This document discusses advances in arthroscopy of the acromioclavicular (AC) joint. It describes the anatomy of the AC joint and common pathologies like osteolysis, arthritis, cysts, and dislocations that can be treated arthroscopically. Techniques for arthroscopic distal clavicle excision, AC joint reconstruction for dislocations using grafts or ligament transfers are presented. The author's preference is for open reduction and fixation for AC dislocations due to more precise reduction and residual scarring's effect on stability. Several case examples are provided.

1. Advances inAdvances in
Acromioclavicular JointAcromioclavicular Joint
ArthroscopyArthroscopy
Manos AntonogiannakisManos Antonogiannakis
DirectorDirector
Center for Arthroscopy &Center for Arthroscopy &
Shoulder SurgeryShoulder Surgery
IASO General HospitalIASO General Hospital www.shoulder.gr

2. The Shoulder GirdleThe Shoulder Girdle
Three joints:Three joints:
 glenohumeralglenohumeral
 AcromioclavicularAcromioclavicular
 ScapulothoracicScapulothoracic
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3. Acromioclavicular JointAcromioclavicular Joint
AC joint is situated between theAC joint is situated between the clavicleclavicle andand acromionacromion
motion in three planes:motion in three planes:
- AP gliding of acromion during protraction & retraction of- AP gliding of acromion during protraction & retraction of
scapulascapula
- tilting of acromion during abduction & adduction of armtilting of acromion during abduction & adduction of arm
- rotation of the claviclerotation of the clavicle whichwhich occurs during abduction &occurs during abduction &
adduction of shoulder.adduction of shoulder.
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4. AnatomyAnatomy
Consists of two sets ofConsists of two sets of
ligaments:ligaments:
- AC ligamentAC ligament
superiorsuperior - posterior- posterior AC lig isAC lig is
most important ligament inmost important ligament in
stabilizing AC joint for normalstabilizing AC joint for normal
daily activitiesdaily activities
- CoracoclavicularCoracoclavicular
ligaments:ligaments:
ConoidConoid
TrapezoidTrapezoid
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5. AC pathology that can beAC pathology that can be
treated by arthroscopytreated by arthroscopy
 Osteolysis of the clavicleOsteolysis of the clavicle
 AC arthritisAC arthritis
 AC infection/cystsAC infection/cysts
 AC dislocationAC dislocation
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6. Osteolysis of the clavicleOsteolysis of the clavicle
 Unclear PathogeneticUnclear Pathogenetic
mechanismmechanism
 Acute injury (type I/IIAcute injury (type I/II
AC sprains)AC sprains)
 Repetitive microtraumaRepetitive microtrauma
 Usually in male athletesUsually in male athletes
(weight-lifters)(weight-lifters)
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7. Osteolysis of the clavicleOsteolysis of the clavicle
Unclear Pathogenetic mechanismUnclear Pathogenetic mechanism
 autonomic neurovascular originautonomic neurovascular origin
 synovial invasion of the subchondral bonesynovial invasion of the subchondral bone
 Cahill proposed that repetitiveCahill proposed that repetitive
microtrauma caused subchondral stressmicrotrauma caused subchondral stress
fractures and remodelingfractures and remodeling JBJS(Am)1982JBJS(Am)1982
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8. Osteolysis of the clavicleOsteolysis of the clavicle
TreatmentTreatment
 Consernative (Rest, NSAIDs,Consernative (Rest, NSAIDs,
Corticosteroid injections)Corticosteroid injections)
 Surgical (Open or Arthroscopic distalSurgical (Open or Arthroscopic distal
clavicle excision)clavicle excision)
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9. AC ArthritisAC Arthritis
 Post – TraumaticPost – Traumatic
 DegenerativeDegenerative
ConcommitantConcommitant
lesion to RClesion to RC
tearstears
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10. AC cystAC cyst
O. Levy Arthroscopy 2007

11. Surgical TreatmentSurgical Treatment
Open distal clavicle excisionOpen distal clavicle excision
Described by Mumford and Gurd in 1941Described by Mumford and Gurd in 1941
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12. Arthroscopic Distal Clavicle ExcisionArthroscopic Distal Clavicle Excision
SnyderSnyder Arthroscopy 1995Arthroscopy 1995
BiglianiBigliani Arthroscopy 1992/2000Arthroscopy 1992/2000
FlatowFlatow JSES 1995JSES 1995
AugeAuge AJSM 1998AJSM 1998
Surgical TreatmentSurgical Treatment
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13. Arthroscopic vs Open DistalArthroscopic vs Open Distal
Clavicle ExcisionClavicle Excision
 Better cosmesisBetter cosmesis
 Less PainLess Pain
 Avoids Muscle WeaknessAvoids Muscle Weakness
 Residual AC instabilityResidual AC instability
 Comparable outcome resultsComparable outcome results
JP Warner Arthroscopy 2009JP Warner Arthroscopy 2009
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14. TechniqueTechnique
 Patient positioning exactly the same asPatient positioning exactly the same as
shoulder arthroscopyshoulder arthroscopy
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15. Skin Marking & PortalsSkin Marking & Portals
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16. Subacromial DebridementSubacromial Debridement
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17. AcromioplastyAcromioplasty
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18. Starting distal clavicle excisionStarting distal clavicle excision
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19. External depression of theExternal depression of the
clavicleclavicle
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20. Establishing Anterior AC portalEstablishing Anterior AC portal
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21. Check Lateral PortalCheck Lateral Portal
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22. Scope in AC portalScope in AC portal
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23. Use 70˚ scope to completeUse 70˚ scope to complete
excisionexcision
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24. Final AC space 5-8mmFinal AC space 5-8mm
Zhang et al.Arthroscopy 2007
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25. Check distance in abductionCheck distance in abduction
and external rotationand external rotation
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26. AC dislocationAC dislocation
Rockwood ClassificationRockwood Classification

27. AC dislocationAC dislocation
 Conservative treatment for types I – IIConservative treatment for types I – II
 Surgical treatment for types IV – VISurgical treatment for types IV – VI
 What about type III ?What about type III ?
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28. AC dislocationAC dislocation
 Treatment of acute Type III dislocationsTreatment of acute Type III dislocations
remains controversialremains controversial
“More prospective randomized studies using
validated outcome measures are needed to identify the
suitable operation techniques for the acute injuries”
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29. Arthroscopic AC reconstructionArthroscopic AC reconstruction
Several techniques have been publishedSeveral techniques have been published
either full arthroscopic or arthroscopicallyeither full arthroscopic or arthroscopically
assisted by Wolf, Boileau, Lafosseassisted by Wolf, Boileau, Lafosse
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30. AC reconstruction usingAC reconstruction using
synthetic graftsynthetic graft
E. WOLF – W. PENINGTON ARTHROSCOPY 2001
First publication of all arthroscopic AC reconstruction
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31. Arthroscopic CA ligamentArthroscopic CA ligament
transfertransfer
LAFOSSE et al.
ARTHROSCOPY 2005
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32. Arthroscopic Weaver DunnArthroscopic Weaver Dunn
P. BOILEAU et al. ARTHROSCOPY 2010
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33. Our Experience in ACOur Experience in AC
dislocationsdislocations
We prefer open reduction – fixation of theWe prefer open reduction – fixation of the
AC because ofAC because of
 Small incisionSmall incision
 Precise reductionPrecise reduction
 Residual scaring seems to have effect onResidual scaring seems to have effect on
stabilitystability
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34. Methods of FixationMethods of Fixation
 For Acute dislocations use of syntheticFor Acute dislocations use of synthetic
ligaments (Tightrope – Arthrex, Surgilig –ligaments (Tightrope – Arthrex, Surgilig –
Surgicraft) along with ligament suturingSurgicraft) along with ligament suturing
 For Chronic dislocations use of syntheticFor Chronic dislocations use of synthetic
ligaments along with hamstrings autograftligaments along with hamstrings autograft
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35. Interesting CaseInteresting Case
Patient has his 3Patient has his 3rdrd
revision for ACrevision for AC
dislocation (Surgilig along with hamstringsdislocation (Surgilig along with hamstrings
autograft)autograft)
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36. Pre - op Post - op
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37. 6 months later after a fall from6 months later after a fall from
his bikehis bike
Note that the ac remains intact!!!
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38. Final Outcome (4Final Outcome (4thth
operation)operation)
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39. Thank you!!!Thank you!!!
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