Acromioclavicular Joint Dislocation: Repair

Through Open Ligament Transfer and Nonabsorbable

Suture Fixation
Ricardo Canquerini da Silva, M.D., Bruno Silveira Pavei, M.D., Márcio B. Ferrari, M.D.,
George Sanchez, B.S., Luiza Barbosa Horta Barbosa, M.D., and
João L. Ellera Gomes, M.D., Ph.D.

Abstract: Acromioclavicular (AC) joint instability is a fairly common and particularly limiting injury that may result in
persistent pain and reduced quality of life. In most cases, conservative management is successful. However, in the case of a
severe AC joint dislocation, surgical intervention may be warranted. Previous surgical techniques for treatment of AC joint
instability include screw fixation between the coracoid and clavicle, coracoacromial ligament transfer from its acromial
insertion to the clavicle, and reconstruction of the coracoacromial and/or coracoclavicular ligaments. The purpose of this
Technical Note is to describe our preferred technique for the treatment of a high-grade AC dislocation through cor-
acoacromial ligament transfer to the lateral clavicle and nonabsorbable suture fixation between the coracoid process and
clavicle.

A cromioclavicular (AC) joint dislocations are rela-

tively common and particularly disabling injuries
of the shoulder, often affecting male athletes who
adducted position. However, in the case of an indirect
force, the patient may fall onto the elbow, which results
in a force vector that pushes the proximal humerus
participate in a contact sport. In fact, the estimated against the AC joint and leads to an AC dislocation.2
overall incidence of AC joint injuries is 9.2 per 1,000 To accurately and consistently diagnose an AC dislo-
person-years in young athletes.1 Although almost 90% cation, a thorough physical examination and a set of
of these injuries are low grade (Rockwood grade I or II), imaging examinations must be completed. In the acute
high-grade injuries may result in chronic pain, persis- setting, the patient may often complain of pain directly
tent muscular weakness, aesthetical deformity of the over the AC joint. Moreover, a visible deformity of the
clavicle, and an overall reduced quality of life.2 The joint may be present especially in cases of Rockwood’s
mechanism of injury is usually described as a direct grades III and V. After the physical examination, a
force to the acromion if the patient falls with the arm in series of radiographs must be completed including a
shoulder trauma series3,4 as well as the Zanca view,
which is reported to be the most accurate view for
From the Hospital de Clínicas de Porto Alegre (R.C.d.S., B.S.P., M.B.F.,
L.B.H.B., J.L.E.G.), Porto Alegre, Rio Grande do Sul, Brazil; and Steadman examination of the AC joint.5 Furthermore, the ante-
Philippon Research Institute (G.S.), Vail, Colorado, U.S.A. roposterior view may be used to identify any vertical
The authors report the following potential conflicts of interest or sources of displacement of the clavicle, whereas the axillary view
funding: The authors have received research grants from Health South East would be particularly useful in the case of a posterior
and Arthrex. However, these research grants did not involve and, ultimately,
dislocation. In the setting of a more complex case,
did not influence the production of this work. Full ICMJE author disclosure
forms are available for this article online, as supplementary material. computed tomography may be required for better
Received February 6, 2017; accepted May 2, 2017. assessment of fractures as well as the articular surfaces,
Address correspondence to Ricardo Canquerine da Silva, M.D., Hospital de whereas magnetic resonance imaging may be used to
Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350dSanta Cecilia, 90035- eliminate possible concomitant pathologies including
903, Porto Alegre, Rio Grande do Sul, Brazil. E-mail: coe.orto@terra.com.br
associated ligamentous and cartilaginous injuries.4,6
Ó 2017 Published by Elsevier on behalf of the Arthroscopy Association of
North America. Open access under CC BY-NC-ND license. The purpose of this Technical Note is to describe our
2212-6287/17149 preferred technique for the treatment of a high-grade
http://dx.doi.org/10.1016/j.eats.2017.05.004 AC dislocation through coracoacromial ligament

Arthroscopy Techniques, Vol 6, No 4 (August), 2017: pp e1263-e1270 e1263

e1264 R. C. DA SILVA ET AL.

(CAL) transfer to the lateral clavicle and nonabsorbable beginning at the coracoid process and extending to the
suture fixation between the coracoid process and most proximal aspect of the clavicle to ensure a good
clavicle. overall exposure of the AC and coracoclavicular joint
space. A scalpel is then used to perform the longitudinal
Surgical Technique incision (Fig 1). After this, the subcutaneous tissue is
bluntly dissected. The deltotrapezoidal fascia is exposed
Preoperative Setup and Examination Under and opened in line with the skin incision through the
Anesthesia use of Metzenbaum scissors. The superior and anterior
The patient is positioned supine on the operating table aspects of the clavicle are then exposed with a coagu-
and regional anesthesia is then applied by way of an lator, Cobb elevator, or Penfield dissector (Fig 2). It is
interscalene block. In our experience, the initial use of important to maintain the integrity of all surrounding
regional anesthesia reduces immediate postoperative soft tissues that will be approximated later on in the
pain and allows the patient to effectively abide with the procedure. Maintenance of these soft tissues ensures
proposed rehabilitation protocol. After induction of adequate soft tissue coverage of the sutures as well as
general anesthesia, the patient is transferred to a beach proximal deep structures. In addition, the coagulator is
chair position to optimize shoulder mobility during the used to demarcate the AC joint while releasing the
procedure. Using a foam pad, the knees are kept in lateral border of the clavicle from all previous scar tis-
slight flexion and all bony prominences are well padded. sues formed in the AC joint in a chronic setting. Then,
The head is then checked to confirm that it is secured in attention is turned to the CAL. For this portion of the
position. After this, safety straps are used to fasten the technique, thorough knowledge of the anatomy of the
patient to the operating table. Once the preoperative AC joint including the CAL and other surrounding
setup is complete, a physical examination of the structures is necessary. Metzenbaum scissors are used
shoulder is performed. The physical examination spans to carefully identify and isolate the CAL with care to
the following tests: range of motion of both shoulders, avoid damage to all nearby structures.
palpation of the AC joint, and ease of reducibility of the
clavicle through application of superoinferior pressure Release of the CAL From the Acromial Insertion
onto the lateral pole of the clavicle. After examination Once the CAL is sufficiently exposed, sharp dissection
under anesthesia, the nonoperative arm is maintained is performed on the acromial insertion of the CAL using
in adduction with a neutral position. Afterward, the left a scalpel (Fig 3). For dissection of this portion of the
arm is sterilely prepped and draped in standard fashion technique, we recommend the use of a scalpel, instead
while the arm is kept adducted and next to the body. All of Metzenbaum scissors or a coagulator. Once the CAL
relevant bony prominences on the shoulder are identi- is released from the lateral portion, a No. 5 Ethibond
fied via palpation, and then a surgical pen is used to suture (Ethicon, Somerville, NJ) is used to prepare this
outline the acromion, clavicle, and coracoid process to end of CAL using the Kessler suture technique.
avoid unnecessary surgical exposure of any surrounding
structures. Tunnel Preparation and Excision of the Lateral End
A surgical ruler is used on the superior aspect of the
Exposure clavicle to mark the position of 3 cm from the most
Once the patient is in the correct position, the initial lateral aspect of the clavicle with either a coagulator or
incision is completed based on Langer’s lines to provide surgical pen. A 2.5-mm drill is then used to make a
a more cosmetic scar. The incision is first marked, tunnel at this position in a superior-to-inferior direction.

Fig 1. The patient is positioned in a beach chair position with the left arm prepped in a standard fashion. The coracoid process,
acromion, and clavicle are palpated and marked using a surgical pen. Based on Langer’s lines, a line is drawn from the coracoid
process to the clavicle (A). A scalpel is then used for the surgical approach (B), starting at the coracoid process and extending to
the superior border of the clavicle.
 ACROMIOCLAVICULAR JOINT REPAIR e1265

Fig 2. The surgical approach for exposure of the acromioclavicular joint in the left shoulder is completed. Once the skin is
incised, blunt dissection of the subcutaneous tissue is performed using Metzenbaum scissors (A). The deltotrapezoidal fascia is
incised in line with the skin incision. Then, the superior and anterior aspect of the clavicle is exposed with release of all
surrounding soft tissue (B). After this, exposure of the coracoacromial ligament (CAL) is completed (C).

Once the first tunnel is complete, the surgical ruler is damage to the ligamentous and muscle attachments of
used again to measure the position 1 cm lateral to the the coracoid. Once the outline of the coracoid process
first tunnel. The position is marked with either a coag- and its attachments are properly visualized, a coracoid
ulator or surgical pen, and then a 2.5-mm drill is again suture passer (Hospitalia Cirurgica, Florianopolis,
used to make this second tunnel in a superior-to-inferior Brazil) is used to deliver the passing suture from medial
direction (Fig 4). To ensure stability of the clavicle during to lateral, directly under the coracoid process. Once the
this portion of the procedure, we recommend secure- passing suture has reached the lateral side of the cora-
ment of the clavicle with a Weber or similar clamp. After coid process, 4 No. 5 Ethibond sutures (Ethicon) are
this, a total distance of 1 cm of the lateral aspect of the passed under the coracoid process. Once the sutures
clavicle is measured using a surgical ruler. Then, this have been passed under the coracoid, there are 4 suture
portion of clavicle is excised using a rongeur, thereby limbs on the lateral side and 4 on the medial side, which
exposing the intramedullary canal. Once the lateral totals 8 suture limbs spanning both sides of the cora-
aspect of the clavicle is excised, a 2.5-mm drill is used to coid. Two of the 4 suture limbs on the lateral side of the
form 2 tunnels at the lateral aspect of the clavicle. The coracoid are then passed through the most medial
first tunnel begins at the anterior aspect of the intra- tunnel of the lateral end of the clavicle. Then, 2 of the 4
medullary canal and is constructed toward the posterior suture limbs on the medial side of the coracoid are
aspect of the clavicle. Then, the second tunnel begins at passed through the most lateral tunnel of the lateral
the posterior aspect of the canal and is constructed end of the clavicle to make a figure “X” by passing one
toward the anterior aspect of the clavicle (Fig 5). Care is pair of suture limbs over the other pair (Fig 6).
taken to avoid fractures of the lateral aspect of the
clavicle while forming the tunnels. For this reason, we Suture Fixation on the Superior Surface of the
suggest that the end of both tunnels be at least 0.5 cm Clavicle
medial from the lateral edge of the clavicle. While simultaneously applying a superior-to-inferior
force to reduce the clavicle, both suture limbs inside
Suture Passage Underneath the Coracoid Process the most medial tunnel are tied together. Then, both
Using Metzenbaum scissors, we define the margins of suture limbs inside the most lateral tunnel are tied
the coracoid process with care to avoid any potential together. Once both suture limbs for each tunnel have

Fig 3. The coracoacromial ligament is released from its acromial insertion in the left shoulder through the use of a scalpel. The
lateral border of the ligament is then prepared using a No. 5 Ethibond suture (Ethicon, Somerville, NJ) by way of the Kessler
suture technique (A, B). (CAL, coracoacromial ligament; CHL, coracohumeral ligament.)
e1266 R. C. DA SILVA ET AL.

Fig 4. After the coracoacromial ligament is released from its acromial insertion in the left shoulder, a surgical ruler is used to
measure a 3 cm distance from the lateral end of the clavicle on the superior surface of the clavicle (A). The clavicle is secured and
a 2.5-mm drill (white arrow) is used to create 2 tunnels in a superior-to-inferior direction (B). The first tunnel is located 3 cm
from the acromioclavicular joint and the other is found 1 cm lateral from the first tunnel. Afterward, 1 cm of the most lateral end
of the clavicle is resected using a rongeur (green arrow, C). (Yellow arrow, most lateral aspect of the clavicle.)

been tied, they are tied together on the superior surface the clavicle. Each suture limb is passed inside the
of the clavicle. Although the clavicle remains slightly intramedullary tunnel previously made (Fig 7). The
anterior after the suture limbs are tied, our clinical lateral suture limb passed through the most medial
experience suggests that this has no adverse effects tunnel and the medial suture limb passed through the
postoperatively and, therefore, has no clinical rele- most lateral tunnel. The CAL is then gently introduced
vance. The excess suture is then removed. The other 2 inside the intramedullary canal and both suture limbs
suture limbs on the lateral side of the coracoid process are tied and secured on the superior surface of the
are then passed over the lateral aspect of the clavicle, clavicle. The integrity and strength of the repair is then
1 cm from the lateral edge of the clavicle and 1 cm verified by taking the shoulder through normal range of
lateral from the most lateral clavicular tunnel. Once the motion. This confirms excellent stability of the AC joint
2 suture limbs on the lateral side of the coracoid process after the repair as seen in Video 1. Finally, copious
have been passed over, they are tied to the remaining irrigation with a saline solution is performed; then the
2 suture limbs on the medial side of the coracoid pro- deltotrapezoidal fascia is closed using a No. 2 Vicryl
cess. The 4 suture limbs are tied and secured on the suture (Ethicon). After this, the subcutaneous tissue
superior surface of the clavicle. The excess suture is layer is approximated using a No. 2 Vicryl suture
then removed. (Ethicon). The skin layer is then closed using an
intradermal suture with Monocryl 3-0 (Ethicon). Post-
Coracromial Ligament Transfer to the Lateral operative radiographs are obtained to verify the success
Clavicle of the technique (Fig 8).
Attention is then turned to the CAL once all suture
limbs running underneath the coracoid process have Rehabilitation Protocol
been secured. The 2 suture limbs arising from the CAL After surgery, the patient is immediately placed in a
end, previously prepared through the Kessler suture sling for 6 weeks. The goal during the rehabilitation
technique, are then passed through the previously protocol is to optimize the AC joint stability, while
prepared tunnels located 0.5 cm from the lateral end of providing a safe environment for healing of the CAL in

Fig 5. Once the lateral end of the left clavicle is resected, a 2.5-mm drill (white arrows, A and B) is used to create 2 intra-
medullary tunnels. The first tunnel starts at the anterior aspect of the intramedullary canal and is constructed toward the
posterior aspect of the clavicle. The second tunnel begins at the posterior aspect of the canal and is constructed toward the
anterior aspect of the clavicle.
 ACROMIOCLAVICULAR JOINT REPAIR e1267

Fig 6. In the left shoulder, 4 No. 5 Ethibond sutures (Ethicon, Somerville, NJ) are passed underneath the coracoid process
(yellow arrow, A) from lateral to medial. To facilitate the passage of all the sutures at once, a coracoid suture passer (Hospitalia
Cirurgica, Florianopolis, Brazil) is used from medial to lateral with a total of 4 suture limbs on each side of the coracoid process.
Two suture limbs on the lateral side are then passed through the most medial tunnel in the clavicle and 2 suture limbs on the
medial side are passed through the most lateral tunnel one pair over the other (B).

the clavicular intramedullary canal. At the patient’s Discussion

discretion, we suggest active hand, wrist, and elbow This Technical Note describes in detail our preferred
exercises with no resistance as soon as possible. At method for the treatment of high-grade and chronic AC
week 2, the use of the sling is discontinued during joint instability. Our technique has several advantages,
physiotherapy sessions, in which exercises of passive which include low cost, no need for hardware fixation,
movement in the scapular plane is initiated. However, satisfactory reduction of the AC joint, no need of
no abduction of the shoulder is allowed at this time. The arthroscopy proficiency, and no donor site morbidity.
range of motion is gradually increased from passive to Several conservative and surgical techniques have been
active-assisted/active in nature based on the individual previously described for the treatment of all AC joint
progress and discretion of the patient. At week 6, the injury grades (Rockwood’s grades I-VI). However, there
sling is entirely discontinued and abduction exercises is a lack of consensus regarding the best treatment
are initiated. Weightlifting is not permitted during the option for Rockwood’s grades III, given that surgery
initial 4 months after surgery. Then, after these may be needed in these cases.7,8 Although the literature
4 months, the patient can begin progressive weight- suggests and supports conservative treatment for grades
training exercises. Although the return to sport is I and II, optimal treatment, whether conservative or
patient dependent, we recommend a return to surgical, of grade III injuries remains controversial.9
noncontact sports no sooner than 6 months and a Spencer9 performed a systematic review and, despite
return to contact sports no sooner than 9 months. a low-evidence level, concluded that conservative
Advantages and disadvantages as well as pearls and treatment for grade III injuries resulted in less time
pitfalls associated with the technique are summarized in away from physical activity and less risk of potential
Tables 1 and 2, respectively. complications; similar findings and conclusions

Fig 7. Once the clavicle of the left shoulder is reduced and kept in position using the nonabsorbable sutures, the sutures
previously passed through the lateral end of the coracoacromial ligament (CAL, yellow arrow, (A)) are inserted through the
intramedullary tunnels and tied and secured on the superior aspect of the clavicle. This fixation introduces the CAL into the
intramedullary canal (B).
e1268 R. C. DA SILVA ET AL.

Fig 8. Postoperative imaging showing the preoperative (A) and postoperative (B) views of the affected left shoulder and
contralateral shoulder. Note the complete dislocation of the acromioclavicular joint on the left side (yellow arrow, A) compared
with the noninjured, contralateral side (white arrows) as well as the reduction of the joint after our surgical technique (yellow
arrow, B).

regarding grade III injuries were reported by Ceccarelli complication rates including a rate of 86.7% of
et al.10 Nevertheless, controversy persists regarding this excellent results in patients after treatment. In addition,
specific injury given that conservative management has Lin et al.18 reported positive outcomes after cor-
resulted in chronic and recalcitrant symptoms.11-13 acoclavicular screw fixation in association with CAL
Treatment options for severe AC joint instability reconstruction as 30 patients reported an 88.9%
include screw fixation between the coracoid and satisfaction rate after 23.6 months after surgery.
clavicle as well as transfer of the CAL onto the coracoid, Outcomes after isolated CAL transfer to treat severe
both in isolation and in association with supplementary AC joint instability have been associated with success
fixation methods.14-16 Several authors have described and high patient satisfaction.19,20 The first description of
positive outcomes after screw fixation. Esenyel et al.17 this procedure was reported by Weaver and Dunn,19 in
reported that the modified Bosworth procedure was which the fixation of the shortened acromial end of the
associated with low AC joint degeneration and low CAL into the medullary canal of the clavicle in
conjunction with a combined oblique arthroplasty
Table 1. Advantages and Disadvantages
resection of the AC joint was illustrated. Shoji et al.21
also reported positive outcomes after CAL transfer for
Advantages Disadvantages the treatment of grade III AC joint instability with 14 of
Low cost and reproducible Open procedure with more 15 patients reporting full range of shoulder motion with
exposure and damage to the no pain after surgery. However, a biomechanical study
surrounding soft tissues as well
as greater risk of infection
performed by Wilson et al.22 described that CAL
No need for hardware fixation Nonanatomical reconstruction of transfer when completed in association with the
that avoids potential hardware the joint fixation of the clavicle to the coracoid process provides a
complication more reliable fixation that less likely results in revision.
Satisfactory reduction of the joint Sood et al.23 performed a systematic review on differ-
is achievable regardless of
severity of acromioclavicular
ences in outcomes between isolated CAL transfer and
joint instability CAL transfer associated with a concomitant fixation
No arthroscopic proficiency is procedure and found satisfactory results with similar
required recurrence rates. Despite similar outcomes, the group
No donor site morbidity with an associated fixation procedure aside from CAL
 ACROMIOCLAVICULAR JOINT REPAIR e1269

Table 2. Pearls and Pitfalls References

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