OT: Surgery to repair Grade V AC joint separation.

[stackie]

Interesting topic.

I sustained an AC separation in my last year of anesthesia residency at age 32. Initially graded as grade 3, and told either surgery or conservative non operative therapy. Got a second opinion from another orthopod. Second guy said grade 4 and definitely needed repair, especially as he considered me athletic due to my cycling. I wound up having surgery from initial orthopod as he was more if a sports med specialist. At time of surgery was found to be grade 5. He fixated clavicle with a screw. It loosened twice and had to be tightened once and the removed. So three surgeries. First was major and hella painful. Next two not such a big deal. Wound up with grade 2 separation still. But, I have no functional limitation due to shoulder. I can ride without any problem from shoulder ( not that riding works the shoulder ), lift weights including bench press, shoulder press. I’m fine with my decision to have surgery. Was well worth the $10 I paid for it. Guess there are some benefits of being a resident MD. Ha ha. Seriously, I don’t regret going with surgery.

Newer surgical procedures have better results than previous fixating techniques. I would lean toward looking for a surgeon who can and will use a newer technique, I.e., using a cadaver allograft to repair the coraco clavicular ligament. Can be done arthroscopically.

That said, it’s not going to be easy to find someone who can do this. Trust me, I work with a number of pretty good surgeons. Most of whom do not do this surgery. If it were me, I would be looking at the younger guys or a sports med guy and asking them if they will do a cadaveric repair and how many they have done. But then again, I’m an old fart so maybe I wouldn’t do anyway.

How old are you? How serious are you about your athletic performance? What do you do for work? All questions that should be asked and you should be thinking about.

Going back to your original post it sounds like you are older (5 decades of skiing ) and have a desk job. You’d probably be fine with conservative therapy. But I havent seen your films or examined you. So this is just musings from an anesthesiologist who happened to have same injury.

I would however emphatically recommend multiple opinions and if you can get dirt on any of the ortho pods from someone in the know, get it. Like ask an anesthesiologist or even surgical technologist.

Jon

[bshell]

Could not imagine skiing after a grade 3.

[glepore]

Originally Posted by bshell

Could not imagine skiing after a grade 3.

I did mine skiing, and subsequently made it worse after a driver right hooked me.

If you're conservative after the initial trauma and don't do repetitive overhead stuff, my experience has been you'll be fine, but individual response is individual.

[Seramount]

one more account...sustained a Grade 3 sep after a hit/run driver took me out on the bike.

the surgeon I consulted wanted to do surgery...not shocking.

but, after asking around, at least half of the people with similar injuries that had the procedure said they wished they'd just done PT instead...so, after some deliberation, opted for rehab and no cutting.

altho functional, the shoulder has never regained its original stability (makes clicking/clunking noises at times) and has the unsightly bulge.

the joint does NOT like excessively vigorous activities or lifting weights, so trying to build strength has been problematic. some actions (like using an axe or hedge shears) results in acute soreness. doing a pushup is particularly difficult.

even with with the reduced strength/utility, would go the same route again.

[jimcav]

FYI, I had some friends who played ice hockey (collegiate) and in conversations on injures learned it is not uncommon for them to have AC separation from all the constant hits and checking, yet they play and do everything else. This aligns with those I know who've had serious AC separations skiing or cycling, I didn't ask the grade (3-5) but for all of them there was an obvious drop and "indent" at the top of the shoulders. Some had surgery, some didn't, all had normal function after. I've injured both shoulders, significant rotator cuff stuff, although I've also had one decent AC sep. Several ortho surgeons in the navy wanted to operate on both my shoulders. I had a friend die on the table 20 years ago--getting his shoulder scoped, they nicked his lung, and didn't recognize the subsequent tension pneumothorax. I now have some issues with pull-ups and freestyle swimming--probably could do them more if I took time to gradually work at it, but since they aren't integral to my life or workouts, I just tend to avoid those activities. If my shoulders interfered with biking I'd get surgery. I'd give the conservative care route a trial, but that's me--with my perspective shaped by the above experiences. Good luck with recovery

[bshell]

In time, yes. Luckily/ thankfully. I was amazed that the OP skied three days after separation.

[stackie]

I had an AC separation in my last year of anesthesia residency. Saw an orthopedic surgeon who said was grade 3 and could go either way. Got second opinion who said was grade 4 and given my young age and athletic profile as a cyclist opined that I would be good candidate for repair. I wound up have the first surgeon repair as he was a more sports oriented ortho. He fixated the clavicle with a screw. At the time of surgery, he found clavicle was beginning to disrupt the deltoid muscle so met criteria for grade 5. I had problems with screw loosening and had to have tightened and eventually removed. I am at grade 2 separation now.

I don’t have any limitations or arthritis... yet. I expect at some point I will need a distal clavicle excision. But so far so good.
I can do over the shoulder work and ride without any shoulder issues. So I am happy for that. Would I have been ok without repair? Probably not. But who knows.

You said you are older (50 years) and have a desk job so it sounds like you might do well with conservative treatment.

Knowing what I know now after 20 years of anesthesia and seeing a lot of ortho pods, two opinions is not enough. I would dig around seriously and find out someone with inside intelligence on the local orthopods. Like an anesthesiologist or maybe surgical technologist. Even an orthopedic sales rep and ask them who they would go to for the particular injury.

Modern approach would be a arthroscopic coraco clavicular repair with a cadaver allograft. In my neck of the woods I’d only have 1 out of maybe 12 orthopedic surgeons do it. There are some who would refer me to the correct person. But there are some who would try to do an outdated repair because that’s what they know. Sad to say.