Revision AC Joint Surgery

Management of Failed AC Joint Surgery

Lennard Funk, updated 2024

Background:

Failed AC Joint Excision Surgery

Arthroscopic distal clavicle resection is a common procedure for the management of refractory pain arising from the acromioclavicular joint (AC Joint) due to degenerative arthritis. Clinical results are good to excellent in over 85% of patients, however a small subset of patients may experience persistent post-operative discomfort arising from the AC Joint.

The cause may be inadequate resection, incorrect pre-operative diagnosis, other co-existing shoulder pathology or over-resection leading to instability.

Biomechanical studies have demonstrated that the ACJ capsular ligaments, in particular the superior and posterior components, are responsible for up to 50% of the restraint to anterior translation and 90% restraint to posterior translation of the distal clavicle. Fukuda et al., 1986 Klimkiewicz et al., 1999.

At higher loads, the conoid ligament contributes 60% resistance to superior translation with the trapezoid ligament providing the primary restraint to axial compression of the clavicle on the acromion.

When performing distal clavicle resection, greater than 10mm excision may violate the superior ACJ capsular ligaments, Renfree and Wright, 2003 which can lead to excessive AP motion of the distal clavicle and encroach on the trapezoid ligament. Boehm et al., 2003.

A significant increase in anterior, horizontal translation of the distal clavicle can be seen following a 10mm resection and is further exacerbated by sectioning the ACJ capsular ligaments, whereas posterior translation significantly increases following a 10mm resection only after sectioning of the ACJ ligaments. Beitzel et al., 2012.

Gross instability from excess distal clavicle resection may be diagnosed on physical and radiographic examination but more subtle instability in the presence of conservative resection margins is difficult to diagnose clinically.

As such symptomatic ACJ instability following distal clavicle resection may be an underappreciated entity, which is reflected by the paucity of data regarding this condition

Failed AC Joint Reconstruction Surgery

There is no “gold standard” technique for the surgical stabilization of AC joint disruptions and each of the described techniques has a failure rate. The management of failed AC Joint stabilisations is a difficult problem and salvage procedures may often be constrained by the original procedure and the resultant anatomy. Each case is unique depending on the nature of the primary procedure and the mode of failure.

Reliable anatomical and biomechanically robust revision procedures for failed AC Joint stabilisation are therefore required.

Procedure:

My preferred approach is to perform a coracoclavicular ligament reconstruction using a LARS technique with a modification to reconstruct the acromioclavicular ligaments by passing the LARS through the acromion and under the coracoid a second time (LARS LF Modification 2).

LARS LF Modification 2:

I would also recommend biological supplementation if the tissue quality is poor. This can be in the form of a biceps flip procedure (aponeurosis of the short head of biceps), reverse coraco-acromial ligament (CAL) transfer, hamstring or Palmaris Longus - autograft or allograft. The choice of biological supplementation depends on the quality of the local tissues and quality of the patient (comorbidities, smoking, age, multiple previous surgeries, previous infection, etc).

LF Modification 2 with Bicep Flip Procedure:

Our early results have been published and referenced below - Baxter et al. J Orthop. 2018.

Failed acj excision from Lennard Funk

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