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HPI

This is a 75-year-old male, RHD, bus driver who sustained an injury of the left acromioclavicular joint 8 months ago. Patient had a direct fall onto his left shoulder after a hit-and-run. He admits that pain gets worse with any movement. Patient had extensive non-op management including PT, rest, and Nsaids. Persistent pain and disability from the AC separation were affecting his QOL. He is very active and pain was 5-8/10.

PMH

No significant medical history.

PE

There is a prominence of the distal clavicle that is reducible to manual pressure. There is no winging or psuedo-winging. Full passive and active ROM of the shoulder. There is full range of motion to the elbow, wrist, and hand. Tender to palpation at the AC joint. Abduction in the plane of the scapula (Supraspinatus): 5/5 ER with the arm at the side (Infraspinatus)- 5/5 IR (Subscapularis)- 5/5 ER Strength at 90 deg of abduction (Teres Minor): 5/5 Deltoid: Ant: 5/5 Mid: 5/5  Post: 5/5 Patient is neurovascularly intact.

Poll
1 of 15
1. Would you obtain additional imaging studies to guide management?
No - current radiographs are sufficient
60%
516/851
Yes - additional radiographic views (aXR)
7%
63/851
Yes - CT scan of the shoulder (CT)
6%
54/851
Yes - MRI of the shoulder (MRI)
19%
166/851
Yes - aXR + CT
0%
6/851
Yes - aXR + MRI
3%
27/851
Yes - aXR + CT + MRI
0%
8/851
Outside my area of expertise - best if I don't vote
1%
11/851
2. How would you classify this injury with the Rockwood Classification?
I would not - a classification system would not help me
6%
53/825
Rockwood type II
1%
16/825
Rockwood type III
35%
291/825
Rockwood type IV
19%
164/825
Rockwood type V
33%
276/825
Outside my area of expertise - best if I don't vote
3%
25/825
3. How would you manage this injury at this time?
Nonoperative (continued physical therapy)
16%
134/823
Operative
82%
677/823
Outside my area of expertise - best if I don't vote
1%
12/823
4. If you choose Operative management, what type of fixation would you perform to hold your AC reduction?
I would not choose Operative management
3%
28/788
Fixation across AC joint (AC fixation) Alone
11%
93/788
Fixation to the Coracoid (CC fixation) Alone
34%
274/788
AC fixation + CC fixation
46%
368/788
Outside my area of expertise - best if I don't vote
3%
25/788
5. It you choose Fixation across AC joint Alone, what fixation technique would you use?
I would not choose Fixation across AC joint only
43%
322/746
CRPP (Percutaneous K wire, +/- Tension Band Wire)
4%
35/746
Hook plate
25%
190/746
Heavy Suture Fixation across AC joint
10%
76/746
Graft (auto or allo) across AC joint
12%
94/746
Outside my area of expertise - best if I don't vote
3%
29/746
6. If you choose Fixation to the Coracoid (+/- fixation across AC joint), what type would you use?
I would not choose Fixation to the Coracoid
5%
41/738
Coracoclavicular Screw Fixation (Screw) (ex. Bosworth screw)
4%
36/738
Synthetic implant (Heavy Suture, Trans-cortical device, Anchor)
31%
229/738
Ligament reconstruction (allograft, autograft)
19%
144/738
Screw + Ligament reconstruction
5%
37/738
Synthetic implant + Ligament reconstruction
29%
221/738
Outside my area of expertise - best if I don't vote
4%
30/738
7. If you choose Fixation to the Coracoid with a Synthetic implant, what fixation type would you use on the Coracoid?
I would not choose Fixation to the Coracoid with Software
8%
55/681
Heavy Suture loop around Coracoid (e.g., suture tape, Fiberwire, Lockdown)
36%
250/681
Trans-bicortical device (Dogbone, Cortical button, Juggernaut))
45%
309/681
Trans-unicortical device (Suture anchor, Juggernaut)
4%
28/681
Outside my area of expertise - best if I don't vote
5%
39/681
8. If you choose Ligament reconstruction, what surgical approach would you use?
I would not choose Ligament reconstruction
12%
83/668
All arthroscopic
4%
30/668
Arthroscopic-assisted open
23%
158/668
Open only
54%
365/668
Outside my area of expertise - best if I don't vote
4%
32/668
9. If you choose Ligament reconstruction, what type of graft would you use?
I would not choose Ligament reconstruction
14%
98/662
Allograft
35%
236/662
Autograft - palmaris longus
12%
85/662
Autograft - semi-tendinosus
27%
179/662
Autograft - plantaris
1%
9/662
Autograft - other
2%
18/662
Outside my area of expertise - best if I don't vote
5%
37/662
10. If you choose Ligament reconstruction, what fixation techniques would you use on the Coracoid and Clavicle?
I would not choose Ligament reconstruction
13%
81/580
Coracoid loop + Clavicle loop (figure of eight)
21%
125/580
Coracoid loop + Clavicle bone tunnel(s)
21%
126/580
Coracoid loop + Clavicle cortical device to graft (cortical button)
9%
55/580
Coracoid cortical device to graft (suture anchor) + Clavicle loop
4%
24/580
Coracoid cortical device to graft + Clavicle bone tunnel(s)
3%
21/580
Coracoid cortical device to graft + Clavicle cortical device to graft
3%
21/580
Coracoid bone tunnel(s) + Clavicle loop
2%
13/580
Coracoid bone tunnel(s) + Clavicle bone tunnel(s)
7%
45/580
Coracoid bone tunnel(s) + Clavicle cortical device to Graft
1%
9/580
Outside my area of expertise - best if I don't vote
10%
60/580
11. If you choose Ligament reconstruction, in addition to graft fixation on the coracoid and clavicle, would you extend fixation of the graft to the acromium?
I would not choose Ligament reconstruction
14%
80/556
No
40%
223/556
Yes
38%
215/556
Outside my area of expertise - best if I don't vote
6%
38/556
12. If you choose Ligament reconstruction, would you include a distal clavicle resection?
I would not choose Ligament reconstruction
9%
50/549
No - never
15%
83/549
Yes - only if pre-existing arthritis
18%
100/549
Yes - only if irreducible
7%
43/549
Yes - if irreducible OR pre-existing arthritis
26%
143/549
Yes - always
18%
101/549
Outside my area of expertise - best if I don't vote
5%
29/549
13. If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Active ROM (ex. pendulums)?
I would not choose Ligament reconstruction
6%
32/516
Immediately
12%
64/516
3-6 days post-op
5%
29/516
1 week (7-13 days)
7%
39/516
2 weeks post-op (14-20 days)
12%
67/516
3 weeks post-op (21-27 day)
11%
61/516
4 weeks post-op (28-34 days)
17%
89/516
5 weeks post-op (35-42 days)
3%
18/516
>6 weeks post-op (>42 days)
19%
99/516
Outside my area of expertise - best if I don't vote
3%
18/516
14. If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Strengthening exercises?
I would not choose Ligament reconstruction
5%
27/499
Immediately
1%
6/499
1 month
10%
54/499
2 months
23%
118/499
3 months
47%
235/499
4 months
4%
20/499
5 months
0%
3/499
6 months
3%
19/499
7 months
0%
0/499
8 months or greater
0%
4/499
Outside my area of expertise - best if I don't vote
2%
13/499
15. If you choose Ligament reconstruction and obtained the fixation seen below, when would you allow Unrestricted Activity (ex. skiing)?
I would not choose Ligament reconstruction
5%
29/500
Immediately
0%
1/500
1 month
1%
5/500
3 months
11%
57/500
6 months
63%
318/500
9 months
6%
34/500
12 months (1 year)
8%
40/500
15 months
0%
0/500
18 months (1.5 years) or greater
0%
4/500
Outside my area of expertise - best if I don't vote
2%
12/500
PROCEDURE #1 DOP: 11/9/2022

Reconstruction of Acromioclavicular Joint, Superior Capsule, and Coracoclavicular Ligaments Using an Interpositional Acellular Dermal Matrix and Tibialis Tendon Allograft

POLL#
Surgeon's Choices
1
Would you obtain additional imaging studies to guide management?
No - current radiographs are sufficient
2
How would you classify this injury with the Rockwood Classification?
Rockwood type III
3
How would you manage this injury at this time?
Operative
4
If you choose Operative management, what type of fixation would you perform to hold your AC reduction?
AC fixation + CC fixation
5
It you choose Fixation across AC joint Alone, what fixation technique would you use?
I would not choose Fixation across AC joint only
6
If you choose Fixation to the Coracoid (+/- fixation across AC joint), what type would you use?
Ligament reconstruction (allograft, autograft)
7
If you choose Fixation to the Coracoid with a Synthetic implant, what fixation type would you use on the Coracoid?
Trans-bicortical device (Dogbone, Cortical button, Juggernaut))
8
If you choose Ligament reconstruction, what surgical approach would you use?
Open only
9
If you choose Ligament reconstruction, what type of graft would you use?
Allograft
10
If you choose Ligament reconstruction, what fixation techniques would you use on the Coracoid and Clavicle?
Coracoid loop + Clavicle bone tunnel(s)
11
If you choose Ligament reconstruction, in addition to graft fixation on the coracoid and clavicle, would you extend fixation of the graft to the acromium?
Yes
12
If you choose Ligament reconstruction, would you include a distal clavicle resection?
Yes - only if irreducible
13
If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Active ROM (ex. pendulums)?
>6 weeks post-op (>42 days)
14
If you choose Ligament reconstruction and obtained the fixation seen below, when would you start Strengthening exercises?
3 months
15
If you choose Ligament reconstruction and obtained the fixation seen below, when would you allow Unrestricted Activity (ex. skiing)?
6 months
Intra-procedure P1
icon
OUTCOMES
8 weeks after
Post-procedure P1
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