AC Joint Excision

Mr Chris Roberts

Consultant Orthopaedic Surgeon

Ipswich Hospital NHS Trust

2nd Indian Watanabe meeting, Chennai

Anatomy

• Diarthrodial joint

• Two types of fibrocartilage discs :

complete partial (meniscoid)

• No function after 4th decade

• Nerve supply : axillary

suprascapular

lateral pectoral

Anatomy

Superior and Posterior

Acromioclavicular Ligaments

(antero-posterior stability)

16mm 30mm

ct

Coracoclavicular ligaments

Footprint of Superior ligament

Up to 17mm

Urist 100 shoulders :

49% clavicle over-riding acromion

27% vertical

21% incongruent

3% clavicle under-riding acromion

‘Normal’ x-rays

Correct operation done correctly

Right reasons

Full excision

Safely

AC Joint Excision

•Indications:

– Symptomatic OA

– Painful ACJ

(osteolysis)

– Prominent inferior

osteophyte

•Beware:

– Instability

AC Joint Excision

OA of AC joint very

common

But rarely symptomatic

AC Joint Excision

OA of AC joint very common

But rarely symptomatic

SO

Excision based on clinical findings

Examination

Examination

Provocative tests

Most important test

Accurate ACJ intra-

articular injection,

ideally USS guided,

resulting in relief of

symptoms/signs

AC Joint Excision

Investigations

Specific X-rays - ↓ penetration

- 10-15º cephalic tilt

MRI - not routine

- other causes

Bone scan - rarely

ACJ excision options

•Open ACJ excision still

commonly performed

•Commonest

arthroscopic approach is

bursal

•2-superior portal ACJ

excision: some

advantages but

technically challenging

Set-up

• Beach chair/lateral decubitus

• Hypotensive anaesthesia

• Radio-frequency device

• 4.0 or 5.5mm acromionizer

Posterior viewing portal

Anterior working portal

Lateral and Neviaser viewing

portal

Work to a pattern

• Clear antero-inferior capsule and surrounding fat

• Ensure correct resection depth by excising antero-

inferior clavicle to depth of burr

• Excise remaining inferior clavicle to same depth

• Excise superior clavicle preserving superior

capsule

• Excise central bump

Inferior osteophyte without

symptoms

Co-plane osteophyte level with acromion

or

Excise whole depth of clavicle

Avoid excision part clavicle depth

Pitfalls

•Incomplete excision

– Posterior

– Superior osteophyte

•Instability

Summary

• Assess clinically – decision before

operation

• Vary portals for good view

• Work to a pattern

• Preserve postero-superior capsule

AC Joint Excision

Thank you