Chronic AC joint separation - Reconstruction using allograft and anatomic technique

Chronic AC joint separations are a challenging problem which requires non biologic and biologic fixation to avoid failure of the reconstructive surgery. Surgical treatment is offered to candidates who can be compliant with the restrictions in activity. Healing requires at least 3 months as tendon to bone healing is involved with this type of reconstruction. From the ACL reconstruction literature it is known that tendon to bone healing is completed at 6 months based on histology. For that reason, return to full activity is permitted at 6 months.

The biologic reconstruction is achieved by looping a tendon allograft (semitendinosus, or gracilis) around the base of the coracoid and fixing it through drill holes in the lateral clavicle. We avoid drilling of the coracoid because it creates a stress riser that may lead to coracoid fracture. The Augustus Mazzocca technique provides an anatomic fixation which mimics the anatomy of trapezoid an conoid ligaments. This technique is depicted below.

The non biologic reconstruction is achieved by looping a No 2 Fiberwire around the coracoid. This type of fixation may eventually fail but in the meantime the incorporation of the tendon graft in the bone tunnels will be complete and strong fixation may be achieved. There is a concern for fracture through the drill holes of the clavicle but it seems to be of low risk because the drill holes are filled with biotenodesis screws. Below are the images of such a reconstruction.

 Axillary view showing the posterior dislocation of the clavicle

AP view showing more than 100% displacement of the clavicle superiorly

 Restoration of the position of the clavicle relative to the acromion using the tendon allograft that was looped around the base of the coracoid (red line). The screws and tunnels are visible. 

Failure of healing (nonunion) of spiral diaphyseal closed humerus fractures

A middle aged patient was treated in a conservative fashion for a closed long spiral humeral shaft fracture. There was no neurologic compromise. Although the Sarmiento application revealed satisfactory reduction, serial radiographs failed to show healing at 4 months followup.

We generally wait for 4 months and decide if healing occurs and we monitor:

1. Pain
2. Motion at the fracture side
3. X-rays of the fracture with Sarmiento brace on and with the brace off at 4 months. A key radiograph is an abducted view of the humerus with the Xray beam perpendicular to the plane of the scapula (similar inclination to the Grashey view). If motion at the fracture site is detected on X-ray then we start the workup for nonunion of the fracture.

In this case the 4 month followup X-rays did not reveal union, there was motion at the fracture site and for that reason operative fixation was decided with a long 4.5mm plate. We routinely avoid placement of two plates or more than 4 screws on each site of the fracture to avoid disturbance in the blood flow of the humeral bone.  If possible a lag screw is used to achieve compression. In this case cancellous bone graft with DBM was added to the construct.

Of particular importance is the protection of the radial nerve which crosses the posterior mid shaft area at 20cm proximal to the medial epicondyle and pierces the IM septum at approximately 10-14cm proximal to the lateral epicondyle. The plate needs to be visualized in its entirety to avoid plating of the nerve, and the placement of the lag screw(s) needs to be performed in way that does not endanger the radial nerve (posterior mid shaft area and spiral groove). Up to 20% radial nerve palsies have been reported with this type of surgery.

The case is illustrated below:

initial X-rays

initial X-rays 

Reduction with Sarmiento

Reduction with Sarmiento

4 months post injury

4 months post injury with Sarmiento brace off

4 months after surgery the fracture is healed as demonstrated by the X-rays below:

Hemiarthroplasty for proximal humerus fractures

There is currently discussion about whether a hemiarthroplasty or a reverse shoulder arthroplasty should be offered to elderly patients with osteopenia or 4 part proximal humerus fractures. The supporters of the reverse shoulder arthroplasty state that there is better pain relief after the surgery and if the tuberosities heal then the ROM will be satisfactory. The supporters of the hemiarthroplasty state that the procedure is revisable, if the tuberosities heal then the ROM is satisfactory most of the time, but if they do not then the patient will have poor ROM.

One of the main concerns of the reverse shoulder arthroplasty is still tuberosity healing.

1. Studies show that tuberosity healing is still of importance to avoid loss of motion after surgery
2. The tensioning of the soft tissues after reverse shoulder arthroplasty for fracture is not easy to be achieved as in primary surgery for arthritis. If the tuberosity healing fails then the construct can loose tension and dislocation may occur.
3. If the reverse arthroplasty fails,  then there is no easy solution other than conversion to (a) a hemiarthroplasty or (b) resection arthroplasty. Both of these procedures have poor outcomes


Below we demonstrate a patient who was treated with a hemiarthroplasty for a 4 part proximal humerus fracture. She is her 60s and for that reason we elected to proceed with a hemiarthroplasty. Although anatomic reduction of the tuberosities is important it seems that most important factor is the healing even if they are over-reduced.


The patient was pain free at 3 months postoperatively, her active forward elevation was equal to the opposite site. The final X-rays reveal healed but "over-reduced tuberosities".