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Managing and Recognizing Complications After Treatment of Acromioclavicular Joint Repair Or Reconstruction

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Managing and Recognizing Complications After Treatment of Acromioclavicular Joint Repair Or Reconstruction See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/272096166 Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction Article in Current Reviews in Musculoskeletal Medicine · February 2015 DOI: 10.1007/s12178-014-9255-6 · Source: PubMed CITATION READS 1 182 6 authors, including: Patrick A Smith Matthew J Smith University of Missouri University of Missouri 28 PUBLICATIONS 255 CITATIONS 16 PUBLICATIONS 115 CITATIONS SEE PROFILE SEE PROFILE Seth L Sherman David L Flood University of Missouri University of Missouri 69 PUBLICATIONS 1,378 CITATIONS 3 PUBLICATIONS 21 CITATIONS SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Commentary & Perspective Total Hip Arthroplasty View project Drug Reaction with Eosinophilia and Systemic Symptoms Associated with a Vancomycin-Impregnated Spacer View project All content following this page was uploaded by Xinning Li on 15 February 2015. The user has requested enhancement of the downloaded file. Curr Rev Musculoskelet Med DOI 10.1007/s12178-014-9255-6 SHOULDER SURGERY: COMPLICATIONS (X LI, SECTION EDITOR) Managing and recognizing complications after treatment of acromioclavicular joint repair or reconstruction Richard Ma & Patrick A. Smith & Matthew J. Smith & Seth L. Sherman & David Flood & Xinning Li # Springer Science+Business Media New York 2015 Abstract Complications of the acromioclavicular joint inju- Introduction ries can occur as a result of the injury itself, conservative management, or surgical treatment. Fortunately, the majority Injuries to the acromioclavicular (AC) joint are common, par- of acromioclavicular surgeries utilizing modern techniques ticularly among the young and active population. AC joint and instrumentation result in successful outcomes. However, dislocations represent ap proximately 12 % of all shoulder clinical failures do occur with frequency. The ability to iden- girdle dislocations, and 8 % of all joint dislocations through- tify the causative factor of failures makes revision surgery out the body [1, 2]. Almost half of the AC joint injuries occur more likely to be successful. The purposes of this review are in patients in their 20s, with a predilection toward males ver- to highlight common problems that can occur following sus females [3]. acromioclavicular joint surgery and discuss techniques that The management of AC dislocation is dependent on the can be utilized in revision surgery. severity of the injury. Lower grade AC injuries (types I and II) are initially treated nonoperatively. This typically consists of sling immobilization until pain subsides, ice, and rest. Oper- Keywords Acromioclavicular joint injuries . ative treatment is recommended for more severe subtypes of Coracoclavicular reconstruction . Shoulder separation . AC separation (types IV, V, and VI injuries) due to the associ- Shoulder surgery complication ated extensive soft tissue disruption and significant morbidity associated with persistently dislocated joints. Management of type III AC injuries remains controversial and a topic of debate. Several different types of complications stemming from both operative and nonoperative treatment of AC injuries have been described. The underlying factors contributing to the fail- ure of AC fixation are varied, which can be both patient and This article is part of the Topical Collection on Shoulder Surgery: surgery dependent. There are a plethora of surgical techniques Complications : : : described to treat symptomatic AC joint dislocations. This is R. Ma (*) M. J. Smith S. L. Sherman D. Flood likely reflective of the inability of one technique to emerge as Missouri Orthopaedic Institute, University of Missouri, the Bgold-standard.^ As a result, most complications encoun- Columbia, MO, 65203 USA e-mail: [email protected] tered following the surgical procedure are often times technique dependent. The objective of this manuscript is to review the M. J. Smith e-mail: [email protected] common complications following acromioclavicular joint re- pair and reconstructions as well as potential salvage solutions. S. L. Sherman e-mail: [email protected] P. A. Smith Classification of acromioclavicular injuries University of Missouri, Columbia, MO, USA X. Li Accurate diagnosis and recognition of the pattern and dis- Boston University, Boston, MA, USA placement in AC injury is essential to successful treatment Curr Rev Musculoskelet Med of acromioclavicular injuries. Critical to this process is obtaining important to realize that complications stemming from nonop- adequate radiographic exams, which includes anteroposterior, erative treatment have been described. Skin and wound com- axillary, and specific AC joint radiographs (Zanca view) of the plications can develop in patients treated nonoperatively for injured shoulder. Comparison AC joint radiographs of the con- AC joint injuries. This includes abrasions or lacerations that tralateral arm are also helpful to establish relative norms for may accompany AC joint injuries as well as skin tenting patients. While it is relatively easy to assess vertical instability which may lead to local infection and skin necrosis, respec- on radiographs, horizontal distal clavicle instability may be sub- tively. Iatrogenic skin complications, such as those associated tle but should be considered. Horizontal AC joint instability may with the Kenny-Howard device, are known to occur with fre- occur independent of vertical instability [4, 5]. Residual horizon- quency as well [1]. tal instability can lead to pain and disability with lesser grade AC The long-term sequelae of nonoperative treatment of AC injuries. Additional special radiographic views (cross arm adduc- joint injuries remain a topic of debate. Persistent pain and tion views or functional axillary views) can assist in identifying disability can occur even with low-grade AC injuries (types horizontal instability in lesser grade AC injuries [6]. An AC I and II) managed conservatively [4, 10]. The success of con- widthanindexof≥60 % measured on the bilateral Zanca view servative treatment may be different depending on the activity ([width of injured side−width of normal side/width of normal demand of the patient. Bergfeld et al. found up to 9 % (9/97— side]×100 %) is highly accurate for posterior AC dislocation or type I) and 23 % (7/31—type II) of the higher demand naval horizontal instability [7]. academy patients reported severe pain with limitation of ac- Classification of AC injuries is based on the extent of in- tivities at follow-up between 6 months and 3.5 years [10]. volvement of the AC and coracoclavicular (CC) ligaments Management of type III injuries remains controversial. While (Table 1)[2]. An understanding of this classification system nonoperative treatment can be successful, studies have shown will assist in guiding patient expectations, discussion of avail- that residual functional deficits may persist, including able treatment options, and formulating a proper surgical plan scapulothoracic dyskinesis, which may require further thera- to address the associated injuries. While MRI examinations are peutic intervention [11, 12]. not standard for all types of AC injuries, concomitant Other causes of pain following nonoperative management intraarticular glenohumeral pathologies have been shown to of AC injuries may be degenerative in nature. Studies have occur from 15 to 18.2 % of patients with type III or greater shown that the rate of posttraumatic arthritis can be significant severity of AC joint injuries [8, 9]. Thus, MRI should be con- [10, 13–15]. Cox reported a 36 % rate of symptomatic arthritis sidered in patients presenting with high-grade AC injuries or after grade I injuries and a 48 % rate after grade II injuries [14]. clinical exam suspicious for intraarticular shoulder pathology. Taft et al. reported posttraumatic arthritis in 43 % of patient who had type III AC injuries treated nonsurgically [15]. In addition to posttraumatic arthritis, distal clavicular osteolysis is also a recognized sequela of nonoperative management. Complication from nonoperative management The treatment of both posttraumatic arthritis and osteolysis of acromioclavicular injuries is similar. Treatment consisting of activity modification, a course of anti-inflammatory medication, and intraarticular in- While the focus of this review is to discuss complications jection is generally the mainstay of nonoperative measures. associated with operative treatment of the AC joint, it is Patients who are refractory to conservative management are candidates for resection of the distal clavicle. In patients with Table 1 Rockwood classification of acromioclavicular injuries higher grade of AC injuries (type III, IV, or V), careful preop- Type AC CC Deltopectoral X-ray CC X-ray AC erative evaluation of AC stability is advised in order to deter- ligaments ligaments fascia distance appearance mine if concomitant stabilization of the coracoclavicular liga- I Sprained Intact Intact Normal Normal ment with reconstruction would be warranted at the time of II Disrupted Sprained Intact <25 % Widened distal clavicle resection. III Disrupted Disrupted Disrupted 25–100 % Widened IV Disrupted Disrupted Disrupted Increased Clavicle posteriorly Complications from operative treatment displaced of acromioclavicular injuries (axillary) V Disrupted Disrupted Disrupted 100–300 % N/A There are over 60 described procedures
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