  you, our audience of mid -senior medical professionals,
• 0:38
  with a solid, practical understanding, moving
• 0:40
  beyond the basics to the kind of detailed insights
• 0:43
  that help in clinic. Looking at everything from
• 0:45
  diagnosis, classification, right through to the
• 0:47
  latest thinking on treatment and recovery. Precisely.
• 0:50
  So let's start at the beginning. An AC joint
• 0:52
  disruption isn't the same as a typical shoulder
• 0:54
  dislocation, is it? Can you clarify that distinction?
• 0:57
  Yes, that's a really crucial point. People often
• 1:00
  use shoulder dislocation quite loosely, but usually...
• 1:03
  That refers to the glenohumeral joint, the main
• 1:05
  ball and socket. Where the humerus comes out
• 1:08
  of the sock. Exactly. An AC joint disruption,
• 1:10
  though, is different. It's a separation right
• 1:13
  at the top, the apex of the shoulder. It's specifically
• 1:15
  where the collarbone, the clavicle, meets the
• 1:19
  acromeon, which is the highest point of the shoulder
• 1:21
  blade. So the injury is a traumatic separation
• 1:24
  of those two bones. The ligaments holding them
• 1:26
  together get damaged to varying degrees. And
• 1:29
  you mentioned it's common in sports. Very. Especially
• 1:31
  contact sports or activities where falls directly
• 1:34
  onto the shoulder are a risk. Think rugby tackles,
• 1:38
  falls in motorsports, equestrian sports. And
• 1:40
  it causes significant pain and limitation. Absolutely.
• 1:44
  It's not just a minor niggle. It can be genuinely
• 1:46
  debilitating, affecting simple daily tasks, let
• 1:49
  alone high level sport or manual work. So understanding
• 1:53
  the anatomy is key then. What makes this small
• 1:56
  joint so important for shoulder function and
• 1:58
  yet seemingly so vulnerable? Well, functionally,
• 2:02
  it's critical. It's technically a diarthrodial
• 2:04
  joint, a synovial joint, but its main job is
• 2:07
  to link the entire arm and shoulder blade assembly,
• 2:09
  the upper limb, to the main trunk, the axial
• 2:12
  skeleton. It's the strip connecting the arm to
• 2:15
  the body, essentially. You could think of it
• 2:17
  like that, yes. It allows the scapula to move
• 2:20
  properly, which is vital for everything from
• 2:22
  reaching up to throwing. Without that stable
• 2:25
  connection, shoulder function is severely compromised.
• 2:28
  And what keeps it stable? It sounds like a complex
• 2:30
  setup. It is. It relies on both static and dynamic
• 2:34
  stabilizers. First, you have the acromioclavicular
• 2:38
  ligaments themselves. They form the joint capsule.
• 2:41
  These are key for horizontal stability, stopping
• 2:43
  the clavicle, moving too far forwards or backwards
• 2:47
  relative to the acromion. Okay, so front -to
• 2:49
  -back stability. Precisely. But arguably even
• 2:52
  more important, especially for vertical stability,
• 2:55
  stopping the collarbone popping up, are the coracuclavicular
• 2:58
  ligaments, the CC ligaments. Ah, yes, the cornoid
• 3:01
  and trapezoid. Exactly, the cornoid and the trapezoid.
• 3:03
  They run from the coracoid process, that hook
• 3:06
  -like bit of bone on the scapula, up to the underside
• 3:09
  of the distal clavicle. Think of them as really
• 3:11
  strong suspension cables. Holding the clavicle
• 3:14
  down. Essentially, yes. Preventing superior displacement.
• 3:18
  If these are torn, that's when you typically
• 3:20
  see that characteristic bump on the shoulder
• 3:22
  in more severe injuries. Their integrity is absolutely
• 3:26
  vital. So those are the static ligamentous restraints.
• 3:29
  What about muscles? Good point. We also have
• 3:33
  crucial dynamic stabilizers. The large deltoid
• 3:36
  and trapezius muscles drape over the shoulder.
• 3:39
  While their main job is movement, they also provide
• 3:41
  dynamic compression and stability to the AC joint.
• 3:44
  Especially if the ligaments are injured. Yes,
• 3:47
  their role becomes even more important then,
• 3:49
  although they can't fully compensate if the main
• 3:51
  ligaments, particularly the CCs, are completely
• 3:54
  ruptured. Is there anything else within the joint
• 3:56
  itself? Well, sometimes there's a meniscal disc,
• 3:59
  a small fibrocardilage pad between the bone ends.
• 4:01
  It's not present in everyone, but when it is,
• 4:04
  it helps with load distribution and acts as a
• 4:05
  bit of a shock absorber. So, quite an intricate
• 4:08
  structure. Given this anatomy, what usually causes
• 4:11
  these ligaments to tear? What are the typical
• 4:13
  mechanisms of injury? It's almost always down
• 4:16
  to trauma, a significant force applied to the
• 4:19
  joint that overcomes the strength of those ligaments.
• 4:21
  The most common mechanism, by far, is direct
• 4:24
  trauma. This is usually a fall directly onto
• 4:28
  the point of the shoulder, hitting the acromeon,
• 4:30
  often with the arm tucked into the side, adducted.
• 4:33
  Like in a rugby tackle or falling off a bike?
• 4:35
  Exactly that scenario. The force drives the shoulder
• 4:38
  blade downwards, but the clavicle stays put,
• 4:41
  creating this massive sheer force across the
• 4:43
  AC joint, tearing the ligaments. OK, that makes
• 4:46
  sense. Are there other ways it can happen? Yes.
• 4:49
  Less commonly, you can get indirect trauma. The
• 4:51
  classic example is a foosh injury, a fall on
• 4:54
  an outstretched hand. Ah, yes, foosh. The force
• 4:57
  travels up the arm, through the humerus and scapula,
• 5:00
  and ultimately stresses the AC joint. Yeah. We
• 5:02
  also see some cases of repetitive microtrauma,
• 5:04
  maybe in weightlifters or overhead athletes,
• 5:07
  but that's usually a lower grade issue managed
• 5:09
  differently. You mentioned earlier it's common.
• 5:11
  Are there specific groups more at risk? Yes,
• 5:14
  there's a really striking demographic pattern.
• 5:16
  Males are affected much more often than females.
• 5:19
  The ratio is something like five to one. Five
• 5:21
  to one, that's significant. It is, and it's particularly
• 5:24
  prevalent in the 20 to 35 age group. This strongly
• 5:28
  correlates with higher participation rates in
• 5:30
  those high -risk contact sports and activities
• 5:32
  we discussed. It really highlights that link
• 5:35
  between activity levels and injury risk. That
• 5:37
  5 .1 ratio certainly reflects what we tend to
• 5:40
  see clinically. So once an injury happens, classifying
• 5:43
  it correctly is the next vital step for management.
• 5:46
  The Rockwood classification is the standard,
• 5:48
  isn't it? Absolutely. Classification is fundamental
• 5:51
  in orthopedics. It gives us a common language
• 5:53
  and guides treatment. The Rockwood system from
• 5:56
  1998 is the most comprehensive and widely used
• 5:59
  for AC joint injuries. And it goes beyond just
• 6:01
  mild, moderate, severe. It does. It defines six
• 6:05
  distinct types based on exactly which ligaments
• 6:07
  are torn, the AC and the crucial cc ligaments,
• 6:10
  and importantly, the direction and degree of
• 6:12
  clavicle displacement relative to both the acromion
• 6:14
  and the coracuate process. It provides a really
• 6:17
  robust framework for prognosis and deciding on
• 6:19
  treatment. Okay, let's walk through them then.
• 6:21
  Starting with the mildest. Type 1. Right. Type
• 6:23
  I is essentially a sprain of the AC ligament
• 6:25
  only. The fibers are stretched, maybe some minor
• 6:28
  tearing, but crucially, the ligament is intact
• 6:31
  overall and the joint remains stable. So no displacement.
• 6:35
  No displacement. Yeah. Radiographically, it looks
• 6:38
  normal. The CC ligaments are completely unharmed.
• 6:41
  Patients present with localized tenderness, but
• 6:43
  it typically settles well with conservative management
• 6:46
  within a few weeks. OK. Moving up to type 2.
• 6:49
  In type 2, the AC ligament is completely torn.
• 6:51
  That's the key difference. However, the CC ligaments,
• 6:55
  while they might be sprained, are still intact
• 6:57
  and functional. Ah, so the main vertical stabilizers
• 7:00
  are okay. Correct. Because the CCs are intact,
• 7:03
  you only get partial displacement or subluxation
• 7:06
  of the joint. On an X -ray, you'll see the clavicle
• 7:09
  slightly elevated relative to the acrimine, maybe
• 7:11
  some overlap, but it's not a complete dislocation.
• 7:15
  And management is usually non -operative for
• 7:16
  type 2 as well? Generally, yes. Because the crucial
• 7:20
  cc ligaments are holding things relatively stable,
• 7:23
  non -operative treatment with structured rehab
• 7:25
  usually yields good results. Now, type 3. This
• 7:30
  is often where the debate starts, isn't it? How
• 7:32
  does Rockwood define it? And perhaps more interestingly,
• 7:35
  how do you approach these clinically? You're
• 7:38
  absolutely right. Type 3 is the controversial
• 7:40
  one. According to the strict Rockwood definition,
• 7:42
  a type 3 injury involves a complete rupture of
• 7:45
  both the AC ligaments and the CC ligaments. So
• 7:48
  everything's torn? Anatomically, yes. This results
• 7:52
  in a complete dislocation of the joint. The clavicle
• 7:55
  displaces superiorly, often quite significantly,
• 7:58
  because there's nothing holding it down anymore.
• 8:00
  This is when you see that obvious step -off deformity
• 8:03
  or the piano key sign on examination. Right.
• 8:05
  Now clinically, This is where nuance comes in.
• 8:08
  While Rockwood says both are completely torn,
• 8:11
  in my practical experience managing these, I
• 8:13
  sometimes view a grade 3 as perhaps having a
• 8:16
  complete AC tear, but maybe only a significant
• 8:19
  sprain or partial tear of the CC ligaments. Ah,
• 8:22
  so not always a complete CC rupture in practice
• 8:24
  for what gets called a type 3. Well, the displacement
• 8:27
  is there, as per Rockwood 3 definition, implying
• 8:30
  significant CC injury. But the absolute necessity
• 8:33
  for surgery isn't always clear -cut for every
• 8:36
  single patient who fits the type 3 x -ray picture.
• 8:39
  It allows us to consider the patient's needs
• 8:41
  more closely. I see. So you'd weigh other factors.
• 8:44
  Absolutely. What are the patient's functional
• 8:47
  demands? Are they a high -level overhead athlete?
• 8:50
  A manual laborer needing maximum shoulder stability?
• 8:53
  In those cases, Even with a standard type 3 appearance,
• 8:56
  surgery might be the better option to restore
• 8:58
  optimal mechanics. Versus someone more sedentary.
• 9:01
  Exactly. A less active individual might do perfectly
• 9:04
  well functionally with non -operative management,
• 9:06
  despite the radiographic appearance. This contrasts
• 9:09
  sharply with what I might term category three
• 9:11
  injuries in my thinking, encompassing rockwood
• 9:14
  types for V insects. The more severe types. Yes.
• 9:18
  In those, there's absolutely no doubt both ligament
• 9:20
  complexes are completely disrupted, the displacement
• 9:23
  is far more dramatic, and the instability is
• 9:25
  profound. Surgery is almost always required for
• 9:29
  those higher grades. So for type 3, it's about
• 9:32
  bridging that gap between the strict anatomical
• 9:35
  classification and the individual patient's context.
• 9:38
  That's a really helpful clinical perspective.
• 9:41
  Okay, let's look at those higher grades then,
• 9:43
  starting with type 4. What's the defining feature
• 9:45
  there? Type 4 is defined by posterior displacement.
• 9:48
  The clavicle doesn't just go up, it goes backwards,
• 9:50
  often getting trapped behind or even punching
• 9:52
  through the trapezius muscle. Button -holing
• 9:55
  through the muscle. That's the term, yes. This
• 9:57
  makes it incredibly unstable and very difficult
• 10:00
  to reduce and hold non -operatively. Because
• 10:03
  of this inherent instability and the soft tissue
• 10:05
  damage, early surgical stabilization is pretty
• 10:07
  much always necessary to avoid long -term problems.
• 10:10
  Right. And type V, how much worse does it get?
• 10:13
  Type V represents a very severe superior displacement.
• 10:16
  We're talking significant vertical distance between
• 10:19
  the clavicle and the acromeon, often 100 % or
• 10:22
  more displacement compared to the normal side.
• 10:24
  Wow. This indicates not just complete AC and
• 10:28
  CC ligament rupture, but also extensive stripping
• 10:30
  of the muscle attachments, the deltoid and trapezius
• 10:34
  fascia from the distal clavicle. The deformity
• 10:36
  is usually very obvious. And surgery is mandatory.
• 10:39
  Almost invariably, yes. The instability is profound.
• 10:42
  The functional deficit is huge. Non -operative
• 10:44
  management simply doesn't work for type V. You
• 10:47
  need surgery to restore function and stability.
• 10:49
  And finally, the rare type VI. Type VI is indeed
• 10:52
  very uncommon. Here, the clavicle displaces inferiorly,
• 10:56
  downwards, getting lodged underneath the acromand,
• 10:58
  or even more rarely, the coracoid process. Downwards?
• 11:01
  How does that happen? Usually requires a very
• 11:03
  specific high energy impact. Like the higher
• 11:06
  grades of IV and V, it represents profound instability
• 11:09
  due to massive ligamentous and muscular disruption.
• 11:12
  Surgery is required here too. So that covers
• 11:14
  the adult classifications. But you sometimes
• 11:17
  see these in children. Are there special considerations
• 11:20
  for pediatric AC injuries? Ah, yes. A very important
• 11:24
  distinction. Children aren't just small adults,
• 11:27
  especially skeletally. The key difference is
• 11:29
  the periosteum around the distal clavicle in
• 11:32
  a child's that fibrous sleeve covering the bone.
• 11:35
  It's stronger in kids. It's relatively much thicker
• 11:38
  and stronger compared to the ligaments themselves.
• 11:41
  So when a child sustains a force that would tear
• 11:43
  ligaments in an adult, in the child, it's more
• 11:46
  likely to cause an injury through the bone's
• 11:48
  growth plate. or cause the periosteal sleeve
• 11:51
  to tear or avulse off the bone rather than a
• 11:54
  pure mid -substance ligament tear. So the injury
• 11:57
  pattern is different. Exactly. The periosteal
• 11:59
  sleeve can sometimes even remain partially intact,
• 12:02
  acting like a natural tether or hinge, which
• 12:04
  can influence the degree of displacement and
• 12:06
  often leads to better healing potential and remodeling
• 12:09
  capacity compared to adults. While you can still
• 12:12
  see injuries resembling the higher rockwood types
• 12:14
  in children, the underlying pathology and healing
• 12:17
  response are different. That's fascinating. Okay,
• 12:20
  let's shift to diagnosis. We suspect an AC joint
• 12:23
  injury. How does the patient typically present
• 12:26
  and what's the diagnostic pathway? Well, the
• 12:29
  presentation really mirrors the severity, the
• 12:31
  walk would type. For lower grades, type I and
• 12:34
  II, the main feature is localized pain right
• 12:37
  over the AC joint. It's often quite tender to
• 12:41
  touch. And worst with certain movements? Definitely.
• 12:43
  Bringing the arm across the chest, horizontal
• 12:46
  adduction usually provokes it. Lying on that
• 12:48
  side at night is often very uncomfortable, too.
• 12:51
  You might see some mild swelling, but usually
• 12:53
  no obvious deformity. And for the higher grades,
• 12:55
  three and above? It's usually much more obvious.
• 12:58
  Besides more intense pain, you'll likely see
• 13:00
  that visible deformity, the step off or bump
• 13:02
  where the clavicle is riding high. The whole
• 13:04
  arm might hang slightly lower on the affected
• 13:06
  side. So the visual inspection is key. What about
• 13:09
  the hands -on clinical examination? What are
• 13:11
  you specifically looking for? The physical exam
• 13:13
  is crucial. First, visual inspection for that
• 13:16
  asymmetry or step -off deformity. Then, careful
• 13:20
  palpation directly over the AC joint itself tenderness
• 13:22
  is a very consistent sign. And testing stability.
• 13:25
  Yes. We gently assess for abnormal movement.
• 13:29
  Can you press the clavicle down? Does it reduce?
• 13:31
  Does it spring back up when you release pressure?
• 13:33
  Panache sign. That indicates instability. Do
• 13:36
  you ever hear or feel anything? Sometimes. Yes.
• 13:40
  During testing, or even with a patient's own
• 13:42
  movement, you might hear or feel a painful clunk
• 13:45
  as the joint subluxes or reduces. That's a strong
• 13:48
  indicator of significant ligament damage. We
• 13:51
  also check range of motion, noting pain on specific
• 13:54
  movements like adduction or elevation. Okay,
• 13:56
  so a clinical exam gives you a strong suspicion.
• 13:59
  How does imaging confirm things and help classify
• 14:02
  the injury accurately? Let's start with x -rays.
• 14:05
  X -rays are the first -line investigation. Absolutely
• 14:07
  essential. They confirm the diagnosis by showing
• 14:10
  the relationship between the clavicle and the
• 14:11
  acromion, revealing the degree of displacement.
• 14:14
  They also crucially rule out associated fractures.
• 14:17
  Are there specific views you need? A standard
• 14:19
  AP view is useful, but often a Zonka view is
• 14:22
  preferred. It's angled slightly to give a clearer,
• 14:25
  unobstructed view of the AC joint itself. What
• 14:27
  about stress views? You hear about those. Yes,
• 14:30
  stress x -rays can be very helpful, especially
• 14:32
  if you suspect a type 3 injury. But the resting
• 14:35
  films look only mildly displaced, or perhaps
• 14:37
  like a type 2. The patient holds weights in each
• 14:39
  hand. To pull the arm down. Exactly. The weight
• 14:42
  stresses the joint, pulling the scapula and arm
• 14:45
  down, which exaggerates any underlying instability
• 14:48
  and makes the clavicle displacement much more
• 14:50
  obvious if the CC ligaments are indeed torn.
• 14:53
  It helps differentiate between stable type 2
• 14:55
  and unstable type 3 injuries sometimes. Right.
• 14:58
  When might you use a CT scan? CT gives much better
• 15:01
  bony detail than x -rays. It's particularly useful
• 15:04
  if you suspect an associated fracture, maybe
• 15:07
  of the distal clavicle, the acromeon, or, importantly,
• 15:10
  the coracoid process. It can also show the degree
• 15:13
  of static displacement very clearly, especially
• 15:15
  any posterior displacement seen in type 4. An
• 15:18
  MRI. Is that commonly used? MRI isn't usually
• 15:21
  the first -line test for an acute, straightforward
• 15:23
  AC separation. Its strength isn't showing soft
• 15:26
  tissues in great detail. So the ligaments themselves?
• 15:29
  Precisely. MRI is excellent for visualizing the
• 15:32
  ligaments directly, assessing the extent of tearing,
• 15:35
  partial versus complete, and identifying any
• 15:38
  associated injuries to other soft tissues like
• 15:40
  the rotator cuff or labrum. It's most useful
• 15:43
  when the diagnosis is uncertain after x -rays,
• 15:46
  perhaps in lower grade injuries with persistent
• 15:48
  symptoms or if you suspect complications later
• 15:51
  on. Okay, that clarifies the imaging pathway.
• 15:54
  So diagnosis made, classification determined.
• 15:57
  Now we face the treatment decision non -operative
• 15:59
  versus operative. Let's start with the non -operative
• 16:01
  route. What's the approach and who's it best
• 16:04
  suited for? Non -operative management is definitely
• 16:06
  the mainstay for lower grade injuries. Rockwood
• 16:09
  type I and II, and often considered for type
• 16:11
  III, as we discussed. The initial focus is purely
• 16:14
  on symptom control. How do you achieve that?
• 16:16
  Rest is key, initially. Using an arm sling provides
• 16:19
  comfort and support, ideally a broad arm sling
• 16:21
  that supports the elbow and takes the weight
• 16:23
  off the shoulder, rather than a simple collar
• 16:25
  and cuff. We also use ice therapy frequently
• 16:28
  in the acute phase to reduce swelling and pain,
• 16:30
  alongside NSAIDs, nonsteroidal anti -inflammatory
• 16:33
  drugs. And how long does that initial phase last?
• 16:36
  It depends. For a type Y, the sling might only
• 16:39
  be needed for comfort for a week or so. For type
• 16:41
  2, maybe longer, perhaps four to six weeks for
• 16:45
  symptoms to really settle. Once the acute pain
• 16:47
  starts to subside, the focus shifts very quickly
• 16:50
  towards rehabilitation. So rehab starts quite
• 16:53
  early then. Can you walk us through the typical
• 16:55
  phases? Yes. Rehab shouldn't be delayed. It's
• 16:58
  a structured, phased process. Phase one is the
• 17:01
  acute phase. Pain control, protecting the joint,
• 17:04
  but starting gentle range of motion exercises,
• 17:07
  often passive or active assisted, and isometric
• 17:09
  exercises, contracting muscles without moving
• 17:11
  the joint much. Keeping things moving gently.
• 17:14
  Exactly. Then phase two is about strengthening.
• 17:16
  As pain allows, we introduce isotonic exercises,
• 17:19
  moving against resistance, initially keeping
• 17:22
  movements below shoulder height to avoid stressing
• 17:24
  the joint too much. We focus on strengthening
• 17:27
  the rotator cuff, the scapular stabilizers, the
• 17:29
  bigger shoulder muscles, building back the support
• 17:31
  system, precisely. Phase three involves progressing
• 17:34
  to more functional movements, increasing strength,
• 17:37
  power, endurance, and crucially, neuromuscular
• 17:40
  control, teaching the muscles to work together
• 17:42
  effectively again, getting ready for more demanding
• 17:45
  tasks. And the final phase. Phase 4 is the return
• 17:48
  to activity. This is highly individualized, focusing
• 17:51
  on sport -specific or work -specific drills,
• 17:55
  gradually reintroducing the demands the patient
• 17:57
  needs to meet. For example, return to contact
• 18:00
  sports might be considered around 6 -12 weeks,
• 18:03
  depending on progress and injury severity. That
• 18:05
  sounds very thorough. What are the typical outcomes
• 18:07
  for non -operative treatments, say for type I
• 18:10
  and 2, and maybe select a type 3? For type I
• 18:12
  and 2, the outcomes are generally excellent.
• 18:14
  Most patients get significant pain relief within
• 18:16
  a few weeks, and many athletes can return to
• 18:19
  sport quite quickly, sometimes within 2 -4 weeks
• 18:21
  for type 2. Full recovery might take up to 12
• 18:24
  weeks, perhaps a bit longer, for some type 3s
• 18:26
  managed this way. Are there any potential downsides
• 18:29
  or long -term issues with non -operative management?
• 18:32
  While most do very well, a minority might experience
• 18:35
  persistent symptoms. This could be some residual
• 18:38
  ache, discomfort with specific activities, or
• 18:41
  potentially developing AC joint arthritis down
• 18:44
  the line. There's also some evidence suggesting
• 18:46
  a slight reduction in things like bench press
• 18:48
  strength. In some individuals, although most
• 18:50
  don't find it functionally limiting, if symptoms
• 18:53
  are still significant at six months, they're
• 18:55
  more likely to persist beyond a year. Okay. So
• 18:58
  when does surgery become the recommendation?
• 19:00
  What are the main indications and the goals of
• 19:03
  operating? Surgery is generally reserved for
• 19:05
  the higher grade injuries, definitely types 4,
• 19:07
  V, and 6. And it's strongly considered for type
• 19:10
  3 injuries, particularly in active individuals
• 19:13
  with high demands or when non -operative treatment
• 19:16
  for a type 3 has failed to provide satisfactory
• 19:18
  function or pain relief. And what are you trying
• 19:21
  to achieve with surgery? The main goals are,
• 19:24
  firstly, an anatomical reduction, getting the
• 19:26
  clavicle back into its proper position relative
• 19:28
  to the acromion and coracoid. Secondly, secure
• 19:33
  a fixation to hold it there while the tissues
• 19:35
  heal. And thirdly, restoring stability both horizontally
• 19:39
  and vertically to allow for good long -term function.
• 19:42
  Ultimately, we want a stable, pain -free shoulder.
• 19:45
  How have surgical techniques changed over the
• 19:48
  years? Oh, considerably. Older techniques, like
• 19:51
  the Weaver Dun procedure, often involved resecting
• 19:54
  the end of the clavicle and using local tissues
• 19:56
  like the coracoacromial ligament for reconstruction.
• 19:59
  Now, the trend is much more towards anatomical
• 20:01
  reconstruction, often using stronger fixation
• 20:04
  methods. Like what? Things like suspensory fixation
• 20:07
  devices have become very popular. These use strong
• 20:10
  sutures or synthetic tapes passed around the
• 20:12
  coracoid and through tunnels in the clavicle
• 20:14
  to replicate the function of the native cc ligaments.
• 20:17
  Some techniques involve plates or screws, though
• 20:20
  these often require removal later. In chronic
• 20:23
  cases, sometimes biological grafts are used to
• 20:25
  augment the repair. You mentioned there are over
• 20:27
  a hundred techniques described. That suggests
• 20:29
  there isn't one single best way. That's absolutely
• 20:32
  right. The sheer number of techniques reflects
• 20:34
  the ongoing challenge and the lack of universal
• 20:37
  consensus on the perfect repair. Options range
• 20:40
  from direct ligament repair, if possible acutely,
• 20:44
  using local tissue transfers, synthetic ligaments,
• 20:47
  suture button devices, hook plates. The list
• 20:49
  goes on. The choice depends on the injury pattern,
• 20:53
  the surgeon's preference and experience, the
• 20:56
  patient's needs, and whether the injury is acute
• 20:58
  or chronic. It's fascinating though that even
• 21:01
  with surgery aiming for perfect anatomical reduction,
• 21:04
  research hasn't always shown a direct link between
• 21:06
  that perfect x -ray and better pain or function
• 21:09
  outcomes. That's a really key observation in
• 21:12
  the field. While we strive for anatomical correction,
• 21:15
  the correlation between radiographic appearance
• 21:17
  and patient -reported outcomes isn't always straightforward.
• 21:21
  So a perfect x -ray doesn't guarantee a perfect
• 21:23
  result for the patient? Not necessarily. You
• 21:26
  can have a patient with a radiographically flawless
• 21:28
  reduction who still has some pain or functional
• 21:31
  limitation. And conversely, someone with slight
• 21:34
  residual displacement on x -ray might be completely
• 21:36
  asymptomatic and function at a very high level.
• 21:38
  Why is that? It's complex. Factors like muscle
• 21:41
  strength, neuromuscular control, individual pain
• 21:44
  perception, biological healing response, and
• 21:48
  the demands placed on the shoulder all play a
• 21:50
  huge role. It underscores that our ultimate goal
• 21:52
  isn't just to fix the x -ray image, but to achieve
• 21:55
  a stable, painless shoulder that allows the patient
• 21:58
  to return to their desired activities. Patient
• 22:01
  function and satisfaction are the real measures
• 22:03
  of success. A very important perspective. So,
• 22:06
  looking at the bigger picture of prognosis, how
• 22:09
  do the recovery paths and long -term outcomes
• 22:11
  generally compare between non -op and surgical
• 22:14
  approaches? Well, for types 1 and 2, non -op
• 22:16
  is the clear winner, good outcomes, quicker return
• 22:19
  to activities generally. Sling use is short.
• 22:22
  maybe 7 -10 days for type 1, perhaps 4 -6 weeks
• 22:25
  for type 2 protection. Long -term studies show
• 22:27
  good results, though as mentioned, a few might
• 22:29
  have lingering issues or develop arthritis later.
• 22:32
  If symptoms persist at 6 months, they might linger
• 22:34
  longer. And for the higher grades where surgery
• 22:36
  is more common? For types 3 and above, surgery
• 22:39
  generally provides better anatomical reduction
• 22:41
  and stability. However, it comes with a higher
• 22:44
  risk of complications compared to non -operative
• 22:47
  treatment. What kind of complications are we
• 22:48
  talking about? Things like mild residual instability
• 22:51
  can still occur, despite the surgery. Hardware
• 22:55
  issues are possible migration, prominence needing
• 22:58
  removal. Infection is a risk, though thankfully
• 23:01
  low, maybe around 1%. Nerve injury is rare, but
• 23:05
  possible. Stiffness or soft tissue ossification
• 23:08
  can also occur. So there are definite trade -offs?
• 23:11
  Absolutely. Non -operative might mean quicker
• 23:13
  initial recovery, but potentially more residual
• 23:15
  instability or cosmetic deformity for higher
• 23:18
  grades. Surgery aims for better anatomical stability,
• 23:22
  but has a longer recovery and carries those surgical
• 23:24
  risks. Despite the risks though, meta -analyses
• 23:27
  show high return to sport rates, around 94%,
• 23:30
  for patients having surgery for type 3 or higher
• 23:32
  injuries. And rehabilitation after surgery is
• 23:34
  presumably just as crucial. Even more so, arguably.
• 23:37
  Post -surgical rehab is absolutely vital to protect
• 23:40
  the repair, regain motion safely, build strength,
• 23:43
  and ultimately optimize the outcome. It's carefully
• 23:46
  progressed. What does that involve initially?
• 23:49
  Initially, there might be restrictions, perhaps
• 23:52
  limiting abduction above 90 degrees for a period.
• 23:55
  Gentle pendulum exercises are often started early
• 23:57
  to maintain some motion and prevent stiffness
• 24:00
  without stressing the repair. And then building
• 24:02
  up. Yes, then progressively introducing range
• 24:05
  of motion followed by strengthening exercises
• 24:07
  for the rotator cuff, deltoid, and scapular muscles.
• 24:11
  It's all about providing dynamic support to the
• 24:13
  reconstructed joint. The protocol needs tailoring
• 24:16
  to the specific surgery performed. So, summing
• 24:20
  up the long -term picture. It really hinges on
• 24:22
  the initial injury, severity, and the chosen
• 24:24
  management. But regardless of whether it's non
• 24:27
  -op or surgical, a meticulously planned patient
• 24:30
  -specific rehabilitation program is paramount.
• 24:33
  That tailored rehab, considering the patient's
• 24:35
  individual goals and activity levels, is probably
• 24:37
  the single most important factor in achieving
• 24:39
  the best possible long -term function. Okay,
• 24:42
  that leads us nicely into modern approaches.
• 24:45
  Many listeners will be keen to hear about current
• 24:47
  thinking on reconstruction. Could you share your
• 24:50
  management philosophy, particularly how you differentiate
• 24:53
  acute versus chronic injuries when deciding on
• 24:56
  intervention? Certainly. My approach is very
• 24:59
  much guided by the timing, the acuity of the
• 25:01
  injury. I generally define acute as less than
• 25:05
  about one week from injury. And how does that
• 25:07
  guide your initial steps? For most acute injuries,
• 25:10
  one week after diagnosis, my preference is usually
• 25:13
  to start with conservative management. That means
• 25:15
  a sling, but mainly just for comfort. not strict
• 25:18
  immobilization, analgesia for pain, and crucially
• 25:22
  starting rehabilitation with early active mobilization
• 25:25
  as soon as the patient feels able. So give conservative
• 25:28
  treatment a chance first in most acute cases.
• 25:31
  In many, yes, but the initial inflammation settles
• 25:34
  see how the patient progresses functionally.
• 25:36
  However, there are definite exceptions where
• 25:37
  I'd recommend early surgery even in the acute
• 25:39
  phase, such as cases with really severe pain,
• 25:42
  especially if the clavicle is clearly buttonholed
• 25:45
  through the trapezius, a type 4. Also, high -level
• 25:49
  overhead athletes often benefit from early surgery
• 25:51
  to restore mechanics optimally. Any associated
• 25:54
  neurovascular injury or an open fracture are,
• 25:57
  of course, immediate surgical indications. What's
• 26:00
  your follow -up strategy, then, for those managed
• 26:02
  conservatively initially? I typically review
• 26:05
  them at three weeks. If they're improving well,
• 26:08
  symptoms settling, function returning, we continue
• 26:10
  with the symptomatic management and gradual return
• 26:12
  to activity plan in another review around three
• 26:14
  months. And if they're not doing well at three
• 26:16
  weeks? If they're still really struggling with
• 26:18
  pain or instability or just not coping functionally,
• 26:22
  then I'd offer early surgical reconstruction
• 26:24
  at that point. No sense in delaying further if
• 26:26
  it's clearly not working. And the three month
• 26:28
  review? At three months, if they've successfully
• 26:31
  returned to their activities with minimal issues,
• 26:34
  fantastic. They could be discharged. If they're
• 26:37
  still not coping despite extended rehab, then
• 26:39
  surgery is offered as the definitive solution.
• 26:42
  It's a pathway that allows for non -operative
• 26:44
  management where appropriate but ensures timely
• 26:47
  intervention if needed. That makes good clinical
• 26:49
  sense. When surgery is the path chosen, what
• 26:53
  constitutes an ideal reconstruction technique
• 26:55
  today? What are the key goals? Ah, the ideal
• 26:58
  technique. That's what we're all striving for.
• 27:00
  Based on current understanding, I think there
• 27:02
  are about six key criteria we aim for. One, anatomical
• 27:07
  restoration. We want to recreate both the CC
• 27:09
  and AC ligament anatomy as closely as possible.
• 27:12
  Right, putting things back where they belong.
• 27:15
  Two, strength plus flexibility. The repair needs
• 27:18
  to be strong enough immediately, but also allow
• 27:20
  some natural physiological motion at the AC joint.
• 27:23
  Two, rigid isn't good either. Makes sense. Three,
• 27:26
  allow early rehabilitation. The construct must
• 27:28
  be stable enough to let patients start moving
• 27:30
  relatively early to prevent stiffness and speed
• 27:33
  up recovery. Get them gone and quickly. 4. Biological
• 27:36
  integration. Ideally, the repair encourages the
• 27:40
  body's own tissues to heal into it, providing
• 27:42
  long -term, durable stability. Less reliance
• 27:44
  on artificial materials long -term. 5. Avoid
• 27:48
  donor site morbidity. If using the patient's
• 27:51
  own tissue, Autographed. We want to minimize
• 27:53
  any problems from the harvest site. That's an
• 27:56
  advantage of good synthetic options. And six,
• 28:00
  eliminate routine hardware removal. We want techniques
• 28:03
  where implants don't routinely need a second
• 28:05
  operation just to take them out. That's a very
• 28:07
  clear checklist. With those criteria in mind,
• 28:10
  can you tell us about your preferred approach
• 28:12
  to the triple anatomical technique? What does
• 28:14
  it involve? Yes, this technique is designed to
• 28:16
  hit those criteria, aiming for anatomical restoration
• 28:19
  with biological potential, creating a strong
• 28:22
  construct that allows early mobilization. It
• 28:24
  has three main parts. Triple technique, three
• 28:26
  parts. Makes sense. First is an anatomic corcoclavicular
• 28:30
  ligament reconstruction. I use a strong synthetic
• 28:33
  ligament, specifically the Lars ligament, which
• 28:35
  is polyethylene tetrafasolate, because it's incredibly
• 28:38
  strong, stronger than the native CC ligaments,
• 28:41
  providing immediate stability. Its braided structure
• 28:44
  also encourages tissue ingrowth, aiming for that
• 28:46
  biological integration over time. We pass it
• 28:49
  anatomically through tunnels in the clavicle
• 28:51
  at the ligament footprints and then secure it
• 28:54
  around or through the coracoid. Okay, so that
• 28:56
  replaces the CC ligaments. What's the second
• 28:58
  part? Second is an acromoclavicular ligament
• 29:00
  reconstruction, often using a transfer of the
• 29:03
  nearby coraco -chromial ligament. This directly
• 29:06
  addresses the AC joint capsule and ligament,
• 29:09
  restoring horizontal stability, which the CC
• 29:11
  reconstruction alone doesn't fully address. Got
• 29:13
  it. And the third component. The third part is
• 29:16
  a delto -tripetal fascia repair. This involves
• 29:20
  carefully repairing the torn fascia of the deltoid
• 29:23
  and trapezius muscles where they attach to the
• 29:26
  clavicle and acromion. This is especially important
• 29:29
  in higher grade injuries, like type V, where
• 29:31
  the fascia is often ripped off. It adds significant
• 29:34
  reinforcement and dynamic stability to the whole
• 29:36
  construct. So you're rebuilding the CCs, the
• 29:40
  ACs, and reinforcing the muscle envelope. Exactly.
• 29:43
  It's a comprehensive belt and braces approach.
• 29:46
  We also believe transferring a ligament like
• 29:48
  the CA ligament might help restore some proprioception
• 29:51
  that joint position sends. Overall, we find it
• 29:54
  safe, reproducible, and very effective at restoring
• 29:57
  stability, which allows for that crucial early
• 30:00
  recovery and return to sport. It certainly sounds
• 30:03
  robust. Finally, for those patients, especially
• 30:06
  athletes undergoing this kind of reconstruction,
• 30:09
  how do you manage their return to sport? What
• 30:11
  are realistic timelines? Return to sport is always
• 30:14
  a gradual, criterion -based process, not just
• 30:17
  about time. It absolutely requires teamwork between
• 30:20
  me, the physiotherapist, and often strength and
• 30:22
  conditioning coaches. Everyone has to be on the
• 30:24
  same page. Completely. We need to see the patient
• 30:26
  meet specific functional milestones, strength,
• 30:29
  range of motion, stability, sport -specific movements
• 30:32
  before they progress. But based on our experience,
• 30:36
  contact athletes like rugby players usually take
• 30:38
  around three to four months post -op before returning
• 30:40
  to full contact. They need that time for solid
• 30:42
  healing and to rebuild the strength to withstand
• 30:44
  impacts. And overhead athletes, pitchers, tennis
• 30:48
  players. They typically need longer, often six
• 30:50
  to nine months. Their sports require extreme
• 30:53
  ranges of motion, power and fine motor control.
• 30:56
  Rushing them back risks re -injury or poor performance.
• 30:59
  Any activities that allow a quicker return. Interestingly,
• 31:02
  we find horse riders and cyclists can often get
• 31:05
  back sooner, sometimes in less than three months,
• 31:08
  while falls can cause the initial injury. The
• 31:10
  actual activity itself doesn't usually place
• 31:13
  the same high -impact repetitive stress on the
• 31:15
  AC joint as contact or overhead sports. And sport
• 31:19
  -specific rehab is key throughout. Absolutely
• 31:22
  critical. A rugby player needs drills with a
• 31:24
  ball, controlled contact simulation. A swimmer
• 31:27
  needs pool -based rehab. Tailoring the exercises
• 31:30
  to mimic the demands of their specific sport
• 31:32
  ensures they are truly ready and confident when
• 31:34
  they return to competition. Professor, this has
• 31:36
  been incredibly insightful. We've covered a huge
• 31:38
  amount from the basic anatomy right through to
• 31:40
  your specific advanced surgical technique for
• 31:42
  AC joint disruptions. Thank you for clarifying
• 31:45
  so much complexity. It's been a real pleasure.
• 31:47
  These are common injuries, and getting the management
• 31:50
  right based on a detailed understanding really
• 31:53
  does make a difference for our patients. Absolutely.
• 31:56
  Just as a final thought for our listeners, as
• 31:58
  our understanding of biomechanics and biology
• 32:01
  continues to advance, perhaps with things like
• 32:03
  better biological augmentation or even more refined,
• 32:07
  minimally invasive techniques, how do you see
• 32:10
  the approach to AC joint stability and recovery
• 32:12
  evolving further in the future? That's the exciting
• 32:15
  part, isn't it? Always looking ahead. Indeed.
• 32:18
  If this deep dive has sharpened your perspective
• 32:20
  on AC joint injuries, please do consider rating
• 32:22
  and sharing it with your colleagues. Thank you
• 32:24
  for joining us. Thank you.