I hope everyone had a great weekend! It was beautiful here in Charleston, although it is starting to get hot. Quickly I want to congratulate two teams. The Academic Magnet High School girls’ soccer team won the state championship Friday. It is one of the high schools we cover, and the team has several former patients, so I could not happier for them. It is perennially one of the top academic schools in the United States, proving that it is possible to be smart and good at sports. Also, congratulations to the Lowcountry Highrollers All Stars. Despite a few injuries, our awesome roller derby team continued its undefeated season Saturday. It is great to work with these girls!
Next week’s Ask Dr. Geier column will be a little different, as I will describe a typical week for me at the request of a reader considering sports medicine and orthopaedic surgery as a career. Look out for that. Spoiler alert – I’m actually not that exciting, but it will still make for an interesting post.
As always, please keep in mind my disclaimer about not discussing specific medical advice online or by email.
Terry in Rochester, Indiana asks:
I have a type III shoulder separation since October 2010. I’m 47-year-old male who is very active in sports and active in mission trips that require rugged and heavy travel. I still have the same range of motion, but I lack the strength. At times when I use it during sports and piano, I experience pain.
1) Can you please tell me how many surgeries, for this injury, you have performed?
2) And what surgical technique do you use?
Thank you very much for your time and expertise. Terry
Surgery for shoulder separations (acromioclavicular joint separations, or AC separations) is actually not that common. I probably perform 5-10 of these surgeries each year, although they are among my favorite surgeries. The most common types of AC separations are the less severe ones, namely types I and II. They fortunately rarely require surgical treatment. Types V and VI, which are much more serious and usually require surgical treatment, are fairly uncommon. Type III AC separations, like the reader has, often do well with nonsurgical treatment. Even in athletic individuals, studies have shown fairly good outcomes with nonsurgical treatment for these injuries, so most sports medicine surgeons will at least offer and try nonoperative treatment for type III injuries first.
A type III AC separation has a moderate amount of vertical instability of that joint. There is approximately 100% displacement between the end of the clavicle and the acromion. If surgical fixation is attempted, the surgeon uses a technique that reduces this vertical instability. Simply cutting off the end of the clavicle won’t change this instability. In the past, surgeons tried to take a ligament from one part of the shoulder and transfer it to the end of the clavicle to try to hold the end of the clavicle in position.
Newer techniques include implants that try to pull the clavicle down to the coracoid. I use a technique that takes a tendon, either from the patient himself or herself or from a donor. The tendon is looped under the coracoid and then passed through the end of the clavicle through two drill holes. It is anchored in the clavicle with absorbable screws in each drill hole, and then the tendon is sewn upon itself. The tendon reconstructs the ligaments that are torn in the injury, holding the end of the clavicle down in the appropriate position. Studies have shown that this technique, at least in simulated biomechanical studies, is among the strongest for stabilizing this joint. Readers who are considering surgery for AC separations should consult with their surgeons about the necessity of surgical treatment and the options for surgical fixation.
Have you suffered a shoulder separation? Did you have surgery for it, or did you let it heal on its own? Let me know about your experience!