Ó 2005 Lippincott Williams & Wilkins, Philadelphia
Techniques in Shoulder and Elbow Surgery 6(1):1–7, 2005
O R I G I N A L A R T I C L E
Technique of Stabilization in Acromioclavicular
Joint Dislocation
Philippe Clavert, MD, Pierre Moulinoux, MD, and Jean-Francxois Kempf, MD
Orthopaedic Department
University Hospital
Strasbourg, France
n ABSTRACT
Acromioclavicular injury is a frequent pathology of collision sports, cycling and motorcycling sports. For stages
I and II most of the authors agree that conservative treatment must be the rule; also, for type V and VI lesions, it
seems obvious that surgery has to be performed. However,
treatment remains controversial for type III separation,
between conservative and surgical. The authors suggest
a modiﬁcation of the classic modiﬁed Weaver–Dunn
technique and a new technique of clavicle stabilization
with a screwed anchor in case of acute acromioclavicular
dislocation. The main advantage of this technique is that
there is no hardware that has to be removed, and there is
also no morbidity related to a second incision. Short-term
results of surgery usually show excellent functional outcomes without any residual pain. But long terms results
of grades I to III are usually associated with arthritis; and
for grades IV to VI there is most of the time a decrease of
shoulder strength and recurrence of pain in time.
toid and trapezius muscles). In 1963 Tossy et al2 suggested a 3 type classiﬁcation, as did Allman et al3 in
1967 and Juillard in 1976.4 Then, in 1987, Rockwood
et al5 improved these classiﬁcations and proposed a
new one in 6 types, based on a true anterior–posterior
radiographic analysis.
The first proponent of using the coracoacromial ligament as an autograft to stabilize the joint was Neviaser
in 1952.6 The coracoacromial ligament was detached
from the coracoid process and sutured to the lateral
end of the clavicle. Then Weaver and Dunn in 19727 suggested detaching it from its insertion to the lateral clavicular end. The transferred ligament was secured across the
bone marrow to the upper part of the clavicle. As others
did, Rockwood8 suggested that a minimum of 2 cm of the
lateral end of the clavicle must be taken out. He also proposed to secure the repair by a coracoclavicular screwing
to protect the graft in the ﬁrst 12 weeks postoperatively.
n INDICATIONS AND
n HISTORICAL PERSPECTIVES
CONTRA-INDICATIONS
Hippocrates was the first to diagnose this pathologic condition. He also suggested a treatment consisting of bandages. He quoted that that treatment was not as satisfying
as for a shoulder dislocation. He also stated that there are
no real complications other than ‘‘a tumefaction’’ or ‘‘a
deformity.’’1 Since then, more than for any other joint of
the body, surgeons have suggested different classiﬁcations and treatments.
Classifications became more sophisticated in time
due to a better understanding of the physiopathology
of these lesions. All are based on the damages of the different joint stabilizers, that is, the capsular ligaments
(acromioclavicular ligaments), the extra-capsular ligaments
(coracoclavicular ligaments), and the musculature (delReprints: Philippe Clavert, MD, Orthopaedic department, CHRU
Strasbourg, Avenue Molie`re, 67085 Strasbourg, France. E-mail:
[email protected].
Careful preoperative determination of pathology is critical in selecting the best method of treatment.
Clinical Evaluation
First, an evaluation of the patient’s expectations is necessary. That must include his age, job, and hobbies; his
sport and the level of his sporting activities are also
important.
Then the mechanism of injury has to be analyzed.
Most of the time a direct contact to the shoulder with
the arm at the side is responsible for the sprain. Rarely,
an indirect upward force by the upper extremity or an indirect and downward force leads to an acromioclavicular
joint separation.
In case of a stage III, IV, or VI acromioclavicular dislocation, visual inspection also reveals a fullness upward
displacement of the clavicle relative to the downward
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Clavert et al
displaced shoulder (Fig. 1). The physical ﬁndings of an
acromioclavicular separation are a tenderness over the
joint area and an abnormal mobility of that joint.
The initial examination also has to look for associated
injuries, such as nerve and vascular injuries as well as
fractures around the shoulder girdle (coracoid process,
acromion, and scapular neck). The motor examination
of the deltoid and trapezius must demonstrate normal
function of these muscles.
Radiographic Evaluation
A specific X-Ray examination must be requested not to
have overpenetrated films.1 Routine anteroposterior
views of the acromioclavicular joint should be taken with
the patient standing, the arm unsupported at the side. The
X-ray cassette is against the patient’s back. There must
be a 10° to 15° of cephalic tilt view to analyze the joint
space, that is, not to superimpose the acromion and the
distal end of the clavicle. Sometimes a comparative Xray of both sides is necessary. Then a lateral view is necessary to classify the injury. An axillary view will reveal
any posterior displacement of the clavicle, as well as
associated fractures of the distal part of the clavicle.
Finally, even if Bossart et al9 concluded that stress
radiographs are not appropriate, these views may help
the clinician to diagnose a stage III separation.
Of course, in the case of associated lesions of the
shoulder, a CT-arthrogram of the shoulder or an MRI
may be necessary.
From these views the physiopathology of the lesions
are inferred and classified. (For this article we will only
discuss Rockwood’s classification.) Type I corresponds
to a sprain of the acromioclavicular ligament with an
AC joint intact; the coracoclavicular ligament remains
intact, as well as the deltoid and trapeze muscles. Type
II corresponds to a rupture of the acromioclavicular ligament and a sprain of the coracoclavicular ligaments,
leading to an increase of the AC joint space, but there
is no superior displacement of the clavicle, that is, the
coracoclavicular space is fairly increased. In type III,
there is a rupture of the acromioclavicular ligaments associated to a coracoclavicular ligament rupture, leading
to an AC joint dislocation. The coracoclavicular space
increases from 25% to 100%. In this case, the deltoid
and the trapeze muscles are deinserted from the end of
the clavicle. In type IV, there is a posterior displacement
of the clavicle within or through the trapeze muscle, with
a deltoid and trapeze muscle deinsertion from the end of
the clavicle. The coracoclavicular space looks normal on
the X-rays. In type V, more than the rupture of the different ligaments, there a major AC joint dislocation from
100% to 300% in relation to a deinsertion of the muscles
from the lateral half of the clavicle. At least, in type VI,
there is an inferior AC joint dislocation observed on the
plain radiographs, under the acromion or under the coracoid process. In this case the coracoclavicular space is
decreased. There is a muscle deinsertion from the end of
the clavicle.
Contraindication
Acromioclavicular joint dislocations may be associated
with other trauma of the shoulder, such as fractures of
the distal or midshaft clavicle, of the acromion process,
or of the coracoid process.10,11 Also, injuries of the respiratory tract may be observed.12,13 Nerve injuries may occur even if this is a rare condition, such as brachial plexus
palsy.13 Such injuries are related to a scapulothoracic dissociation (lateral displacement of the scapula associated
with an acromioclavicular joint separation and/or bony
lesions). Of course, these associated lesions have to be
cleared before planning any acromioclavicular surgery.
n PREOPERATIVE PLANNING
FIGURE 1. Clinical presentation of a type V acromioclavicular separation. Note the upward displacement of the clavicle relative to a downward displacement of the shoulder.
2
Even if it is still controversial14 for types I and II, a conservative treatment must be the rule. We recommend
leaving the patient’s arm in a sling; the use of an ice
bag and light analgesic are recommended. Patients are
suggested to gently maintain their range of motion by
pendulums and home program exercises. After pain
Techniques in Shoulder and Elbow Surgery
Surgery of A/C Joint Dislocation
resolution and recovery of full range of motion, patients
are allowed to return to a full activity of their upper arm
without restriction.
Many management options have been proposed
for grade III injuries.6–8,15–19 Treatment of these stage
III separations has recently tended to nonoperative
methods,20–24 with a symptomatic treatment with a limited
immobilization. Basically, for most of our patients, a nonoperative treatment is proposed. In the case of a person
doing heavy labor and for young and active patients in
sports, surgical repairs should be performed. One of
the contra-indications for surgical treatment in this case
is the young athlete regularly subject to violent and repeated injuries to its acromioclavicular joint, such as a
rugby player.
For types IV, V, and VI, a surgical treatment is the
rule because the distal part of the clavicle is displaced
and can penetrate the trapezius. But for inactive and nonlaboring patients, the pros and cons must be discussed
with him and sometimes a conservative treatment is
proposed.
More and more, arthroscopic solutions are developed
to treat this condition.25–28 Nevertheless, no large series
are already reported. For us, open reduction and internal
ﬁxation remains the ‘‘gold-standard.’’
n SURGICAL TECHNIQUES
The aims of the surgical treatment are to replace the coracoclavicular ligaments to minimize motion, allow scarring, and increase the subsequent stability of the joint. In
this way the different surgical techniques focus to the intrinsic acromioclavicular ligaments, to the coracoclavicular ligaments, and at least to the surrounding muscular
structures. Most of the actual techniques combine a restoration of 2 or 3 of these structures even though none of
these surgical procedures have the appropriate stiffness
to restore the stability of the intact joint before healing.29
The procedure is performed under regional anesthesia associated if necessary with a general anesthesia. We
prefer to place the patient in the beach-chair position; the
head is slightly deviated toward the controlateral side.
The shoulder should be completely free for full rotation
with the anterior and posterior shoulder girdle exposed.
Prior to beginning surgery it is imperative to document passive motion of the shoulder, as well as the possibility to reduce the dislocation by pushing up the arm
while the clavicle is pushed down. Care must be taken
during draping to allow access from the top of the shoulder to the base of the neck.
A 4 to 6 cm long skin incision is made vertically in
Langer’s lines. It begins posterior to the clavicle and then
crosses the clavicle medially to the acromioclavicular
joint, and then is extended to the tip of the coracoid process.
The rupture of the deltotrapezius fascia is visualized and
developed if needed, as well as the periosteum over the
top of the distal clavicle and the acromion.
Most of the time, the anterior part of the deltoid and
the trapezius muscles have been stripped off the distal
part of the clavicle. If not, we develop this interval so that
the distal part of the clavicle can be freely grasped and
mobilized. In this way, the torn coracoclavicular ligaments are visualized, as well as the base and the knee
of the coracoid process. The acromioclavicular joint is
debrided of any loose fragments or intra-articular disk.
Acute Acromioclavicular Dislocation: The
Screw-In Anchor Technique
Recent data show that posttraumatic arthritis develops
more frequently by using transarticular fixation techniques.23,24 For this reason we have developed a technique that securely keeps the joint reduced while the
ligaments are healing; moreover, there is no hardware
that needs to be removed.
If possible, acromioclavicular ligaments are repaired
by 1 or 2 transosseous sutures. If possible, the torn ends
of the coracoclavicular ligaments are tagged with Fiberwire (Arthrex, Naples, FL) loaded on the anchor or with
No. 2 Ethibond sutures (Ethicon Products, Johnson &
Johnson Company, Westwood, MA) that will be tied at
the end of the procedure (Fig. 2). This step is not required
for some authors1 because they consider that the scarring
tissues will ﬁll the space between the clavicle and the
coracoid process and that will secure the repair.
With a probe, both sides of the base of the coracoid
process as well as its knee are identified. A drill hole is
made on the top of the base of the coracoid, perpendicular to its long axis, and a 5.5 mm or two 3.5 Corkscrews
anchors (Arthrex, Naples, FL) is screwed in the coracoid
FIGURE 2. The torn ends of the coracoclavicular ligaments are tagged with the Fiberwire loaded on the anchor
(triangle).
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Clavert et al
process; care must be taken not to pass through the deep
cortex of the coracoid.
The assistant’s role is to maintain the clavicle down
while he is pulling-up the arm to reduce the dislocation
(Fig. 3). Four bicortical drill holes are made through the
clavicle, right above the coracoid process. Four Fiberwire
sutures (Arthrex, Naples, FL) are passed through these
drill holes. At this time, the 2 sets of the sutures are tied
as well as the sutures previously passed through the coracoclavicular ligaments.
Then the deltotrapezius muscles fascia interval has to
be repaired. They are sutured over the top of the clavicle
by a double row of No. 5 Ethibond sutures. A postoperative X-ray is necessary to control the exact positioning
of the anchors (Fig. 4).
Chronic Acromioclavicular Joint Dislocation:
The Modiﬁed Weaver–Dunn Technique
We think that an isolated excision of the distal end of the
clavicle is not the appropriate technique for acromioclavicular dislocation because symptoms are related to the
displacement that irritates the surrounding soft tissues
and muscles.1,30 That is why the coracoclavicular ligament has to be replaced. We prefer to use the coracoacromial ligament that is already attached to the coracoid and
FIGURE 3. The assistant maintains the clavicle down
while he is pulling-up the arm to reduce the dislocation.
4
FIGURE 4. X-ray showing 2 anchors screwed in the coracoid process.
belongs to the same anatomic layer,18 rather than any
other graft, suture, or other synthetic material.8,31–34
But a temporary ﬁxation is necessary to maintain the
reduction and then protect the healing of the transferred
ligament. This protection is necessary because a graft
elongation or insufﬁciency can occur due to the tension
applied to the transferred ligament.1,30,32 Different synthetic materials have been used to avoid removal of
metallic hardware.7,33,35,36 We prefer the use of a screwed
anchor as described above rather than Kirchner wire,
screws,8 or hook plate,37 in order not to have a second
surgery to perform and to avoid many hardware
complications.
Once the distal end of the clavicle is freely mobilized,
the 1.5 cm of the distal part of the clavicle is excised, to
prevent any postoperative spur formation.1 The medullary canal of the clavicle is curetted to receive the transferred ligament. Using a No. 15 blade, the coracoacromial ligament is harvested from the acomion; most of
the time we prefer to keep it attached to a small bone
block that is harvested with a quarter inch osteotome
(Fig. 5). The clavicle is mobilized to determine if the
length of the ligament will ﬁt or not. If not, the anterior
part of the ligament can be securely released from the
coracoid process.1,17 A No 5 Ethibond suture is passed
through the ligament in a Mason and Allen fashion.38
Two small drill holes are placed through the superior cortex of the distal clavicle for the sutures passed through
the ligament (Fig. 5), and 4 extra bicortical drill holes,
directly above the coracoid process, are needed for the
Fiberwire sutures of the Corkscrew. A No. 5.5 or two
3.5 Corkscrew anchor is then screwed in the coracoid
process as described above (Fig. 5).
The assistant then reduces the acromioclavicular
joint as described above (Fig. 3). The 2 ends of the suture
are passed into the medullary canal and out the 2 drill
Techniques in Shoulder and Elbow Surgery
Surgery of A/C Joint Dislocation
That last condition may also be observed after surgery.46
Chronic pain may also be related to secondary impingement in relation to a non-rotation of the scapula while the
arm is elevated or abducted. At least as for every sprain,
climatic pains may be recurrent. Recurrence of a dislocation may also occur.
Speciﬁc Complications of the
Surgical Treatment
Recurrence remains the first complication of that surgery.
The rate extends from 10 to 15%.30,47 Other complications include infections, hardware complications (fracture, migration), foreign-body reaction to any augmentation material used,48,49 or hypertrophic wounds. More
speciﬁc complications, such as breakage of the grafts
or of the tunnels, or residual deformity, may be encountered.
n RESULTS AND PROGNOSIS
FIGURE 5. The modiﬁed Weaver–Dunn technique—the
anchor is screwed in the coracoid process.
holes in the superior cortex of the clavicle (Fig. 5); the 4
Fiberwire sutures are also passed through the clavicle.
These 2 sets of suture are tied ﬁrst to maintain the reduction and then the sutures through the coracoacromial
ligament are tightened so that the bone block gets into
the medullary canal of the clavicle.
n POSTOPERATIVE CARE
Postoperatively the arm is in a sling for 4 weeks. During
this time the patient is allowed to perform some pendulum exercises. After this time, the patient can use his arm
for most everyday living activities. Heavy lifting or
resisting exercises remain prohibited for the next 6
weeks. In this way no specific rehabilitation is required,
but patients are trained to do some home exercises. After
recovery of full strength and full range of motion of the
shoulder, patients are allowed to practice contact sports.
Usually the immediate prognosis of types I and II acromioclavicular dislocation is excellent: patients recover
full range of motion with mild or without pain.50 However, acromioclavicular joint arthritis may occur with
signiﬁcant symptoms of pain and loss of strength within
the next 5 years.51–53 But referring to Moushine et al,14
the long-term consequences of conservative treatment,
even for stages I and II, are underestimated. Main complications are residual symptomatic instability and tenderness over the AC joint in relation to degenerative
changes, ossiﬁcation of the coracoclavicular ligaments
or association of both, and distal clavicular osteolysis.
For chronic type III injuries, both treatments have
shown immediate good results, but long-term results lead
to arthritis and loss of strength. That loss of strength may
be significantly greater for patients operated on versus
patients treated conservatively.53
Patients with acute and chronic types IV, V, and VI
lesions require open reduction and fixation.
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