1. Failed ACJ Excision
Lennard Funk

2. 2

3. Plan:
 Anatomy & Mechanics
 ACJ Excision procedure
 Complications
 Management
3

4. Functional Anatomy
1.5mm
Beardon
4

5. AC Ligaments
 Superior AC Lig = 56% Posterior Translation
 Posterior AC Lig = 25% Posterior Translation
 Klimkiewikcz
 Superior AC Lig = Rotational Stability
 Branch et al.
Urist, JBJSA. 1946 5

6. AC Ligaments
6

7. AC Ligaments
 Attaches over 2.6cm of clavicle in men, 2.3cm in
women
 Renfree & Wright
6

8. AC Ligaments
 Attaches over 2.6cm of clavicle in men, 2.3cm in
women
 Renfree & Wright
 (1.5cm - Hearnden 2012)
6

9. AC Ligaments
 Attaches over 2.6cm of clavicle in men, 2.3cm in
women
 Renfree & Wright
 (1.5cm - Hearnden 2012)
 No difference if superior or inferior AC lig. cut
(horizontal, vertical & rotatory)
 Branch et al. AJSM 1996
6

10. AC Ligaments
 Attaches over 2.6cm of clavicle in men, 2.3cm in
women
 Renfree & Wright
 (1.5cm - Hearnden 2012)
 No difference if superior or inferior AC lig. cut
(horizontal, vertical & rotatory)
 Branch et al. AJSM 1996
 Superior & Posterior not capable of stabilising
clavicle - 32% incr. of posterior translation after
Ant & Inf capsular resection
 Corteen & Teitge
6

11. Normal Joint Space = 1-3mm
7

12. ACJ Angle
8

13. ACJ Excision Aims
 Remove arthritic surfaces
 Preserve AC superior & posterior Ligs.
9

14. Results
 Open:
 76% Good-Excellent at 4.6yrs
 Rabalais & MCarty, CORR 2007
 Scope:
 85% Good-Excellent
 Elhassan et al, Arthroscopy 2009
 Faster return to activities
 Pensak et al. Arthroscopy 2010
10

15. Failed ACJ Excision (Basmania, 1995)
1. Diagnostic Error
2. Inadequate resection
3. Joint Instability
4. Weakness
5. Miscellaneous
11

16. Failed ACJ Excision (Strauss et al. 2010)
Common Causes Less Common Causes
Instability Distal Clavicle Fracture
Under Resection Suprascapular neuropathy
Over Resection Other Cause
- Neck pain, SLAP, etc.
Stiffness (29%)
Bony regrowth
Untreated Concomitant
Pathology
Infection
12

17. Failed ACJ Excision (Strauss et al. 2010)
Common Causes Less Common Causes
Instability Distal Clavicle Fracture
Under Resection Suprascapular neuropathy
Over Resection Other Cause
- Neck pain, SLAP, etc.
Stiffness (29%)
Bony regrowth
Untreated Concomitant
Pathology
Infection
12

18. Failed ACJ Excision (Strauss et al. 2010)
Common Causes Less Common Causes
Instability Distal Clavicle Fracture
Under Resection Suprascapular neuropathy
Over Resection Other Cause
- Neck pain, SLAP, etc.
Stiffness (29%)
Bony regrowth
Untreated Concomitant
Pathology
Infection
12

19. Excess ACJ Excision
13

20. Clavicle Excision
14

21. Clavicle Excision
 11mm excision should not violate the
Trapezoid ligament in 98%
 Renfree & Wright
14

22. Clavicle Excision
 11mm excision should not violate the
Trapezoid ligament in 98%
 Renfree & Wright
 >10mm excision detaches 10% of the
Trapezoid ligament
 Boehm et al. Acta Orth Scand. 2003
14

23. Clavicle Excision
 11mm excision should not violate the
Trapezoid ligament in 98%
 Renfree & Wright
 >10mm excision detaches 10% of the
Trapezoid ligament
 Boehm et al. Acta Orth Scand. 2003
 High incidence of post-op pain if >10mm
resected
 Eskola et al. JBJS 1996
14

24. Clavicle Excision
 Only 5mm of the distal clavicle needs to be
resected to ensure that no bone-to-bone
contact occurs in rotation
 Corteen & Teitge
 Edwards et al. Arthroscopy 2007
15

25. Recommended:
 Resect 5mm on clavicle side & acromial
side
 Corteen & Teitge
16

26. Also:
 Post-op pain correlates with Translation,
but not amount of bone resected
 Blazar et al. CORR. 1998
 No difference if superior or inferior AC lig.
cut (horizontal, vertical & rotatory instability)
 Branch et al. AJSM 1996
17

27. Unstable ACJ
18

28. Management
19

29. Management
 Each case is unique
19

30. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
19

31. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
 Blame
19

32. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
 Blame
 Medicolegal
19

33. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
 Blame
 Medicolegal
 Multiple Opinions
19

34. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
 Blame
 Medicolegal
 Multiple Opinions
19

35. Management
 Each case is unique
 May be multiple problems
 Retained bone & unstable
 Excess excision & scar neuroma
 Blame
 Medicolegal
 Multiple Opinions
 Diagnostic Injection
19

36. Retained bone & Unstable
20

37. 21

38. 22

39. Arthroscopic Stabilisation
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40. Arthroscopic Stabilisation
23

41. Arthroscopic Stabilisation
23

42. Arthroscopic Stabilisation
23

43. Arthroscopic Stabilisation
23

44. Open Stabilisation
24

45. Open Stabilisation
24

46. Open Stabilisation
24

47. Open Stabilisation
24

48. Open Stabilisation
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49. Open Reconstruction
25

50. Under Resection
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51. Under Resection
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52. Under Resection
26

53. Under Resection
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54. Under Resection
26

55. Missed the joint
27

56. 28

57. Open ACJ
29

58. Failed ACJ Excision (Strauss et al. 2010)
Common Causes Less Common Causes
Instability Distal Clavicle Fracture
Under Resection Suprascapular neuropathy
Over Resection
Stiffness
Bony regrowth
Untreated Concomitant
Pathology
Infection
30

59. Pain - ? Neuroma
Mazzocca, 2003
image from DeLee & Drez Orthopaedic Sports Medicine. Elsevier. 2003
31

60. Recognition
 Awareness
 Test for Horizontal & Vertical Instability
 Ultrasound
 X-Ray
 CT Scan
 Stabilise if unstable
32

61. THANK YOU