acj excision watanabe india
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AC Joint Excision
Mr Chris Roberts
Consultant Orthopaedic Surgeon
Ipswich Hospital NHS Trust
2nd Indian Watanabe meeting, Chennai
Anatomy
• Diarthrodial joint
• Two types of fibrocartilage discs :
complete partial (meniscoid)
• No function after 4th decade
• Nerve supply : axillary
suprascapular
lateral pectoral
Anatomy
Superior and Posterior
Acromioclavicular Ligaments
(antero-posterior stability)
16mm 30mm
ct
Coracoclavicular ligaments
Footprint of Superior ligament
Up to 17mm
Urist 100 shoulders :
49% clavicle over-riding acromion
27% vertical
21% incongruent
3% clavicle under-riding acromion
‘Normal’ x-rays
Correct operation done correctly
Right reasons
Full excision
Safely
AC Joint Excision
•Indications:
– Symptomatic OA
– Painful ACJ
(osteolysis)
– Prominent inferior
osteophyte
•Beware:
– Instability
AC Joint Excision
OA of AC joint very
common
But rarely symptomatic
AC Joint Excision
OA of AC joint very common
But rarely symptomatic
SO
Excision based on clinical findings
Examination
Examination
Provocative tests
Most important test
Accurate ACJ intra-
articular injection,
ideally USS guided,
resulting in relief of
symptoms/signs
AC Joint Excision
Investigations
Specific X-rays - ↓ penetration
- 10-15º cephalic tilt
MRI - not routine
- other causes
Bone scan - rarely
ACJ excision options
•Open ACJ excision still
commonly performed
•Commonest
arthroscopic approach is
bursal
•2-superior portal ACJ
excision: some
advantages but
technically challenging
Set-up
• Beach chair/lateral decubitus
• Hypotensive anaesthesia
• Radio-frequency device
• 4.0 or 5.5mm acromionizer
Posterior viewing portal
Anterior working portal
Lateral and Neviaser viewing
portal
Work to a pattern
• Clear antero-inferior capsule and surrounding fat
• Ensure correct resection depth by excising antero-
inferior clavicle to depth of burr
• Excise remaining inferior clavicle to same depth
• Excise superior clavicle preserving superior
capsule
• Excise central bump
Inferior osteophyte without
symptoms
Co-plane osteophyte level with acromion
or
Excise whole depth of clavicle
Avoid excision part clavicle depth
Pitfalls
•Incomplete excision
– Posterior
– Superior osteophyte
•Instability
Summary
• Assess clinically – decision before
operation
• Vary portals for good view
• Work to a pattern
• Preserve postero-superior capsule
AC Joint Excision
Thank you
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