What is the step by step procedure for treating AC (acromioclavicular) joint dislocation using anchor sutures and CC (coracoclavicular) screw?

Surgical Procedure for AC Joint Dislocation Using Anchor Sutures and CC Screw

The optimal surgical approach for acromioclavicular joint dislocation involves anatomic reconstruction of both coracoclavicular and acromioclavicular ligaments using anchor sutures and coracoclavicular screw fixation to ensure both vertical and horizontal stability.

Preoperative Considerations

• Evaluate the grade of AC joint dislocation (Rockwood classification)
• Surgical intervention is generally indicated for:
  • Type III dislocations in high-demand patients and athletes
  • Types IV, V, and VI dislocations (require operative reduction and fixation) 1
• Timing: Early reconstruction is preferred as the risk of additional soft tissue damage increases within 3 months of injury 2

Surgical Technique: Step-by-Step Procedure

Step 1: Patient Positioning and Setup

• Position patient in beach chair or lateral decubitus position
• Prepare and drape the shoulder in standard sterile fashion
• Mark anatomical landmarks (clavicle, acromion, coracoid process)

Step 2: Diagnostic Arthroscopy

• Establish standard posterior viewing portal
• Create anterolateral and anterior working portals
• Perform glenohumeral examination to identify and repair any concomitant lesions 3

Step 3: Coracoid Process Exposure

• Identify the coracoid process through the anterior portal
• Dissect the lateral border of the conjoint tendon
• Perform pectoralis minor tenotomy medially for better exposure
• Identify and protect the brachial plexus 3

Step 4: Clavicle and AC Joint Preparation

• Create a superior incision over the distal clavicle
• Dissect the inferior and superior surfaces of the clavicle
• Maintain continuity between deltotrapezoid fascia and AC ligaments
• Expose the AC joint and identify torn ligaments 3, 4

Step 5: Coracoclavicular Ligament Reconstruction

• Tag and expose the torn CC ligaments (conoid and trapezoid)
• Drill two tunnels through the clavicle corresponding to the anatomic footprints of the CC ligaments
• Pass two high-strength suture tapes from the coracoid to the clavicle
• Use dog bone buttons or suture anchors to secure the construct 3, 5

Step 6: CC Screw Placement

• Identify the optimal entry point on the clavicle for CC screw insertion
• Drill a guide hole from the clavicle to the coracoid
• Insert an appropriate length CC screw while maintaining the reduction
• Note: The CC screw provides rigid fixation but may need to be removed later to prevent complications 6

Step 7: AC Joint Horizontal Stabilization

• Identify the superior AC ligament (often torn from the clavicular side)
• Place suture anchors in the distal clavicle
• Repair the superior and inferior AC ligaments to restore horizontal stability
• This step is crucial as it prevents horizontal instability that may persist if only vertical stability is addressed 4

Step 8: Final Reduction and Fixation

• Reduce the AC joint under direct visualization
• Secure all sutures and verify the stability of the construct
• Ensure proper tension in both the vertical (CC) and horizontal (AC) components
• Confirm reduction with intraoperative fluoroscopy

Step 9: Wound Closure

• Repair the deltotrapezial fascia over the clavicle
• Close subcutaneous tissues and skin in standard fashion
• Apply sterile dressing and shoulder immobilizer

Postoperative Management

• Shoulder brace immobilization for 6 weeks 3
• Limited range of motion exercises starting at 2-3 weeks
• Progressive rehabilitation protocol beginning at 6 weeks
• Return to sports activities typically at 6 months postoperatively 5

Potential Complications and Considerations

• Hardware irritation or failure (particularly with CC screw)
• Loss of reduction
• Coracoid or clavicle fracture
• Infection
• Persistent pain or instability

Expected Outcomes

Professional athletes treated with anatomic reconstruction of both CC and AC ligaments with synthetic augmentation have shown significant improvement in functional scores and return to pre-injury activity levels within 6 months 5. Radiographic maintenance of reduction is typically observed at 1 month and 6 months post-surgery.

This combined approach addressing both vertical stability (with CC ligament reconstruction and CC screw) and horizontal stability (with AC ligament repair using suture anchors) provides the most comprehensive treatment for AC joint dislocations, particularly in high-demand patients.