Decision making: operative versus nonoperative treatment of acromioclavicular joint injuries

The classification system devised by Allman and Tossy, and revised by Rockwood, defines the extent of injury to the AC joint and helps to guide management of AC joint injuries [1,4,6]. In general, type I and II injuries may be treated nonoperatively with a sling, mainly for comfort, for a short period of time. Once this is removed, strength and motion are regained with rehabilitation. Patients typically have manageable long-term symptoms without any intervention, but some may require a steroid injection or distal clavicle excision for chronic pain from degenerative changes at the AC joint due to the injury. On the other end of the spectrum, type IV, V, and VI injuries nearly always require operative intervention. The surgical procedures for these injuries are performed in the acute phase if possible to minimize symptoms and maximize long-term function. Type III injuries are the center of the controversy for management of AC joint injuries. No perfect study exists which demonstrates clear superiority of surgical or nonsurgical treatment. Most of the studies in the literature support nonoperative treatment for most patients, however. Yet, other factors must be considered, including the patient's occupation and physical demands as well as the age of the injury. Overhead athletes and manual laborers place high demands on their shoulders, prompting some authors to consider acute surgical management for these patients. We, on the other hand, agree with the current consensus opinion that all type III injuries should initially be treated conservatively, regardless of occupation. The only advantage to operative intervention consistently borne out in the literature is an increased probability of anatomic reduction. There is no correlation between reduction and improvement in pain, strength, or motion, however. These patients usually are able to return to full sport with no deficits if rehabilitation is emphasized. For those patients who fail conservative management, a multitude of surgical techniques, such as the modified Weaver-Dunn procedure, exist to reconstruct the AC joint.