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Dr.Sawhney, Orthopedic Surgeon
Category: Orthopedics
Satisfied Customers: 6817
Experience:  More than a decade of post qualification experience
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Credentials, please? Second, is it possible to resect (like

Customer Question

Credentials, please? Second, is it possible to resect (like shorten and suture back together) acromioclavicular, conoid, and trapezoid ligaments attached from clavicle to coracoid if the ligaments healed lax (elongated) from a previous shoulder separation? Would the it be accurate enough to match structure of unafflicted shoulder? It seems like ligaments are causing imbalance/misshapen shoulder as compared to the other seeing as while the shoulder is suspended by the trapezius muscles/tendons, force is still transmitted through aforementioned ligaments and appear to cause shoulder to ride superiorly up into joint further than normal to compensate for laxity maintaining (though poorly) balance.
Submitted: 4 months ago.
Category: Orthopedics
Expert:  Dr.Sawhney replied 4 months ago.
I am Dr.Sawhney an Orthopaedic surgeon and I would be happy to help you today.
Please tell me your age and gender.
How long back was the injury and what are your symptoms at present?
Customer: replied 4 months ago.
M/30 yrs. This would have occurred years ago. Cracking, poppoing, pain with forced overhead movement, clavicle "bump" protrusion, shoulder sags forward as well.
Expert:  Dr.Sawhney replied 4 months ago.
Thanks for your reply.
From the description you have provided it seems that acromioclavicular joint is involved and arthritic.
This may be related to old injury you had.
In addition you should be examined and investigated to rule out a rotator cuff tear.
Rotator cuff muscles are the main stabilizers for overhead motion and if pain is there on overhead activities, rotator cuff pathology is suspected.
The ligaments you have mentioned in your original question do not seem to be major factor in your present problems and should not be interfered with.
Feel free to ask any follow-up questions.
Customer: replied 4 months ago.
That doesn't really answer my question. Those ligaments were probably ALREADY interfered with. And my question was, can orthopedists go in and resect those ligaments and get near normal healing? Are ligaments too "slick" or something to cut and resuture? Doctors often reccommend conservative treatment for torn ligaments and they often heal on their own. Is it possible ac joint excisions makes separated shoulders worse if the ligaments are cut and not allowed to heal to a proper length?
Customer: replied 4 months ago.
I appreciate that you are trying to redirect my question to what conventional medicine says about treating shoulder separations. But the convention is controversial for a reason, and I am trying to anatomically/physiologicaloy understand why.
Expert:  Dr.Sawhney replied 4 months ago.
Thanks for replying .
I agree with you that the ligaments are probably already interfered with and they may have torn at the time of index injury.
Ligaments heal with fibrosis and they may have healed in an elongated position.
But the problem is getting them right again.
In an old injury there is extensive fibrosis and scarring in the tissue surrounding the ligament and practically speaking it is difficult to differentiate between the ligamentous tissue and the surrounding fibrous tissue at the time of surgery.
Even if we get to separate the ligaments from the surrounding tissue it is very difficult to cut them and approximate them again in their original
Moreover any surgical attempt in the area would initiate and promote further fibrosis and scarring which interferes with the elasticity and mobility of the ligaments thus compromising final results.
Acromioclavicular joint excision would not make the shoulder any worse at this stage.
Fibrosis in and around the ligaments would ensure that there is no further worsening of the anatomy.
Feel free to ask any follow-up questions.
Customer: replied 4 months ago.
Alrighty, now we're talking. You mention scarring and fibrosis and you seem concerned with integrity of the ligament, which I too am very much concerned with. Wouldn't elongated ligaments be "compromised" as well from the original injury with the fibrosis you mention? My guess would be either from a partial or full tear, and yet they seem to bear loads just fine once they healed. The major problem is the structures they support no longer glide within their allowable clearances causing crackings and grindings. Any "arthritic" symptoms are probably being induced by the deformed anatomy, it is not the source. I've only seen limited footage, but ligaments seem to be "slippery" when doctors handle them.
Customer: replied 4 months ago.
Second, this fibrotic tissue is less elastic, is it not? If so, would it stand to reason to conclude that the ligament is more prone to break because of its fibrotic nature? And is it possible for the fibrotic tissue to gradually strengthen with time, especially within a joint that ISN'T surrounded by synovial fluid?And...what if the original tear wasn't a full thickness tear and was only partial, is it possible for the partial tear to form a wedge since is constantly under load and the ligament heals in an elongated position on one side? And if so, could you remove this wedge surgically and suture it back together restoring original lengths and replacing with scar tissue?
Customer: replied 4 months ago.
By the way, if it feels like I am asking more questions than my original plan called for, would you let me know?
Expert:  Dr.Sawhney replied 4 months ago.
Ligaments even if torn partially can can heal in elongated position but it would not be possible to identify and separate wedge of fibrous tissue and remove that only because fivebrosis engulfs the ligament and the surrounding tissue as well and at the time of surgery it is not possible to differentiate between the fibrosis in the ligament and that in the surrounding tissue.
The slick ligaments you have seen are seen inside the joint like ACL and PCL in the knee joint.
In this location ligaments are not slick and in case of previous injury they may be difficult to identify precisely.
Ligaments which have healed with fibrosis are less elastic and they may be contributing to changes of arthritis in adjacent joint. They do get stronger with repeated loading.
Please complete the positive rating by clicking on 4 or 5 stars at the top of the page.
You may continue asking questions after you have given a positive rating and I would be happy to answer those.
Customer: replied 4 months ago.
Alrighty. Is it even crucial to remove the ALL the fibrotic tissue? As long as you pick anywhere along the length of the ligament (healthy or scarred) and restore it to original length, which may add more scar tissue, does it really compromise the strength of the ligament that much given you mention it does strengthen over time?
Expert:  Dr.Sawhney replied 4 months ago.
In case of incompetent ligaments there are procedures to reconstruct the ligaments.
I am not aware of any published procedure where the coracoclavicular ligaments are shortened.
There are practical difficulties in such a procedure ranging from identification of ligament to measuring the correct length of ligament .and correct amount of shortning during the surgery.
Customer: replied 4 months ago.
What about deflection? When you elongate or shorten a supporting member, the angle and length of deflection changes? Would there be no published procedure or literature on this? Would an upright MRI be able to tell what length you need seeing as how Orthopedists informed me the ligaments were stretched based on their reading of an MRI?
Customer: replied 4 months ago.
Should I negotiate to add $18 or whatever to the question price? So I can get unlimited responses. Sounds like I might need more information than I anticipated?
Customer: replied 4 months ago.
Are we no longer speaking?
Customer: replied 4 months ago.
Expert:  Dr.Sawhney replied 4 months ago.
Sorry for the late reply . I had been extremely busy in my surgery. Elongated ligaments would have an effect on the biomechanics of the joint. Upright MRI can show the elongation when compared to the other side especially if we stretch the acromioclavicular joint by holding weights in both the hands.
Suturing the ligaments after cutting them and shortening them can never be as secure as reconstructing the ligament. In fact torn anterior cruciate ligaments in the knee never sutured back. They are always reconstructed.
Customer: replied 4 months ago.
No problem. Would a surgical reconstruction require cutting ligaments and using internal "bracing" so the ligaments can heal to their proper length? It would essentially be the equivalent to separating the shoulder again and allowing it to heal. Like modified Weaver Dunn procedure. And do they remove the "bracing" after ligaments have healed? It seems like Orthopedists are pushing to restore native ac joint, conoid, and trapezius ligament integrity nowadays.

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