A cadaveric study examining acromioclavicular joint
congruity after different methods of coracoclavicular loop
repair
John E. Baker, MD,a Gregg T. Nicandri, BS,a Dale C. Young, MD,c John R. Owen, PE,a and
Jennifer S. Wayne, PhD,a Richmond, Va
A basic principle in the treatment of joint injuries is to
restore congruity with the hope that restoration may
lessen the incidence of late arthritis. The acromioclavic-
ular (AC) joint is frequently injured. Many AC joint
injuries are treated nonoperatively; others are treated
surgically. Coracoclavicular loop repair of the AC
joint is believed to lead to anterior displacement of the
clavicle relative to the acromion. This cadaveric study
evaluated the effectiveness of three techniques of cora-
coclavicular loop repair in restoring AC joint congruity
through measurement of anterior displacement. Four-
teen shoulders were repaired by the three different
techniques, all of which consisted of fixation through a
drill hole in the clavicle and around the crook of the
coracoid with a suture. The techniques only varied by
the placement of the drill hole in the clavicle (ie, either
posterior, middle, or anterior). The results of this study
indicate that as the drill hole moved anteriorly on the
clavicle, joint congruity was more closely approached
and less anterior displacement of the clavicle oc-
curred. However, none of the methods of coracoclavic-
ular loop fixation restored full AC joint congruity. (J
Shoulder Elbow Surg 2003;12:595-8.)
D islocation of the acromioclavicular (AC) joint usu-
ally occurs as a result of direct trauma to the shoulder
region, most often when a force is applied to the
acromion with the arm in an adducted position.8,13
Tossy et al19 first classified these dislocations into
grades I, II, and III. Grades I and II are considered
From the Departments of Orthopaedic Surgery,a and Biomedical
Engineering, Orthopaedic Research Laboratory, Virginia Com-
monwealth University, Richmond, VA, and West End Orthope-
dics.c
Reprint requests: Jennifer S. Wayne, PhD, Orthopaedic Research
Laboratory, Departments of Biomedical Engineering and Ortho-
paedic Surgery, PO Box 980694, Richmond, VA 23298. (E-
mail: jswayne@vcu.edu).
Copyright © 2003 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2003/$35.00 ⫹ 0
doi:10.1016/S1058-2746(03)00050-8
mild or moderate subluxations of the AC joint, and
grade III represents a disruption of the AC and cora-
coclavicular (CC) ligaments with a displacement of
the outer end of the clavicle of one clavicular diameter
or 1 cm on the anteroposterior radiograph. Rock-
wood et al17 have extended this classification scheme
to include three relatively less common categories,
which make up grades IV to VI.16 Most authors agree
that grade I and II injuries are generally treated
nonoperatively with good outcomes8,13 and that
grades IV to VI need to be treated surgically to
prevent disabling pain, weakness, and deformi-
ty.7,8,13,14,16 The treatment of grade III injuries re-
mains controversial. Many authors recommend early
nonoperative treatment in most cases but suggest that
surgical repair be considered in certain subgroups of
patients such as young, athletic patients or those who
perform heavy labor or overhead work.13,14,21 Ban-
nister et al,1 however, looked at patients with grade III
injuries and noted that patients in whom the clavicle
was displaced greater than 2 cm from the acromion
on the anteroposterior radiograph may benefit from
early operative reconstruction. In addition, not all
patients do well with nonoperative treatment; these
chronic conditions are usually treated surgically.6,21
Many techniques have been developed for the
surgical repair of the AC joint; however, all have
shortcomings.2,3,8,10-12,14,18,20 One surgical tech-
nique is CC loop fixation. Originally, this involved a
loop around the entire clavicle. Recently, a few au-
thors have recommended a modified cerclage tech-
nique in which a synthetic loop is passed through a
hole in the anterior clavicle directly over the coracoid.
The rationale for this approach is that it avoids the
possibility of cutting through the clavicle and has the
added benefit of better AC reduction with less ante-
rior subluxation than that caused by the simple clavic-
ular cerclage technique.9,13-15 This technique, how-
ever, does not replace both the conoid and trapezoid
ligaments in an anatomic manner. Recently, Debski et
al4,5 noted that the magnitude and direction of the in
situ force in the conoid and trapezoid ligaments were
different depending on whether the application of a
load was in the anterior, posterior, or superior direc-
595
596 Baker et al
Figure 1 Apparatus designed to secure shoulder specimens and
for application of a vertical load. A, Dissected shoulder; B, clavicle;
C, bolted plates to secure scapula and manubrium; D, L-angle
pulley for application of weights (W); E, drill hole through scapula
to secure bolted plates.
tion. Therefore, they proposed that surgical proce-
dures should reconstruct the CC ligaments in a more
anatomic manner or treat them separately to prevent
joint degeneration.
The purpose of this study was twofold: to determine
whether restoration of AC joint congruity is possible
with the use of CC loop repair and to compare the
effectiveness of three variations of this technique in
restoring AC joint congruity through measurement of
anterior displacement of the clavicle relative to the
acromion.
MATERIALS AND METHODS
Fourteen fresh-frozen cadaveric shoulders were included
in this study. All were stored for no longer than 1 month at
⫺20°C with tissue intact and thawed at room temperature
before testing. Each shoulder was then dissected of all soft
tissue with the AC and CC ligaments being left intact. The
complete shoulder was placed into an apparatus specifi-
cally designed for this project (Figure 1). A superior/hori-
zontal marking was made on the clavicle and acromion
over the AC ligaments to record their normal anatomic
relationship and to facilitate later measurement of anterior
displacement. A 5-lb weight was applied directly over the
middle of the clavicle by using the pulley system on the
testing apparatus to apply an upward force, and the CC
and AC ligaments were severed simulating a type III dislo-
cation. After all soft tissue was dissected from the underside
of the coracoid, the weight was removed, and the AC joint
was repaired by means of loop fixation through the clavicle
and around the coracoid with No. 5 Ethibond suture (Ethi-
J Shoulder Elbow Surg
November/December 2003
Figure 2 Location of drill holes in the clavicle for performing the
three methods of CC loop repair, with black bars depicting the
spatial orientation of the holes.
con, Inc, Somerville, NJ), ensuring that the suture fit snugly
into the crook of the coracoid. This repair was done with the
use of three different drill hole orientations through the
clavicle (Figure 2): posterior superior to anterior inferior
(Ps/Ai), middle superior to middle inferior ( Ms/Mi), and
anterior superior to anterior inferior (As/Ai). Joint congruity
was then compared after each of these individual proce-
dures by measuring the anterior/posterior displacement
between the original marks on the clavicle and acromion
with digital calipers (Figure 3). Two shoulders were also
prepared by a CC screw fixation technique1 for compari-
son purposes.
Statistical analysis was performed with the use of a
Kruskal-Wallis 1-way analysis of variance on ranks to de-
termine whether differences between groups were present,
and the Student-Newman-Keuls method was used for a
pairwise comparison of the groups.
RESULTS
None of the procedures with the CC loop repair
technique restored perfect joint congruity (Figure 4).
Posterior superior to anterior inferior ( Ps/Ai) showed
a mean displacement of 10.9 mm. Superior middle to
J Shoulder Elbow Surg
Volume 12, Number 6
Figure 3 Shoulder specimen depicting the technique used to
assess joint congruity of the AC joint through measurement of
anterior displacement (d) of the clavicle relative to the acromion.
This specimen was repaired through the posterior-superior to ante-
rior-inferior (Ps/Ai) hole (arrow).
inferior middle ( Ms/Mi) showed a mean displace-
ment of 6.6 mm. Anterior superior to anterior inferior
(As/Ai) showed a mean displacement of 2.6 mm. The
analysis of variance showed significant differences in
the median values among all three treatment groups
(P ⬍ .001). In a pairwise comparison, all possible
pairs showed statistically significant differences (P ⬍
.05). In the 2 shoulders repaired with the CC screw,
no displacement was observed after repair.
DISCUSSION
Many different techniques for the surgical treat-
ment of grade III AC separations have been devel-
oped.2,3,8,10-12,14,18,20 One reason for the numerous
approaches is that all of the different operative tech-
niques currently used have shortcomings. CC cer-
clage causes anterior subluxation of the distal clavicle
with malreduction of the AC joint, which has been
shown to cause pain, arthritis, and weakness. The
synthetic cerclage material, with time, can also wear
through the bone, cutting through the clavicle or cor-
acoid, resulting in possible loss of reduction and
reoperation.14 The CC screw and hook plate tech-
niques require a second surgery for removal.13,14 In
Baker et al 597
addition, the CC screw has the complications pullout,
infection, and irritation over the screw head.7 Pin
fixation has complications of increased AC arthritis
and breakage and migration of the pin.13 K-wires
have reportedly migrated to the lung in some cases.12
A complication of dynamic muscle transfer is that it
reconstructs a static constraint with dynamic tissue,
which is not as anatomically appealing as other
techniques,13 and augmentation with polydioxanon-
sulphate bands is limited by their lack of stiffness.15
A basic principle in the treatment of joint injuries is
to restore joint congruity, and in general, restoration
may lessen the incidence of late joint arthritis. Some
previous studies have suggested that near restoration
of AC joint congruity might be possible with a syn-
thetic loop passed through the clavicle.13-15 This
study, however, found that none of the CC loop repair
procedures that were used restored perfect joint con-
gruity; all had some degree of anterior displacement.
This subluxation of the clavicle can lead to chronic
pain, arthritis, and weakness and ultimately may lead
to another surgery to resect the distal clavicle. The
incidence of late joint arthritis has also been shown to
be as high as 20% when a distal clavicle resection is
not performed.17 Some authors have noted that resec-
tion of the distal clavicle combined with CC fixation
usually leads to good results and that weakness only
occurs when resection of the distal clavicle is used as
an isolated procedure.21 Therefore, some authors
recommend a distal clavicle excision at the time of
primary repair of all grade III injuries, and most other
authors are in agreement that the AC joint should be
inspected and excised when there is evidence of AC
joint injury at the time of primary repair.
Measurement of anterior displacement was chosen
as the variable in this study to describe AC joint
congruity. Rotation of the clavicle was qualitatively
noted after each of the three methods of loop repair.
However, Jerosch et al9 noted that rotational changes
were never more than 10°. Whether uniplanar or
multiplanar measurements are made, the anterior dis-
placements measured here provide substantial evi-
dence that the joint becomes incongruous, thus lead-
ing to potential complications. Multiplanar
movements will be evaluated in future studies. A final
comment must note that it is not known whether the
same displacement pattern in this in vitro study would
be replicated in the clinical setting, with the joint
subjected to variable loads and dynamic forces.
The CC screw technique showed minimal displace-
ment. This confirmed the work of Jerosch et al9 dem-
onstrating that both vertical and horizontal displace-
ment could be corrected with screw fixation. Only 2
specimens were included in this portion of the study
because any displacement induced by this technique
is dictated by the alignment of the structures during
insertion. Thus, zero displacement would be mea-
598 Baker et al
Figure 4 Mean displacement after three methods of CC loop repair. Orientation of drill holes: posterior superior
to anterior inferior (Ps/Ai), middle superior to middle inferior (Ms/Mi), and anterior superior to anterior inferior
(As/Ai).
sured regardless of the number of specimens. The
screw technique likely would not result in the prob-
lems associated with anterior displacement, but this
procedure is limited by the fact that a second surgery
is required to remove the screw after the joint has
healed, in addition to the problems of pullout, infec-
tion, and irritation over the screw head.
The conclusions of this study indicate that as the
drill hole moves anteriorly on the clavicle without
compromising fixation, normal joint congruity is
closely approached. However, it is important to note
that in every CC loop repair, regardless of hole
placement, complete AC joint congruity is not re-
stored. The magnitude of the displacement that clini-
cally results in future arthritis of the joint is not known.
We would like to thank the Departments of Orthopedic
Surgery and Biomedical Engineering, Virginia Common-
wealth University, Richmond, Va.
REFERENCES
1. Bannister GC, Wallace WA, Stableforth PG, Hutson MA. A
classification of acute acromioclavicular dislocation: a clinical,
radiological and anatomical study. Injury 1992;23:194-6.
2. Bosworth BM. Acromioclavicular separation. New method of
repair. Surg Gynecol Obstet 1941;73:866-71.
3. Cadenat FM. The treatment of dislocations and fractures of the
outer end of the clavicle. Int Clin 1917;1:145-69.
4. Debski RE, Parsons IM III, Fenwick J, Vangura A. Ligament
mechanics during three degree of freedom motion at the acromi-
oclavicular joint. Ann Biomed Eng 2000;28:612-8.
5. Debski RE, Parsons IM IV, Woo S, Fu FH. Effect of capsular injury
on acromioclavicular joint mechanics. J Bone Joint Surg Am
2001;83:1344-51.
6. Guy DK, Wirth MA, Griffin JL, Rockwood CA. Reconstruction of
chronic and complete dislocations of the acromioclavicular joint.
Clin Orthop 1998;347:138-49.
7. Harris RI, Wallace AL, Harper GD, et al. Structural properties of
the intact and reconstructed coracoclavicular ligament complex.
Am J Sports Med 2000;28:103-8.
J Shoulder Elbow Surg
November/December 2003
8. Hessmann M, Gotzen L, Gehling H. Acromioclavicular recon-
struction augmented with polydioxanonsulphate bands: surgical
technique and results. Am J Sports Med 1995;23:552-6.
9. Jerosch J, Filler T, Peuker E, Greig M, Siewering U. Which
stabilization technique corrects anatomy best in patients with
AC-separation? Knee Surg Sports Traumatol Arthrosc 1999;7:
365-72.
10. Kiefer H, Claes L, Burri C, Holzwarth J. The stabilizing effect of
various implants on the torn acromioclavicular joint. Arch Orthop
Trauma Surg 1986;106:42-6.
11. Kutschera HP, Kotz RI. Bone-ligament transfer of coracoacromial
ligament for acromioclavicular dislocation. A new fixation
method used in six cases. Acta Orthop Scand 1997;68:246-8.
12. Lancaster S, Horowitz M, Alonso J. Complete acromioclavicular
separations: a comparison of operative methods. Clin Orthop
1987;216:80-7.
13. Lemos MJ. The evaluation and treatment of the injured acromio-
clavicular joint in athletes. Am J Sports Med 1998;26:137-44.
14. Morrison DS, Lemos MJ. Acromioclavicular separation: recon-
struction using synthetic loop augmentation. Am J Sports Med
1995;23:105-10.
15. Motamedi AR, Blevins FT, Willis MC, McNally TP, Shahinpoor
M. Biomechanics of the coracoclavicular ligament complex and
augmentations used in its repair and reconstruction. Am J Sports
Med 2000;28:380-4.
16. Phillips AM, Smart C, Groom AFG. Acromioclavicular disloca-
tion: conservative or surgical therapy. Clin Orthop 1998;353:
10-7.
17. Rockwood CA, Williams GR, Young DC. Disorders of the
acromioclavicular joint. In: Rockwood CA Jr, Matsen FA III,
editors. The shoulder. Philadelphia: Saunders; 1990. p. 483-
553.
18. Sim E, Schwarz N, Hocker K, Berzanovich A. Repair of complete
acromioclavicular separations using the acromioclavicular-hook
plate. Clin Orthop 1995;314:134-42.
19. Tossy JD, Mead NC, Sigmond HM. Acromioclavicular separa-
tions: useful and practical classification of treatment. Clin Orthop
1963;28:111-9.
20. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries,
especially complete acromioclavicular separation. J Bone Joint
Surg Am 1972;54:1187-94.
21. Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU.
Surgical treatment of complete acromioclavicular dislocations.
Am J Sports Med 1995;23:324-31.