Nov 30, 2017
The amount of surgery has to be “just right” to repair severely separated shoulder, says US surgeon
A ‘Goldilocks’ approach is the best way to treat severely separated shoulders, according to one of the world’s leading shoulder specialists.
Orthopaedic surgeons usually favour a less-is-more approach to surgery to minimise risk but they have learnt that severely separated shoulders are the exception to this rule, Dr Robert Hartzler told a recent meeting of the Arthroscopy Association of North America (AANA).
Like the porridge in the fairy tale, the amount of surgery has to be “just right” to ensure a successful outcome and that may mean more rather than less.
“You want just the right amount of surgery: not too much and not too little,” Dr Hartzler said. “Each additional step adds more time and risk of problems but more is often better for these kinds of injuries, especially severe ones.”
Speaking at an international gathering of orthopaedic surgeons organised by the AANA in Chicago, Illinois, Dr Hartzler said early treatment is the other key factor that determines how successful treatment will be.
“The main thing is to get to the injury early,” he told our reporter. “You really want to treat it within a week to give the surgeon the best chance to get things back into their anatomical configuration and to give the body the best chance to heal.”
One of the most common sporting injuries, a separated shoulder involves the acromio-clavicular joint (AC joint). This is where the shoulder blade (acromion) meets the collarbone (clavicle). The injury typically happens when a patient falls directly on to their shoulder.
In mild cases, the patient sprains the AC ligament but the collarbone stays in its natural position. Heavier falls may tear the AC ligament or the adjacent coracoclavicular (CC) ligament tugging the collarbone out of alignment. In the most severe cases, both the AC and CC ligaments tear dislocating the shoulder from the collarbone. This is known as an acromio-clavicular dislocation and is a different injury to a dislocated shoulder, which occurs when the ball and socket separate.
A severe shoulder separation injury will be cosmetically apparent because the patient’s collarbone will protrude.
“These are typically fairly intense traumatic injuries,” said Dr Hartzler, who is a shoulder specialist at the San Antonio Orthopaedic Group in San Antonio, Texas. He said that surgeons have to decide whether to treat just the CC ligament or both the CC and AC ligaments. In the past surgeons focused on the CC joint but now they believe it is more effective to treat both.
“We describe them as AC joint injuries but the CC ligaments are really the key anatomic structures that are addressed with surgery,” Dr Hartzler said. “We have to decide whether to treat one or both of those sites. You want just the right amount of surgery.”
Our principal Mr Simon Moyes, who attended the AANA meeting in Detroit, said: “I regularly do this surgery, particularly for skiers and snowboarders. I absolutely agree with the conclusions Dr Hartzler and his colleagues have reached about the key factors that optimise outcomes, namely early intervention and getting the amount of surgery ‘just right’, which may mean treating the AC joint as well as the CC joint in the most severe cases.”
The basic procedure
Although the operation is called AC Joint Reconstruction, it actually focuses on the CC joint. Once the patient is asleep, Dr Hartzler makes small incisions in the skin and inserts two or three tiny cannulas. These act as passageways both for his arthroscope, which enables him to see inside the shoulder with a miniature camera, and for his surgical instruments.
He shuttles the arthroscope through one of the cannulas and examines the damage to the shoulder. Typically the collar bone is up and the shoulder blade is down because the CC and AC ligaments are torn.
His first task is to find the coracoid process, a small piece of bone on the edge of the scapula that is shaped like a hook (coracoid derives from the Ancient Greek word korakodes meaning ‘like a crow’s beak’). Once he has spotted it, he makes a small incision above the collarbone and inserts a drill.
He uses his arthroscope to ensure the drill is correctly positioned and then bores a small hole (less than 3mm) through the collarbone and down through the middle of the coracoid process. The drill bit is hollow and Dr Hartzler feeds through a special suture with titanium buttons at either end.
Dr Hartzler guides the suture through the hole in the collarbone and then through the hole in the coracoid process. The titanium button at the bottom of the suture anchors it to the coracoid process. Dr Hartzler tightens the suture, which pulls the two bones back to their correct anatomical position, and then secures it above the collarbone.
Depending on the severity of the case, Dr Hartzler will then also stabilise the AC joint by surgically repairing the torn ligaments with sutures using a slightly different technique. This is where the Goldilocks decision comes in: he has to weigh the risks of a longer, more complex procedure against the benefits of stabilising both joints and decide how much surgery is “just right”.
Finally, when the surgery is complete, he closes the incisions. It takes between six weeks and three months for the patient to heal. The sutures, which are made of high-strength polyethylene, and titanium buttons scar into place becoming part of the body.
“The big advantage of doing this surgery arthroscopically is that you can get those bones back into place without having to detach a large amount of deltoid muscle,” Dr Hartzler said. “You can also look inside the joint and make sure nothing else is injured.
“It takes arthroscopic skill to work in that area. There are some very delicate structures nearby so you really want experience and training. In the op room we have live x-ray called fluoroscopy to help make sure the hardware is being put where we want it to be put.”
Shoulder separation injuries usually occur when patients fall directly on to their shoulders. They often happen when people are playing sports or when they fall off bicycles or motorbikes. Patients will feel pain and a sensation that things are shifting when they try to do overhead activities.