Aspects of current management

„ ASPECTS OF CURRENT MANAGEMENT

Injuries to the acromioclavicular joint

J. A. Fraser-Moodie, Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor
N. L. Shortt, subluxations are best managed conservatively, but there is debate concerning the treatment
C. M. Robinson of complete dislocations and the more complex combined injuries in which other elements
of the shoulder girdle are damaged. Confusion has been caused by existing systems for
From the Royal classification of these injuries, the plethora of available operative techniques and the lack of
Infirmary of well-designed clinical trials comparing alternative methods of management. Recent
Edinburgh, advances in arthroscopic surgery have produced an even greater variety of surgical options
Edinburgh, Scotland for which, as yet, there are no objective data on outcome of high quality. We review the
current concepts of the treatment of these injuries.

Anatomy and biomechanics ligaments, respectively. Later studies suggested

The acromioclavicular joint provides a ‘key- that at physiological loads the acromioclavicu-
stone’ link between the scapula and the lar ligaments prevent displacement,6 while if
clavicle. The coupling of scapulothoracic and pathological forces are applied, the coracocla-
glenohumeral movement dictates that the vicular complex prevents subluxation by con-
integrity of the sternoclavicular and acromio- trolling vertical movement. However, the
clavicular joints is important for the normal respective functions of the conoid and trape-
co-ordination of movement of the shoulder zoid components remain unclear.6-8
girdle. Until recently, movement at the acromi- The displacement of the bone ends which
oclavicular joint had not been accurately occurs after acromioclavicular dislocation is
defined and was perhaps underestimated.1-3 It caused by sagging of the shoulder girdle rather
is now appreciated that during abduction of than by superior displacement of the clavicle.4
the shoulder, there is 15° of protraction, 21° of The most common cause of acromioclavicular
upward rotation and 22° of posterior tilting of injury is a force applied directly over the
the scapula relative to the clavicle at the joint.3 superolateral border of the shoulder usually
The acromioclavicular joint is surrounded during a fall with the humerus adducted. This
by a thin fibrous capsule which is reinforced by force drives the clavicle and acromion inferi-
the superior, inferior, anterior and posterior orly, but the strong interlocking ligaments at
„ J. A. Fraser-Moodie, acromioclavicular ligaments. The superior and the sternoclavicular joint limit the amount of
MRCSEd, Clinical Research
Fellow posterior components provide the most signif- inferior displacement of the clavicle9 and the
„ N. L. Shortt, FRCSEd(Orth), icant contribution to horizontal stability at the greater degree of inferior transposition of the
Orthopaedic Registrar
„ C. M. Robinson, BMedSci, joint. The acromioclavicular joint is further acromion ruptures the acromioclavicular and
FRCSEd(Orth), Consultant strengthened by the deltotrapezius aponeuro- coracoclavicular ligaments.
Orthopaedic Surgeon
Edinburgh Shoulder Clinic sis. The coracoclavicular ligament consists of
The Royal Infirmary of the conoid and trapezoid components which Epidemiology
Edinburgh, Old Dalkeith Road,
Edinburgh EH16 4SU, UK. stabilise the acromioclavicular articulation4 Injuries to the acromioclavicular joint account
Correspondence should be sent
and co-ordinate scapulothoracic rotation dur- for approximately 12% of those to the shoul-
to Mr C. M. Robinson; e-mail: ing abduction and flexion of the shoulder. der girdle seen in clinical practice.10 This is
c.mike.robinson@ed.ac.uk
Several studies have attempted to establish likely to be an underestimate of their true pre-
©2008 British Editorial Society the complementary roles of the ligaments when valence, since patients with minor sprains may
of Bone and Joint Surgery
doi:10.1302/0301-620X.90B6.
the joint is subjected to non-physiological not seek medical attention. They are between
20704 $2.00 forces. Urist5 suggested that control of five and ten times more common in males.
J Bone Joint Surg [Br]
horizontal and vertical stability was provided Incomplete separations of the joint are approx-
2008;90-B:697-707. by the acromioclavicular and coracoclavicular imately twice as common as complete disrup-

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698 J. A. FRASER-MOODIE, N. L. SHORTT, C. M. ROBINSON

Fig. 1a Fig. 1b Fig. 1c

Fig. 1d Fig. 1e Fig. 1f

Diagrams showing injuries of the acromioclavicular joint a) type I, b) type II, c) type III, d) type IV, e) type V and f) type VI.

tions.2 In a review of 520 of these injuries, more than 300 through the trapezius. In type-V injuries (Fig. 1e), the
occurred in the first three decades of life and most were degree of separation is greater because of the concomitant
minor sprains and subluxations.2 disruption of the deltotrapezius fascia attached to the lat-
These injuries are typically sustained by younger patients eral end of the clavicle, allowing the end of the clavicle to lie
participating in contact sports. They are the most common subcutaneously. In the very rare type-VI injury (Fig. 1f), the
injury to the shoulder seen in American football players,11 clavicle is displaced inferiorly and comes to lie below the
and in other developed countries are usually sustained in coracoid process underneath the conjoint tendon. MRI of a
sports such as rugby, soccer and Australian rules football.12 limited number of injuries15 has shown some inconsisten-
Among recreational skiers approximately one-fifth of inju- cies in this classification and questioned the current under-
ries to the shoulder girdle involve the acromioclavicular standing of the disruption of the soft tissue. At operation
joint.13 the findings typically support the current classification,16
although more studies on the imaging of these injuries may
Classification yet challenge this.
Isolated injuries of the acromioclavicular joint. Tossy, Mead ‘Pseudodislocation’ is an unusual injury seen in children
and Sigmond14 described three types of acromioclavicular and adolescents, in which the joint is dislocated, but with
dislocation, to which Rockwood et al2 added a further the coracoclavicular ligaments intact and remaining
three subgroups. The classification is based on the extent of attached to a periosteal sleeve stripped off the distal clavi-
disruption of the acromioclavicular and coracoclavicular cle.17 A second uncommon variant is a separation of the
ligaments using the radiological degree of displacement of joint in which the coracoclavicular ligaments are intact but
the clavicle relative to the acromion. there is a bony avulsion fracture of the coracoid process.18
In type-I injuries (Fig. 1a) there is partial and in type II This may involve the superior glenoid and may be difficult
(Fig. 1b) complete disruption of the acromioclavicular liga- to assess on a standard anteroposterior radiograph. CT or
ments. In both, the radiographs will appear to be normal. MR arthrography is useful in assessing the size and extent
The severity of the injury then progresses with complete of displacement of the fragment.
disruption of the acromioclavicular and coracoclavicular The use of weight-bearing views to classify and to pro-
ligaments. In type-III injuries (Fig. 1c), the vertical trans- vide prognostic information for injuries to the acromio-
lation at the joint is up to the width of the clavicle while in clavicular joint has been described16 and some practitioners
type IV (Fig. 1d) the clavicle is displaced posteriorly into or apply them selectively.19 Such views are not commonly

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 INJURIES TO THE ACROMIOCLAVICULAR JOINT 699

which there is a traction injury to the arm. Any of the three

bones and joints of the shoulder girdle may be affected, and
separation of the acromioclavicular joint is often encoun-
tered as part of the disruption of the sternoclavicular-
acromial linkage. Injuries to the vasculature and the
brachial plexus are common, and a widened scapular
index, as measured from the midline of the spine to the
medial border of the scapula, when seen on an antero-
posterior radiograph of the chest, is pathognomonic.

Clinical assessment
The clinical diagnosis of an acute acromioclavicular injury
is usually relatively simple since the pain is commonly
localised accurately to the area of the joint. Marked swell-
Fig. 2 ing, abrasions and ecchymoses may be seen over the
Anteroposterior radiograph of the acromioclavicular joint showing a affected joint, although compromise of the skin is unusual.
type-IV injury in a 24-year-old-man who fell playing rugby.
Concomitant injury to neurovascular structures is uncom-
mon, except in association with another injury to the shoul-
der girdle. The joint is tender to palpation and the clavicle
often feels mobile, the ‘piano-key’ sign. Forced adduction
taken after acute sprains (types I and II) although they are of the symptomatic arm across the chest, the Scarf test,29 is
sometimes used to assess instability in these injuries.20 also likely to reproduce pain at the injured joint. In the
Goss21 defined the concept of the superior shoulder sus- active compression test of O’Brien et al30 the arm is ele-
pensory complex, which is a bony and soft-tissue ring com- vated forward by 90°, adducted by 10° to 15°, initially with
posed of the superior glenoid, the coracoid process, the the forearm fully pronated and then supinated, while the
coracoclavicular ligaments, the distal clavicle, the acromio- examiner applies resisted downward pressure on to the
clavicular joint and its ligaments, and the acromion. As hand. The test is positive if pain is produced by resisted pro-
with injury to the pelvic ring, damage to one part of the nation and relieved by resisted supination. It is specific for
superior shoulder suspensory complex must also produce injury to the acromioclavicular joint only if pain is localised
disruption of another portion of the osteoligamentous ring, to the joint. If the test produces a deep-seated pain ‘inside’
leading to the so-called ‘double disruptions’. By definition, the shoulder, this is suggestive of symptoms related to the
all type-III to type-VI dislocations fall within this category, superior labrum or biceps tendon.
since both the acromioclavicular and coracoclavicular liga- The grading of the injury is made on radiological exam-
ments are injured. Dislocations which occur together with ination as determined by the extent of displacement of the
fracture of another component of the complex such as the articular surfaces (Fig. 2). A 10° cephalad view centred on
lateral clavicle or coracoid process, are also double disrup- the acromioclavicular joint, the Zanca31 view, further high-
tions. This produces an unstable situation which may result lights vertical displacement. An orthogonal view is required
in adverse long-term effects on healing and function. It has to assess the degree of anteroposterior translation of the
therefore been suggested that these injuries should be con- surfaces of the joint.
sidered for operative reduction and stabilisation of at least Ultrasound and MRI are not widely used, but can be
one component of the disruption.22-24 employed to detect effusions from the joint, assess the
Bifocal and other combined patterns of injury. Bifocal inju- extent of injury to the ligaments and the deltotrapezius
ries, in which an acromioclavicular separation occurs in aponeurosis15,32 and to determine the degree of degenera-
combination with another discrete injury to the shoulder tive changes in patients who develop delayed symptoms.33
girdle remote to the superior shoulder suspensory complex, In some patients who present late with chronic discom-
are relatively uncommon. Diaphyseal fractures of the fort in the shoulder girdle after injury, the diagnosis of pain
clavicle can be associated with an injury to the acromiocla- in the acromioclavicular joint may be less clear. Chronic
vicular joint and separation may be difficult to diagnose, symptoms may occur after both minor and severe injuries
particularly with marked displacement of the clavicular to the joint, but are more common in association with
fracture.24,25 Less common still is a complete separation of higher levels of disruption. There may be more than one
the clavicle, the ‘floating clavicle’, with dislocation of both contributory cause for symptoms in these patients and all
acromioclavicular and sternoclavicular joints.26-28 potential sources must be addressed at the time of any
Scapulothoracic dissociation occurs when the scapula is secondary reconstructive procedure (Table I). Up to half of
torn away from the chest wall, effectively producing a the patients with osteolysis of the lateral end of the clavicle
closed amputation of the upper limb. This injury is rare and present with a history of a discrete injury to the shoulder.34
occurs almost exclusively after high-energy trauma in This condition, which usually settles with non-operative

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700 J. A. FRASER-MOODIE, N. L. SHORTT, C. M. ROBINSON

Table I. Differential diagnoses in patients with chronic shoulder pain after injury to the acromioclavicular (AC) joint
Cause Symptoms Clinical findings Investigations Treatment options
Pain in the AC joint from Pain localised over the AC joint Localised tenderness in the Plain radiography Physiotherapy,
osteoarthritis or disc disease AC joint. Steroid injection into the modification of activity,
Positive Scarf/O’Brien30 AC joint oral analgesia
tests MRI/bone scan Excision of the AC joint
Osteolysis of the distal Pain over the lateral clavicle Localised tenderness and Characteristic plain Physiotherapy,
clavicle swelling of the lateral radiological and MRI modification of activity,
clavicle appearances oral analgesia
Excision of the AC joint
Instability of the AC joint Pain localised over the Localised AC joint pain. Plain and stress radiography Physiotherapy
AC joint Positive Scarf/O’Brien30 Ligament reconstruction
tests
‘Piano-key’ sign
Rotator-cuff impingement or Painful arc or shoulder Positive impingement Subacromial injection Subacromial injection of
tear weakness signs. of steroid steroid for impingement
Cuff tear, usually in older Rotator-cuff weakness USS*/MRI for cuff tear Subacromial
patients decompression
Repair of cuff tear
Adhesive capsulitis Diffuse shoulder pain Global restriction of passive Clinical diagnosis Physiotherapy
Night pain movement, especially in Distension arthrography
Shoulder stiffness external rotation Manipulative/arthrolysis
Thoracic outlet syndrome Dysaesthesia Arm position can reproduce Chest radiography Physiotherapy
Motor weakness symptoms Nerve-conduction studies Surgical decompression
Specific tests insensitive MRI of the neck and thoracic
outlet
Superior labral tears Shoulder pain on overhead Positive O’Brien/Speed test MRI arthrography Physiotherapy
(SLAP lesions) activities Arthrograph SLAP repair or
debridement
Complex regional pain Diffuse shoulder pain Reduced movements, skin Clinical diagnosis Multidisciplinary
syndrome Stiffness changes, altered feeling, Radiography may approach:
Neurological dysfunction swelling distally demonstrate osteopenia Physiotherapy
Pain control (pain clinic)
Oral medication
Second-line oral
therapies
Regional nerve blocks
*USS, ultrasound scan

treatment, is characterised by pain and localised discomfort in a sling to give relief from symptoms. A broad arm sling is
over the joint, together with cystic changes and resorption preferable to a collar and cuff because it supports the elbow
of the distal clavicle which can be seen on conventional and tends to minimise sagging of the shoulder. The sling
radiographs.35 Osteoarthritic changes are restricted to should be discarded once the acute symptoms have settled,
patients with type-I and type-II injuries,36 since the greater typically after the first week after injury. It is unusual for
separation of the bone ends in higher-grade injuries pre- the patient to require formal physiotherapy, since weakness
vents the development of this complication. However, and stiffness of the shoulder are seldom a problem.10 A
degenerative changes in the articular disc and lateral end of variety of techniques of external strapping and commer-
the clavicle are often encountered at operation and may be cially-manufactured braces is available. There is no evi-
a source of pain in a higher-grade injury. dence that any of these can reduce subluxation of the
Isotope bone scanning and MRI may be useful in dis- joint,38 and they may give rise to local skin problems, stiff-
criminating the source of symptoms, and abolition of the ness of the shoulder or non-compliance.
symptoms by an ultrasound-guided injection of local anaes- Contact sports and heavy lifting should be avoided for
thetic into the joint may be helpful in clarifying whether the eight to 12 weeks after injury. Aching discomfort may be
symptoms arise from the joint itself.37 felt in the area of the injured joint for up to six months. A
substantial number of patients have reproducible joint pain
The treatment of acromioclavicular joint injury after conservative treatment, and up to one-third of those
The aim should be to return the patient to the level of func- with type-I and type-II injuries has pain on activity at
tion before injury, with a pain-free, strong and mobile longer term follow-up.39 This may be due to degenerative
shoulder. changes within the joint, or in type-II injuries to instability,
resulting from injury to the joint capsule. Operation may be
Conservative treatment considered for these patients if they have ongoing symp-
This is almost universally applicable to type-I and type-II toms at three months after the original injury.
injuries. The most common form of non-operative treat- Conservative treatment also remains the preferred initial
ment involves simple analgesia, topical ice therapy and rest mode of management for most type-III injuries because of

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 INJURIES TO THE ACROMIOCLAVICULAR JOINT 701

the excellent prognosis in most patients with this injury.40-42 tion of the joint is more difficult when several months have
After rehabilitation, the strength and endurance are similar elapsed after the injury, and the native ligaments may then
to those of the uninjured shoulder,41,43 and most patients be difficult to identify and repair. Most techniques of recon-
return to their previous level of employment, sport and struction in the acute injury involve reduction of the joint,
recreational activities. Secondary surgical reconstruction is ligamentous repair and stabilisation of the joint, whereas in
seldom needed. The subluxation persists, but typically pro- most delayed reconstructions an excision of the lateral end
duces minimal cosmetic problems and is well tolerated, and of the clavicle is performed before reduction, with stability
the satisfactory functional results appear to be maintained restored by ligamentous substitution.
in the longer term.44 Despite a lack of compelling evidence, Although it may be felt that acute reconstruction would
it is often suggested that patients with a type-III injury who be associated with a more favourable outcome, it is usually
have a high level of functional demand on the shoulder may reserved for higher-grade injuries (type IV to type VI),
benefit from early intervention.45,46 However, the current double disruptions of the superior shoulder suspensory
view remains in favour of conservative management of complex or when there is an associated soft-tissue or
acute type-III injuries, and a survey of orthopaedic surgeons neurovascular injury. Operative treatment for type-III inju-
treating professional throwing athletes in North America ries is usually only considered for those patients who have
revealed an overall preference for such management.47 persistent symptoms after a trial of conservative care for
three months. Acute repair of these more common lower-
Operative treatment grade injuries results in a substantial degree of over-treat-
Operation is used to treat medically-fit patients with type- ment of patients who may not develop symptoms after con-
IV and type-V injuries.4,48,49 Type-VI injuries are very rare, servative management. Despite the considerable
and almost all reported cases have been treated surgi- technological advances in the treatment of these injuries,
cally.4,50,51 A wide variety of operative procedures has been acute surgery still carries substantial risks of early failure of
described, but none has been shown to be notably superior the reconstruction and other serious soft-tissue complica-
to the others. The latest more minimally-invasive tech- tions.
niques appear to be promising, but well-designed prospec- It is important to establish a positive diagnosis in patients
tive follow-up studies should be performed before their use who have chronic symptoms after initial conservative treat-
becomes widespread. ment in order to prevent inappropriate surgery. Excision of
While the range of operative approaches is considerable, the distal 5 mm to 10 mm of the clavicle alone, the Mum-
certain underlying principles are recognised: ford procedure,52,53 has been used successfully in treating
1) accurate reduction of the acromioclavicular joint chronic problems resulting from degenerative joint disease
must be achieved, by correction of the inferior sag of the after a stable type-I or type-II injury, and in refractory cases
scapula, together with any anteroposterior translation of of post-traumatic osteolysis which fail to respond to con-
the joint surfaces; servative measures.34 It is important not to perform an
2) an acutely reduced joint is inherently unstable, and excessive resection which may destabilise the joint.54 Injury
will re-displace unless the disrupted ligaments are either to the residual superior capsular restraints in direct open
repaired or substituted. Substitution may be performed approaches may also cause instability of the joint. This may
using either an autograft from a local or distant source, or account for the better results after arthroscopic excision,
an allograft, and must closely mimic the normal joint which is usually combined with subacromial decompres-
restraints; sion, performed from the bursal side.55-57 Excision of the
3) the reduction and ligament reconstruction must distal clavicle alone is not appropriate for higher-grade
have sufficient immediate stability to prevent acute re- injuries if there is associated symptomatic instability of the
displacement or else be protected temporarily until the joint. In these circumstances ligamentous reconstruction
repair heals; should also be performed, as described below.
4) rigid implants used for temporary stabilisation of a Surgical approach: open or arthroscopic? Open exposure of
ligament reconstruction must be removed once the repair the dislocation using a ‘bra-strap’ incision remains the most
has consolidated, or they will eventually break, loosen or common surgical approach. Although this causes more
produce stiffness in the shoulder. prominent scarring, it is technically easier, allows direct vis-
The main sources of variation amongst the more com- ualisation of the reduction of the joint and removal of any
mon techniques which are currently performed are best degenerative disc material. Injury to the important delto-
summaried in four categories: the timing of surgery, the trapezius aponeurosis can only be assessed and repaired by
choice of surgical approach, the choice of ligament recon- an open surgical approach.58
struction and the technique to stablise the reconstruction. Advances in instrumentation and implants have pro-
Acute repair or delayed reconstruction? Accurate reduction duced a recent trend towards the use of arthroscopic
of the joint is easier when surgery is performed within the approaches. Many of these techniques are similar to those
first two weeks after injury, when the ruptured ligamentous used for ligamentous reconstruction in the knee. The accu-
restraints can often be repaired directly. Complete reduc- racy of reduction of the joint is more difficult to assess

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702 J. A. FRASER-MOODIE, N. L. SHORTT, C. M. ROBINSON

reconstruction, of approximately 42 mm in an anteroposte-

rior plane and 14 mm vertically, compares with the 8 mm
and 3 mm, respectively, in intact ligaments.64 These param-
eters can be improved significantly by augmentation of the
coracoclavicular suture.60,64,65 Newer suture materials
(Fiberwire; Arthrex Inc., Naples, Florida) and more ana-
tomical techniques may perform better, and approach
the load to failure of the intact ligaments.60 Both
arthroscopically-assisted and all-arthroscopic techniques
have now been described to transfer the coracoacromial lig-
ament, augmented by either autograft or synthetic suture
material.66,67 It remains to be seen whether these techniques
produce results comparable with those of the open tech-
niques.
The conjoined tendon has also been used as a local graft
Fig. 3
to create a ‘dynamic muscle transfer’ stabilisation of the
Diagram showing the ‘classic’ procedure of Weaver and Dunn.59 This lateral clavicle. There are several variations of this pro-
consists of transfer of the coracoacromial ligament into the lateral end
of the clavicle after excision of its lateral 5 mm to 10 mm.
cedure, including direct transfer of the tendon superiorly,
either alone,68 or together with a portion of osteotomised
coracoid origin.69,70 The operation carries the risk of over-
tightening of the coracoclavicular space. A proximally-
based transfer has therefore been developed. This retains
arthroscopically, although the use of intra-operative fluor- the origin of the tendon and divides its lateral half distally,
oscopy may help. Arthroscopic surgery causes less injury to then reverses the tendon and implants it into the lateral end
the soft-tissue envelope, but there is a steeper learning curve of the clavicle71,72 (Fig. 4). Biomechanical studies and clin-
for its use when compared with open reconstructive proce- ical experience suggest that the conjoined tendon has better
dures. properties and greater consistency of quality of the graft
Which ligament reconstruction? There are several types of compared with those of the coracoacromial liga-
repair. ment.69,71,72 It also offers an alternative source of a graft in
Techniques using native ligament. Repair of the ruptured revision procedures when the coracoacromial ligament has
coracoclavicular and acromioclavicular ligaments is only already been harvested. However, when a partial
possible when it is performed within the first two weeks osteotomy of the coracoid is performed there is a risk of
after injury, and as an open procedure. The joint is first subsequent fracture,73 and transfer of the conjoined tendon
reduced under direct vision and similar techniques to those to the clavicle has been associated with injury to the
described for tendon repair are then used to suture the torn musculocutaneous nerve.74,75
ligaments directly. The repair must be protected by tempo- Other techniques of ligament substitution. Coracoclavicular
rary rigid fixation or transfixation of the joint until liga- cerclage is a well-established technique and has been car-
mentous healing occurs. The problems associated with ried out using numerous materials including tendons, wire
these techniques include the technical difficulty of surgical loops and synthetic ligament substitutes such as Dacron,
access and of suturing mid-substance ligamentous injuries, Mersilene tape, or polydioxanone.76-79 This form of recon-
typically of a ‘shaving-brush’ quality, and the uncertainty struction does not rely on biological healing, and tempo-
regarding the structural integrity of the repair. rary rigid stabilisation of the joint after operation is not
Ligament substitution with local ligaments or tendons. Trans- usually required.60 Tendons such as semitendinosus, graci-
fer of the coracoacromial ligament was introduced by lis and the toe extensors have shown strength and stiffness
Weaver and Dunn59 and remains the mainstay of delayed similar to those of the native ligaments,65,80 and the use of
stabilisation (Fig. 3). The procedure as originally described peroneus brevis has also been described.81 The weak point
carries a recognised risk of ongoing pain, which may be of the reconstruction is the method of securing it, but tying
related to instability and recurrent subluxation because of a knot in the graft, or using interference screws, may help to
failure of the fixation. A number of modifications have overcome this problem.60,65 A cerclage graft using semi-
been introduced,19,60,61 and these have been used success- tendinosus with suture augmentation has been described
fully in the management of acute type-III dislocations, as using a minimally-invasive approach.82 One end of the
well as in patients with more chronic symptoms.61,62 graft is sutured to a plate and the other fixed to the clavicle,
The procedure as originally described has only approxi- using a biotenodesis screw. Earlier cerclage techniques were
mately 30% of the strength and 10% of the stiffness of the typically less stable than those using intact ligaments,64 but
intact ligaments, with failure occurring mainly at the suture the latest generation of more robust, non-absorbable
attaching the transferred ligament.63 The mean laxity after sutures perform better.60

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 INJURIES TO THE ACROMIOCLAVICULAR JOINT 703

Fig. 4 Fig. 5

Diagram showing transfer of the lateral half of the conjoined tendon to Radiograph of the acromioclavicular joint showing twin endobuttons in
the distal clavicle augmented by Endobutton fixation of the acromiocla- situ. The endobutton suture technique was used to augment a con-
vicular joint. The arrow shows the pivoting at the origin of the conjoined joined tendon transfer (as shown in Fig. 4) in a 23-year-old man six
tendon and the movement of the distal end of the tendon from A to A* months after a type-III injury which remained significantly symptomatic
where it is sutured into the end of the clavicle. The close proximity of despite conservative treatment.
the musculocutaneous nerve (M) is highlighted.

To prevent excessive anterior subluxation, which may itself.63,88,89 The use of an absorbable suture may reduce
occur using complete clavicular cerclage, the graft may be the risk of fracture and may achieve satisfactory results,
passed through a drill hole in the anterior third of the clav- although, more commonly, non-absorbable implants are
icle rather than over its posterior aspect.77 Alternatively, used and retained.90 Aseptic foreign-body reactions have
two holes may be drilled in the clavicle at the site of inser- also been reported using synthetic grafts,91 but this is prob-
tion of the previous ligament to produce a more anatomical ably less common with the newer suture materials.
reconstruction. The typical attachment of the conoid liga- Protection of the soft-tissue repair. The arm is placed in a
ment is 45 mm medial to the end of the clavicle in its pos- sling for three to six weeks after the surgery in order to
terior half and of the trapezoid 15 mm lateral to this in the avoid early failure. Temporary methods of rigid stabilisa-
midline.60 A double-suture technique may also be adopted tion of the joint have also often been used to protect soft-
when utilising twin drill holes.71 tissue repairs which rely on biological healing of the graft.
Various modifications have been made to the original These must be removed once the soft-tissue repair has con-
techniques of coracoclavicular cerclage. The coracoid cer- solidated sufficiently to withstand normal joint forces, usu-
clage may be retained, or direct fixation to the bone ally at six to 12 weeks after the initial operation. If removal
achieved using either drill holes, endobuttons or suture is carried out too soon there is a risk of rupture of the graft
anchors.83-85 These may help to minimise the risk of injury and re-displacement of the joint, whereas if it is performed
to underlying neurovascular structures and avoid disloca- too late there may be stiffness in the shoulder or failure of
tion of the lower portion of the cerclage loop off the front the implant.
of the coracoid.84 Repair has also been performed using a Fixation using a coracoclavicular screw, first described
continuous loop of suture running between two Endobut- by Bosworth,92 has been the most widely-used technique
tons, which are passed through the lateral clavicle and to provide temporary stabilisation of the joint93,94 (Fig.
coracoid86 (Figs 4 and 5). These techniques lend themselves 6). However, it is technically difficult to achieve good
particularly well to arthroscopic insertion in which a placement of the screw in the narrow corridor of bone in
custom-made drill guide is used to assist in the placement of the horizontal portion of the coracoid, irrespective of
the drill hole in the coracoid. Few data are available on the whether this is performed as an open or fluoroscopically-
clinical outcomes of these techniques, although early assisted technique. Percutaneous insertion of the screw
reports are promising.87 has an unacceptably high rate of technical failure,94 but
Although techniques of cerclage provide more secure the use of arthroscopy to visualise the coracoid directly
reconstruction of the reduction, failure may still occur, may improve its placement.95 Even a technically-satisfac-
from a stress fracture of either the clavicle or the coracoid tory fixation is subject to cyclical loading by movements
as a result of a ‘cheese-wire’ effect, or by failure of the graft transmitted from the adjacent joints and is therefore

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704 J. A. FRASER-MOODIE, N. L. SHORTT, C. M. ROBINSON

Fig. 6 Fig. 7

Anteroposterior radiograph of a coracoclavicular screw used to treat a Anteroposterior radiograph of an acromioclavicular joint hook plate
45-year-old man who fell down several steps, sustaining a type-V injury used in the treatment of a 35-year-old man who fell playing football.
of the acromioclavicular joint.

prone to failure by cut-out or loosening. A prospective, The treatment of acromioclavicular dislocation

randomised study has compared fixation by a coracocla- with associated injuries
vicular screw with non-operative treatment.45 Better Guidelines for the best treatment for these injuries are
results were seen overall in those managed conservatively, difficult to produce, owing to their rarity, and the con-
although a subset of markedly-displaced injuries bene- siderable variation in the patterns of injury. However,
fited more from surgery. there appears to be a general trend towards operative
In the past Kirschner wires have been used extensively treatment of the acromioclavicular joint in combined
to transfix the acromioclavicular joint temporarily after injuries to restore mechanical stability and to facilitate
reduction. These give relatively poor fixation,58 may pre- rehabilitation.
cipitate osteoarthritis within the joint, and severe com- Most ‘pseudodislocations’ can be managed conserva-
plications and even fatalities may occur from distant tively in children,106 although operative reduction of the
migration of the wire to the lung, spinal cord or neck. dislocation and direct repair of the periosteal sleeve may
Given the wider range of better implants which is now be performed if displacement is severe.17 Only a small
available, the use of these wires is now contraindi- number of cases have been reported in which a fracture
cated.96-99 of the coracoid process has occurred in association with
A modified dynamic compression plate (Synthes, Wel- dislocation of the acromioclavicular joint.22 Most have
wyn Garden City, United Kingdom) with a lateral hook occurred in young adults, and successful outcomes have
designed to engage under the posterior part of the been reported with both conservative and operative
acromion, has been used successfully to maintain reduc- treatment.23,107-109
tion of acute dislocations (Fig. 7).81,100,101 This osteo- Smaller case series have also recorded successful out-
synthesis closely reproduces the stability of the intact comes after operative stabilisation of the acromioclavicular
joint,102 but its prolonged retention can produce stifnesss joint in patients with ipsilateral acromioclavicular disloca-
of the shoulder, clavicular osteolysis and peri-prosthetic tion and a mid-clavicular fracture,24 those with dislocation
fracture, whereas its removal at an early stage may lead to of both ends of the clavicle (‘floating clavicle’),28 and in
re-subluxation of the joint.103 Removal of the implant is patients with an ipsilateral fracture of the neck of the
therefore recommended at between eight and 12 weeks glenoid and fracture of the clavicle or injury to the acromio-
after the procedure. The use of a novel alloy coraco- clavicular joint.110
clavicular hook has been described with satisfactory In the presence of a scapulothoracic dissociation, if there
results,104,105 but this still requires early removal. is an unreconstructable vascular injury or if the injury has
In the newer minimally-invasive and arthroscopic produced catastrophic disruption of the brachial plexus,
techniques, insertion of hardware to stabilise the soft-tis- early amputation is advocated,111 whereas only operative
sue repair is not possible, and they rely on the immediate restoration of soft-tissue and bony stability may be required
stability of the graft construct to maintain the clavicle in if the limb is viable, with a prospect of a useful return of
the reduced position. neurological function.

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 INJURIES TO THE ACROMIOCLAVICULAR JOINT 705

Complications of injuries to the acromioclavicular diate repair is indicated. Delayed presentation with an
joint arteriovenous fistula or a false aneurysm may also occur
For the more common complications such as osteoarthritis after a vascular injury from penetration by a drill or screw
of the joint, clavicular osteolysis and the regional pain syn- which was not detected at the time of surgery.
drome, it is usually impossible to assess whether the condi- No benefits in any form have been received or will be received from a commer-
tion has developed as an inevitable consequence of the cial party related directly or indirectly to the subject of this article.
original injury or as a result of the treatment. Most of the
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