Management of

A c rom i o c l a v i c u l a r Jo i n t
Injuries
Charlton Stucken, MD, Steven B. Cohen, MD*

KEYWORDS
 Acromioclavicular  Coracoclavicular  Ligament reconstruction

KEY POINTS
 Nonsurgical treatment is recommended for type I and II injuries.
 Surgical treatment is recommended for type IV, V, and VI injuries.
 Type III injuries are controversial.
 Current operative techniques are trending toward anatomic reconstruction of acromioclavicular
and coracoclavicular ligaments.

INTRODUCTION variable size and thickness that degenerates over

The AC joint serves as a primary link in the sus-
pension of the upper extremity from the axial skel-
eton, and its injury represents 30% to 50% of
athletic shoulder injuries.1–4 Despite the fre-
quency of injury, the treatment of the AC joint re-
mains subject to debate because there is a lack
of consensus regarding optimal management.
More than 60 different procedures have been
described to treat these injuries, which indicates
the difficulty and problems with their manage-
ment. The uncertainty surrounding management
of AC joint injuries centers on 2 debates: first,
nonoperative versus operative treatment; and
second, different operative techniques.
RELEVANT ANATOMY AND BIOMECHANICS
The AC joint is a diarthrodial joint formed by the
distal end of the clavicle and the medial facet of
the acromion with a variable inclination ranging
from nearly vertical to more than 50 of obliquity,
with the superior edge of the clavicle more lateral.5
time and becomes nonfunctional in most individ-
uals after 40 years of age.6
During development, the AC joint first appears
at 3 to 5 years of life. The clavicle first appears in-
trauterine at week 5. It has 2 epiphyses that
contribute to its longitudinal growth: the medial
epiphysis is responsible for most of this growth
via enchondral activity. The medial epiphysis ap-
pears at age 18 years and fuses between 22 and
25 years. The lateral epiphysis is less consistent.
The acromion has between 2 and 5 ossification
centers appearing at puberty, and fusing by age
25 years.
The AC joint has both static and dynamic stabi-
lizers. Static stabilizers include the AC joint
capsule and 4 AC ligaments (superior, inferior,
anterior, and posterior). These AC ligaments are
the principal restraints to anteroposterior transla-
tion between the clavicle and acromion.7,8 The
posterior and superior AC ligaments contribute
most to the horizontal stability of this joint.9 Recent
studies showed that a distal 1-cm clavicle resec-
tion results in a 32% increase in posterior transla-
orthopedic.theclinics.com

Within this joint resides a fibrocartilaginous disk of tion compared with the intact state.10 No

The authors have nothing to disclose.

Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
* Corresponding author.
E-mail address: steven.cohen@rothmaninstitute.com

Orthop Clin N Am - (2014) -–-

http://dx.doi.org/10.1016/j.ocl.2014.09.003
0030-5898/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
2 Stucken & Cohen
consensus exists regarding the amount of
increased horizontal instability that may be clini-
cally significant, but even a small resection of as
little as 2.6 mm could completely release the
clavicular insertion of the AC ligaments in some
patients.11
Vertical stability of the AC joint is provided by the
CC ligaments, which include the conoid ligament
medially and the trapezoid ligament laterally. A
cadaveric study has shown that the distance
from the lateral edge of the clavicle to the medial
edge of the conoid averages 47 mm and, to the
center of the trapezoid, is 25 mm in male pa-
tients.12 Mazzocca and colleagues13 further
showed that, with superior load, the conoid liga-
ment always failed before the trapezoid. The liga-
mentous attachments on the coracoid process
are less well studied, but cadaveric studies have
shown the trapezoid to have a broad attachment
to the lateral upper side and the conoid to have a
smaller attachment on the medial posterior
margin, suggesting independent function of the
ligaments.14,15
The AC joint is not a rigid structure, because it
has micromotion in all planes. If not for this natural
motion, then arthrodesis of the joint would be a
viable option after injury. Inman and colleagues16
and Graichen and colleagues17 reported an
in vivo motion of the AC joint of approximately
20 . With shoulder elevation and abduction, the
clavicle has been shown to rotate more than 40 ,
but relative to the acromion it only rotates 5 to
8 because of concomitant sternoclavicular mo-
tion.18 After injury to the AC joint, the degree of
clavicular displacement depends primarily on the
extent of the injury to the AC and CC ligaments.
CAUSES
Injuries to the AC joint can be the result of direct or
indirect forces. The most common cause is fall
onto the anterior, superior edge of the acromion
Table 1
Modified AC joint injuries classification
Type AC Joint AC Ligament
I Intact Sprain
II Displaced Torn
III Disrupted Torn
IV Disrupted Torn
V Disrupted Torn
VI Inferior displacement — —
of clavicle
with the arm in the adducted position. This force
drives the acromion downward and medially. The
downward displacement of the distal clavicle is
first resisted by the sternoclavicular ligaments,
and, if no fracture of the clavicle occurs, the force
first sprains then ruptures the AC ligaments and
capsule, followed by the CC ligaments and delto-
trapezial fascia.19 At this point, the upper extremity
has lost its suspensory support from the clavicle.
Although conventional thought is that this results
in superior displacement of the clavicle, the major
deformity is the inferior displacement of the
shoulder.
CLASSIFICATION
AC joint injuries are best classified according to
the extent of damage, thus they are graded ac-
cording to the amount of injury to the AC and CC
ligaments. In the past, these injuries have all
been referred to as AC joint injuries, although
these injuries include a spectrum of disruption be-
tween all the joints of the scapula and the clavicle.
Rockwood’s group developed the most widely
accepted classification system, based on the orig-
inal work of Tossy and colleagues20 in 1963.21 This
modified classification is described later and is
summarized in Table 1.
Type I
There is no visible deformity. The patient may have
tenderness over the AC joint, but none over the CC
ligament region. There is mild strain to the fibers of
the AC ligaments because they remain intact, and
the AC joint remains stable. Radiographs appear
normal.
Type II
A moderate force is strong enough to rupture the
ligaments of the AC joint. The distal end of the
clavicle is unstable in the anteroposterior plane,
Deltoid and Trapezius
CC Ligament Muscles
Intact Intact
Sprain/Intact Intact
Torn Usually intact
Torn Detached
Torn Detached
—

but superoinferior stability is preserved because
the CC ligament is intact. There may be a slight up-
ward displacement of the distal end of the clavicle
caused by stretching of the CC ligaments, and
widening of the AC joint may be present (Fig. 1).
There may be tenderness overlying the CC
ligaments.
Type III
A severe force tears the AC and CC ligaments, re-
sulting in complete AC dislocation. The distal clav-
icle appears to be displaced superiorly, although
the AC joint is reducible by an upward force placed
on the elbow. Radiographic findings include a
25% to 100% increase in the CC space compared
with the contralateral shoulder.
Type IV
Posterior dislocation of the distal end of the
clavicle is rare. With an anterior and inferior force
to the acromion, the clavicle is displaced posteri-
orly into or through the trapezius muscle. Tenting
may be seen on the posterior aspect of the shoul-
der. Crucial for this diagnosis is the axillary view
radiograph showing the posterior displacement
of the clavicle in relation to the acromion.
Type V
This dislocation is a more severe type III in which
the distal clavicle has been stripped of all of its
soft tissue attachments, including the deltotrape-
zial fascia. The clavicle lies subcutaneously.
Compared with type III dislocations, the AC joint
is not reducible. On radiographs, the CC space is
increased greater than 100% compared with the
contralateral shoulder. There is marked disfigura-
tion of the shoulder with droop of the extremity.
Fig. 1. Type II injury.
Management of AC Joint Injuries 3
Type VI
Inferior dislocation of the distal end of the clavicle
is rare, resulting from hyperabduction and external
rotation. This injury is often the result of severe
trauma and is frequently combined with multiple
injuries. The distal clavicle occupies either a suba-
cromial or subcoracoid location. Gerber and
Rockwood’s22 series of 3 patients is the largest re-
ported in the literature.
IMAGING
Routine imaging for AC joint evaluation includes
routine anteroposterior (AP) and axillary views.
The AP view identifies the amount of vertical
migration of the clavicle, whereas the axillary
view evaluates anteroposterior displacement.
The Zanca view (an AP with a 10 –15 cephalic
tilt) provides improved visualization of the AC joint
because it removes the scapula from the field. AP
and Zanca views should ideally be taken with a
wide plate to show bilateral AC joints on the
same film so that the 2 AC joints can be directly
compared. Stress views of the AC joint, taken
while the patient is holding weights in each arm,
have fallen out of favor because they are uncom-
fortable for the patient and do not provide addi-
tional information.23,24
MANAGEMENT
Type I Injury
There is no role for operative management in the
acute setting.25 Nonsurgical treatment consists
of a sling for 7 to 10 days, ice, and nonsteroidal
medications. The sling is used for comfort, with
gradual return to unrestricted daily activities usu-
ally within 2 weeks.
Type II Injury
Nonsurgical treatment is generally recommen-
ded for all type II injuries. Most investigators sug-
gest a period of immobilization in a sling to
remove the stress from the injured AC and CC
ligaments, generally for up to 2 weeks. Once
the pain has subsided, an early and gradual
rehabilitation program is initiated with a focus
on passive-assisted and active-assisted range
of motion. The patient is not allowed to do any
heavy lifting, pushing, pulling, or contact sports
for at least 3 to 6 weeks to allow the ligaments
to heal. Earlier return to athletics can be facili-
tated through use of protective padding over
the superior aspect of the joint. Continued, unre-
lieved pain can be treated with a corticosteroid
or an anesthetic injection into the AC joint. There
4 Stucken & Cohen
is a general consensus for nonoperative treat-
ment of type I and type II injuries.26–28
Type III Injury
In contrast with type I and type II injuries, there is
general uncertainty regarding treatment of type III
injuries, but initial nonoperative treatment is
favored in most cases.28 When managing these
injuries, patient characteristics should be taken
into account, including type of sport, level of
play, timing relative to the season, and throwing
demands of the sport. There have been many
reports of nonoperative and operative manage-
ment, with various techniques of surgical treat-
ment.29–33 Current literature suggests that the
decision for treatment should be made on a
case-by-case basis with an emphasis on initial
nonoperative management.34,35
No prospective, randomized controlled trial
(level 1) has been published to compare nonoper-
ative and operative treatment of these injuries,
and thus only retrospective case series are
available. A recent meta-analysis by Smith and
colleagues36 concluded that operative manage-
ment resulted in a better cosmetic outcome but
greater duration of sick leave. They found no dif-
ference in strength, pain, throwing ability, and
incidence of AC joint osteoarthritis compared
with nonoperative management. Only 1 study
has shown a higher Constant score for operative
management compared with nonoperative man-
agement.37 A prior meta-analysis by Philips and
colleagues38 advised against surgical treatment
of these injuries. Thus the operative versus
nonoperative debate has remained in effect, and
so too has the debate surrounding surgical
technique, because many options have been
described. Even the diagnosis of a type III injury
has come into question, because much of the un-
certainty when managing type III injuries is in
differentiating them from type V injuries. In sum-
mary, the debate remains, but it has been
proposed that surgical indications for type III sep-
arations are patients with persistent symptoms
and functional limitations after a course of nonop-
erative management (minimum of 6–12 weeks)
focused on attaining full range of motion and
scapula stabilization.39
Type IV
There is consensus in the literature that the treat-
ment of type IV injuries should be surgical.40–43
The CC ligaments are usually, but not always,
torn, in addition to the AC ligaments. Thus, surgi-
cal treatment focuses on AC joint reduction, AC
ligament fixation, and reconstruction of the
deltotrapezial fascia, with CC reconstruction if
necessary.44
Type V
Surgical treatment is generally recommended for
these types of injuries.25,45
Type VI
All type VI injuries in the literature have been
treated with surgery.46–48 Two subtypes must be
distinguished: a subacromial type with the CC lig-
aments intact and a subcoracoid type with
completely torn CC ligaments. The treatment is al-
ways operative with reduction of the distal clavicle
and AC joint stabilization.
SURGICAL TECHNIQUES
The orthopedic literature is replete with an abun-
dance of case series and comparative studies on
surgical techniques for AC joint reconstruction.
This large body of work is evidence that no sin-
gle, conclusively effective surgical technique ex-
ists. However, they all share a common goal: to
stabilize the distal clavicle. Surgical techniques
can be grouped into 3 basic categories: (1) AC
joint fixation, (2) CC fixation, and (3) ligament
reconstruction.
Acromioclavicular Joint Fixation
Many methods of intra-articular AC joint fixation
are described in the literature; however, clinicians
should be cautious when using these techniques,
because the placement of hardware across the
AC joint can be problematic. Eskola and
colleagues49 compared 3 different methods,
including transfixion with 2 smooth Kirschner
wires, 2 threaded Kirschner wires, and 1 cortical
screw. In a 4-year follow-up on 70 of the 100
cases, the results were graded as good in 67 of
70 patients. The investigators preferred the use
of the threaded Kirschner wires. This method has
been abandoned because of potentially cata-
strophic occurrence of pin migration.50,51 Another
technique of primary AC joint fixation is the hook
plate. In 1976, Balser52 first introduced this plate,
which is fixed by screws on the superior surface
of the distal clavicle end and ensures AC joint
reduction by a transarticular hook engaging at
the undersurface of the acromion. This technique
is still popular in Europe, although it requires a sec-
ond surgery for implant removal at 3 months. One
recent study of 225 patients with hook plate fixa-
tion showed 89% excellent results at a mean of
36 months, but with an overall complication rate
of 10.6%.53 The potential complications with this
 Management of AC Joint Injuries 5

technique are acromion osteolysis or fractures

caused by the subacromial hook.54 Another report
of 16 patients reported 8 complications, including
1 bent plate, 1 plate dislocation, and 6 infections.55

Coracoclavicular Fixation
The technique of placing a screw between the
clavicle and the coracoid was described by Bos-
worth56 in 1941. This surgery consists of an
open reduction of the AC joint dislocation with
the insertion of a screw from the distal clavicle to
the coracoid process. Because of the high rate
of hardware migration and screw breakage over
time, a second surgery is usually recommended
between 8 and 12 weeks postoperatively.57,58
This screw may be placed percutaneously, Fig. 2. Preoperative radiograph of type IIB distal clav-
although Tsou59 reported a 32% technical failure icle fracture; an equivalent of a CC ligament tear.
rate in 53 patients with this technique. Placement
of synthetic loops between the coracoid process
and clavicle have been described by several in- shoulder. No. 5 FiberWire fails biomechanically at
vestigators. Stam and Dawson60 and Goldberg 485N, whereas the native CC ligament complex
and colleagues46 described the use of cerclage fails at 589N, so the tensile strength of 2 strands
Dacron ligaments looped between the clavicle of FiberWire is greater than that of the native liga-
and coracoid. Morrison and Lemos61 reported ment.69 Other biomechanical studies have
12 of 14 good and excellent results when using a confirmed the strength of the fixation.70,71 The us-
synthetic loop placed through drill holes in the age of TightRope systems is promising, and these
base of the coracoid and anterior third of the procedures are able to be performed arthroscopi-
clavicle. cally or open with good preliminary results; howev-
Anatomic reconstruction techniques have er, radiographic anteroposterior instability has
recently been adopted in an effort to provide phys- been observed in up to 43% of patients.66 Venja-
iologic conditions that restore strength and stiff- kob and colleagues72 presented the longest term
ness of the normal AC joint. Some of these use follow-up of 23 patients using fixation with 2
autograft or allograft soft tissue, whereas others suture-button devices and, at 58 months postop-
use synthetics. A prosthetic device, such as the eratively, 96% remained very satisfied or satisfied
TightRope device (Arthrex, Naples, FL) can be with the procedure outcome with an average Con-
placed as a synthetic CC ligament reconstruction. stant score of 91.5, despite 8 radiographic failures.
Titanium buttons are placed on top of the clavicle
and under the coracoid and connected with a
continuous loop of no. 5 FiberWire suture (Arthrex,
Naples, FL) (Figs. 2 and 3). To ensure local CC lig-
ament healing, it is recommended that this tech-
nique only be performed within the first 3 weeks
after trauma.62 Other modifications have been
described.63–65 The first generation consisted of
a single construct, and now second-generation
techniques use 2 TightRope systems. Midterm re-
sults were recently published, with a mean Con-
stant score of 91.5 and Taft score of 10.5 points
at 24-month follow-up.66 Jensen and colleagues67
followed 26 patients for 17 months and found a
Constant score of 92.4 and Taft score of 10, with
no removal of hardware necessary. Beris and col-
leagues68 studied 12 patients at 18-month follow-
up treated with this technique and found a mean Fig. 3. Postoperative radiograph after synthetic CC lig-
Constant score of 94.8 with no significant distance ament reconstruction with a dog bone button and Fi-
in CC distances compared with the contralateral berTape sutures. (Arthrex, Naples, FL.)
6 Stucken & Cohen
Ligament Reconstruction
Weaver and Dunn73 first described the use of the
native coracoacromial (CA) ligament in the recon-
struction of AC injuries. Described in 1972 and
modified since, this procedure consists of excision
of the distal clavicle, release of the coracoacromial
ligament from its acromial attachment, and trans-
fer to the distal clavicle. The modified Weaver-
Dunn has been reported to have 75% good to
excellent results.73 However, the initial strength
of the CA ligament after transfer is only 25% of
normal, and stability in the anteroposterior plane
is not restored.74,75 Thus, the low strength of this
reconstruction can lead to recurrent subluxation
in up to 30% of cases.73,76
Current trends in ligament reconstruction
involve the use of allogenic or autogenous graft
to reconstruct the CC and AC ligaments. In cases
of delayed surgery or failed conservative manage-
ment, this open anatomic reconstruction is gaining
favor.77 First, the AC joint is relocated, and then a
tendon graft is passed around the coracoid and
through 2 clavicular tunnels (drilled in anatomic
position on the clavicle) and is fixed with interfer-
ence screws (Fig. 4). The remaining longer limb
exiting the lateral tunnel is then used to reconstruct
the posterior and superior AC ligaments. The del-
totrapezial fascia is then carefully reattached
over the AC joint. This reconstruction attempts to
anatomically recreate both CC ligaments as well
as the AC ligament. Biomechanical studies have
shown this to more closely approximate the stiff-
ness of the native CC ligaments than does a stan-
dard Weaver-Dunn repair.78,79 Other techniques
call for the insertion of a second free tendon graft
for the reconstruction of the AC ligaments.80,81 De-
Berardino and colleagues82 described a new ar-
throscopically assisted reconstruction technique
Fig. 4. Postoperative radiograph following CC ligamen-
tous reconstruction. Note the 2 clavicular tunnels.
using the GraftRope system (Arthrex, Naples, FL)
to replace the ruptured CC ligaments with a soft
tissue graft protected by a subcoracoid button,
nonabsorbable sutures, and a special clavicular
washer. Others have modified this technique with
good results.83 However, Cook and colleagues84
reported a 28% failure rate at 7 weeks, attributing
their failures to medial clavicular tunnel placement.
The learning curves for these anatomic recon-
structions are steep, because the coracoid and
clavicular bone is thin and prone to fracture. A
study by Milewski and colleagues85 found both
coracoid fractures (7%) and clavicle fractures
(11%) in their 27 patient cohort. Although prom-
ising, the anatomic reconstruction of high-grade
AC separations should be undertaken with
caution, and further long-term evaluation is
necessary.
POSTOPERATIVE CARE
In the literature, there is a broad spectrum of post-
operative care ranging from early unrestricted mo-
tion86 to early active mobilization after 2 to 3 days87
to passive motion up to 90 with immobilization in a
sling.37 Gravity creates a continuous stress to the
CC and AC ligaments, thus protection of the AC
joint repair in the immediate postoperative period
is recommended. After anatomic reconstruction,
the arm is maintained in a simple sling, and
pendulum exercises are initiated at 2 weeks, fol-
lowed by light activities at 4 weeks. Active range
of motion is encouraged at 6 to 8 weeks with resis-
tance initiated at 12 weeks. Return to sports and
manual labor are permitted only after full range of
motion and strength are obtained.
COMPLICATIONS
Complications may occur as a result of nonopera-
tive as well as operative treatment. Patients with
type I and II AC joint injuries may develop late degen-
erative changes and instability.88,89 Note that these
patients should not be treated with isolated distal
clavicle excision, because this just shortens the
clavicle without stabilizing it; distal clavicle excision
should be combined with a stabilization procedure.
Complications following surgical treatment are
related to the chosen technique. Many different
techniques have been described, and there are
complications for each; while the gold standard for
treatment is awaited, clinicians do their best to
optimize outcomes while minimizing risk.
SUMMARY
Although recent advances have been made in the
treatment of AC joint injuries, they still represent a

diagnostic and therapeutic challenge for shoulder
surgeons. There is a consensus that type I and II
injuries should be treated nonoperatively,
whereas acute type IV, V, and VI injuries should
be treated surgically. There is no algorithm for
correctly diagnosing and treating type III injuries,
but, for the average patient, the current trend is
toward nonoperative treatment except for those
with persistent symptoms and functional limita-
tions after a course of conservative management.
As surgical techniques continue to evolve, nonop-
erative management may provide similar func-
tional outcomes with fewer complications. If
surgery is indicated, newer anatomic techniques
of reconstructing the CC and AC ligaments are
recommended, either with soft tissue or synthetic
grafts.
REFERENCES
1. Kaplan LD, Flanigan DC, Norwig J, et al. Preva-
lence and variation of shoulder injuries in elite col-
legiate football players. Am J Sports Med 2005;33:
1142–6.
2. Thorndike AJ. Injuries to the acromioclavicular
joint: a plea for conservative management. Am J
Surg 1942;55:250–61.
3. Pallis M, Cameron KL, Svoboda SJ, et al. Epidemi-
ology of acromioclavicular joint injury in young ath-
letes. Am J Sports Med 2012;40:2072–7.
4. Dragoo JL, Braum HJ, Bartlinski SE, et al. Acromio-
clavicular joint injuries in National Collegiate Athletic
Association football: data from the 2004-2005
through 2008-2009 National Collegiate Athletic As-
sociation injury surveillance system. Am J Sports
Med 2012;40:2066–71.
5. Stine IA, Vangsness CT Jr. Analysis of the capsule
and ligament insertions about the acromioclavicu-
lar joint: a cadaveric study. Arthroscopy 2009;
25(9):968–74.
6. DePalma AF. The role of the discs of the sternocla-
vicular and acromioclavicular joints. Clin Orthop
Relat Res 1959;13:7–12.
7. Fukuda K, Craig EV, An KN, et al. Biomechanical
study of the ligamentous system of the acromiocla-
vicular joint. J Bone Joint Surg Am 1986;68:434–40.
8. Debski RE, Parsons IM 4th, Woo SL, et al. Effect of
capsular injury on acromioclavicular joint me-
chanics. J Bone Joint Surg Am 2001;83A(9):
1344–51.
9. Klimkiewics JJ, Williams GR, Sher JS, et al. The
acromioclavicular capsule as a restraint to poste-
rior translation of the clavicle: a biomechanical
analysis. J Shoulder Elbow Surg 1999;8:119–24.
10. Corteen DP, Teitge RA. Stabilization of the clavicle
after distal resection: a biomechanical study. Am
J Sports Med 2005;3:61–7.
Management of AC Joint Injuries 7
11. Renfree KJ, Wright TW. Anatomy and biome-
chanics of the acromioclavicular and sternoclavic-
ular joints. Clin Sports Med 2003;22:219–37.
12. Rios CG, Arciero RA, Mazzocca AD. Anatomy of
the clavicle and coracoid process for reconstruc-
tion of the coracoclavicular ligaments. Am J Sports
Med 2007;35:811–7.
13. Mazzocca AD, Sprang JT, Rodriguez RR, et al.
Biomechanical and radiographic analysis of partial
coracoclavicular ligament injuries. Am J Sports
Med 2008;36:1397–402.
14. Takase K. The coracoclavicular ligaments: an
anatomic study. Surg Radiol Anat 2010;32:683–8.
15. Salzmann GM, Paul J, Sandmann GH, et al. The
coracoidal insertion of the coracoclavicular liga-
ments: an anatomic study. Am J Sports Med
2008;36:2392–7.
16. Inman VT, Saunders JB, Abbott LC. Observations
of the function of the shoulder joint: 1944. Clin Or-
thop Relat Res 1996;330:3–12.
17. Graichen H, Stammberger T, Bonel H, et al. Mag-
netic resonance-based motion analysis of the
shoulder during elevation. Clin Orthop Relat Res
2000;370:154–63.
18. Flatow EL. The biomechanics of the acromioclavic-
ular, sternoclavicular, and scapulothoracic joints.
Instr Course Lect 1993;42:237–45.
19. Bearn JG. Direct observations on the function of
the capsule of the sternoclavicular joint in clavic-
ular support. J Anat 1967;101:159–70.
20. Tossy JD, Mead NC, Sigmond HM. Acromioclavicu-
lar separations: useful and practical classification
for treatment. Clin Orthop Relat Res 1963;28:111–9.
21. Williams GR, Nguyen VD, Rockwood CR. Classifi-
cation and radiographic analysis of acromioclavic-
ular dislocations. Appl Radiol 1989;12:29–34.
22. Gerber C, Rockwood CA. Subcoracoid dislocation
of the lateral end of the clavicle: a report of three
cases. J Bone Joint Surg Am 1987;69A:924–7.
23. Yap JJ, Curl LA, Kvitne RS, et al. The value of
weighted views of the acromioclavicular joint: re-
sults of a survey. Am J Sports Med 1992;27(6):
806–9.
24. Bossart PJ, Joyce SM, Manaster BJ, et al. Lack of
efficacy of “weighted” radiographs in diagnosing
acute acromioclavicular separation. Ann Emerg
Med 1988;17(1):20–4.
25. Galatz LM, Hollis RJ Jr, Williams GR Jr. Acromiocla-
vicular joint injuries. In: Bucholz RW, Hechman JD,
Court-Brown CM, et al, editors. Rockwood and
green’s fractures in adults. 7th edition. Philadel-
phia: Lippincott Williams & Wilkins; 2010. p. 1224.
26. Tauber M, Gordon K, Koller H, et al. Semitendino-
sus tendon graft versus a modified Weaver-Dunn
procedure for acromioclavicular joint reconstruc-
tion in chronic cases: a prospective comparative
study. Am J Sports Med 2009;37:181–90.
8 Stucken & Cohen
27. Bontempo NA, Mazzocca AD. Biomechanics and
treatment of acromioclavicular and sternoclavicular
joint injuries. Br J Sports Med 2010;33:361–9.
28. Tamaoki MJ, Belloti JC, Lenza M, et al. Surgical
versus conservative interventions for treating acro-
mioclavicular dislocation of the shoulder in adults.
Cochrane Database Syst Rev 2010;(8):CD007429.
29. Powers JA, Bach PJ. Acromioclavicular separation:
closed or open treatment. Clin Orthop Relat Res
1974;104:213–33.
30. Cox JS. Acromioclavicular joint injuries and their
management principles. Ann Chir Gynaecol 1991;
80:155–9.
31. Cox JS. Current method of treatment of acromiocla-
vicular joint dislocations. Orthopedics 1992;15:
1041–4.
32. Larsen E, Bjerg-Nielsen A, Christensen P. Conser-
vative or surgical treatment of acromioclavicular
dislocation. A prospective, controlled, random-
ized study. J Bone Joint Surg Am 1986;68A:
552–5.
33. Bannister GC, Wallace WA, Stableforth PG, et al.
The management of acute acromioclavicular dislo-
cation. A randomized prospective controlled trial.
J Bone Joint Surg Br 1989;71B:848–50.
34. Trainer G, Arciero RA, Mazzocca AD. Practical
management of grade III acromioclavicular sepa-
rations. Clin J Sport Med 2008;18:162–6.
35. Murena L, Canton G, Vulcano E, et al. Scapular
dyskinesis and SICK scapula syndrome following
surgical treatment of type III acute acromioclavicu-
lar dislocations. Knee Surg Sports Traumatol Ar-
throsc 2013;21(5):1146–50.
36. Smith TO, Chester R, Pearse EO, et al. Operative
versus non-operative management following Rock-
wood grade III acromioclavicular separation: a
meta-analysis of the current evidence base.
J Orthop Trauma 2011;12(1):19–27.
37. Gstettner C, Tauber M, Hitzl W, et al. Rockwood
type III acromioclavicular dislocation: surgical
versus conservative management. J Shoulder
Elbow Surg 2008;17:220–5.
38. Phillips AM, Smart C, Groom AF. Acromioclavicular
dislocation. Conservative or surgical therapy. Clin
Orthop Relat Res 1998;353:10–7.
39. Beitzel KB, Cote MP, Apostolakos J, et al. Current
concepts in the treatment of acromioclavicular joint
dislocations. Arthroscopy 2013;29(2):387–97.
40. Echo BS, Donati RB, Powell CE. Bipolar clavicular
dislocation treated surgically. A case report.
J Bone Joint Surg Am 1988;70(8):1251–3.
41. Hastings DE, Horne JG. Anterior dislocation of the
acromioclavicular joint. Injury 1979;10(4):285–8.
42. Malcapi C, Grassi G, Oretti D. Posterior dislocation
of the acromio-clavicular joint: a rare or an easily
overlooked lesion? Ital J Orthop Traumatol 1978;
4(1):79–83.
43. Sondergard-Petersen P, Mikkelsen P. Posterior
acromioclavicular dislocation. J Bone Joint Surg
Br 1982;64(1):52–3.
44. Tauber M. Management of acute acromioclavicular
joint dislocations: current concepts. Arch Orthop
Trauma Surg 2013;133(7):985–95.
45. Collins DN. Disorders of the acromioclavicular joint.
In: Rockwood CA, Wirth MA, Lippit SA, editors. The
shoulder. 4th edition. Philadelphia: Saunders;
2009. p. 453–526.
46. Goldberg JA, Viglione W, Cumming WJ, et al. Re-
view of coracoclavicular ligament reconstruction
using Dacron graft material. Aust N Z J Surg
1987;57:441–5.
47. McPhee IB. Inferior dislocation of the outer end of
the clavicle. J Trauma 1980;20:709–10.
48. Sage J. Recurrent inferior dislocation of the clavicle
at the acromioclavicular joint. Am J Sports Med
1982;10:145–6.
49. Eskola A, Vainionpaa S, Korkala O, et al. Acute
complete acromioclavicular dislocation. A pro-
spective randomized trial of fixation with smooth
or threaded Kirschner wires or cortical screw.
Ann Chir Gynaecol 1987;76:323–6.
50. Norrell H Jr, Llewellyn RC. Migration of a threaded
Steinmann pin from an acromioclavicular joint into
the spinal canal: a case report. J Bone Joint Surg
Am 1965;47:1024–6.
51. Sethi GK, Scott SM. Subclavian artery laceration
due to migration of a Hagie pin. Surgery 1976;80:
644–6.
52. Balser D. Eine neue. Moethode zur operative Be-
handlung der akromioklavikularen Luxation. Chir
Prax 1976;24:275.
53. Kienast B, Thietje R, Queitsch C, et al. Mid-term
results after operative treatment of Rockwood
grade III-V acromioclavicular joint dislocations
with an AC-hook-plate. Eur J Med Res 2011;
16(2):52–6.
54. Chiang CL, Yang SW, Tsai MY, et al. Acromion os-
teolysis and fracture after hook plate fixation for
acromioclavicular joint dislocation: a case report.
J Shoulder Elbow Surg 2010;19(4):e13–5.
55. Sim E, Schwarz N, Hocker K, et al. Repair of com-
plete acromioclavicular separations using the
acromioclavicular-hook plate. Clin Orthop Relat
Res 1995;314:134–42.
56. Bosworth BM. Acromioclavicular separation: new
method of repair. Surg Gynecol Obstet 1941;73:
866–71.
57. Iannotti J, Williams G Jr. Disorders of the shoul-
der: diagnosis and management. 2nd edition.
Philadelphia: Lippincott Williams & Wilkins; 2007.
p. 979–1006.
58. Kwon YM, Iannotti JP. Operative treatment of acro-
mioclavicular joint injuries and results. Clin Sports
Med 2003;22(2):291–300.

59. Tsou PM. Percutaneous cannulated screw coraco-
clavicular fixation for acute acromioclavicular dislo-
cations. Clin Orthop Relat Res 1989;243:112–21.
60. Stam L, Dawson I. Complete acromioclavicular dis-
locations: treatment with a Dacron ligament. Injury
1991;22:173–6.
61. Morrison DS, Lemos MJ. Acromioclavicular sepa-
ration. Reconstruction using synthetic loop
augmentation. Am J Sports Med 1995;23:105–10.
62. Salzmann GM, Walz L, Buchmann S, et al. Arthro-
scopically assisted 2-bundle anatomical reduction
of acute acromioclavicular joint separations. Am J
Sports Med 2010;38(6):1179–87.
63. Murena L, Vulcano E, Ratti C, et al. Arthroscopic
treatment of acute acromioclavicular joint disloca-
tion with double flip button. Knee Surg Sports Trau-
matol Arthrosc 2009;17(12):1511–5.
64. Petersen W, Wellmann M, Rosslenbroich S, et al.
Minimally invasive acromioclavicular joint recon-
struction (MINAR). Oper Orthop Traumatol 2010;
22(1):52–6.
65. Wei HF, Chen YF, Zeng BF. Triple endobutton tech-
nique for the treatment of acute complete acromio-
clavicular joint dislocations: preliminary results. Int
Orthop 2011;35(4):555–9.
66. Scheibel M, Droschel S, Gerhardt C, et al. Arthro-
scopically assisted stabilization of acute high-
grade acromioclavicular joint separations. Am J
Sports Med 2011;39(7):1507–16.
67. Jensen G, Katthagen JC, Alvarado LE. Has the ar-
throscopically assisted reduction of acute AC joint
separations with double tight-rope technique advan-
tages over the clavicular hook plate fixation? Knee
Surg Sports Traumatol Arthrosc 2014;22(2):422–30.
68. Beris A, Lykissas M, Kostas-Agnantis I, et al. Man-
agement of acute acromioclavicular joint disloca-
tion with a double button fixation system. Injury
2013;44(3):288–92.
69. Imhoff AB, Chernchujit B. Arthroscopic anatomic
stabilization of acromioclavicular joint dislocation.
Oper Tech Sports Med 2004;12:43–8.
70. Walz L, Salzmann GM, Fabbro T, et al. The anatomic
reconstruction of acromioclavicular joint disloca-
tions using 2 TightRope devices: a biomechanical
study. Am J Sports Med 2008;36:2398–406.
71. Ladermann A, Gueorguiev B, Stimec B, et al. Acromio-
clavicular joint reconstruction: a comparative biome-
chanical study of three techniques. J Shoulder
Elbow Surg 2013;22(2):171–8.
72. Venjakob AJ, Salzmann GM, Gabel F, et al. Arthro-
scopically assisted 2-bundle anatomic reduction of
acute acromioclavicular joint separations. 58-month
findings. Am J Sports Med 2013;41(3):615–21.
73. Weaver JK, Dunn HK. Treatment of acromioclavic-
ular injuries, especially complete acromioclavicular
separation. J Bone Joint Surg Am 1972;54(6):
1187–94.
Management of AC Joint Injuries 9
74. Harris RI, Wallace AL, Harper GD, et al. Structural
properties of the intact and the reconstructed cora-
coclavicular ligament complex. Am J Sports Med
2000;28(1):103–8.
75. Lee SJ, Nicholas SJ, Akizuki KH, et al. Reconstruc-
tion of the coracoclavicular ligaments with tendon
grafts: a comparative biomechanical study. Am J
Sports Med 2003;31(5):648–55.
76. Weinstein DM, McCann PD, McIlveen SJ, et al. Sur-
gical treatment of complete acromioclavicular dis-
locations. Am J Sports Med 1995;23(3):324–31.
77. Carofino BC, Mazzocca AD. The anatomic coraco-
clavicular ligament reconstruction: surgical tech-
nique and indications. J Shoulder Elbow Surg
2010;19:37–46.
78. Costic RS, Labriola JE, Rodosky MW, et al. Biome-
chanical rationale for development of anatomical
reconstructions of coracoclavicular ligaments after
complete acromioclavicular joint dislocations. Am J
Sports Med 2004;32(8):1929–36.
79. Michlitsch MG, Adamson GJ, Pink M, et al. Biome-
chanical comparison of a modified Weaver-Dunn
and a free-tissue graft reconstruction of the acro-
mioclavicular joint complex. Am J Sports Med
2010;38:1196–203.
80. Freedman JA, Adamson GJ, Bui C, et al. Biome-
chanical evaluation of the acromioclavicular
capsular ligaments and reconstruction with an in-
tramedullary free tissue graft. Am J Sports Med
2010;38:958–64.
81. Gonzalez-Lomas G, Javidan P, Lin T, et al. Intrame-
dullary acromioclavicular ligament reconstruction
strengthens isolated coracoclavicular ligament
reconstruction in acromioclavicular dislocations.
Am J Sports Med 2010;38:2113–22.
82. DeBerardino TM, Pensak MJ, Ferreira J, et al.
Arthroscopic stabilization of the acromioclavicular
joint using the AC graftrope system. J Shoulder
Elbow Surg 2010;19(Suppl 2):47–52.
83. Jensen G, Katthagen JC, Alvarado L, et al. Arthro-
scopically assisted stabilization of chronic AC-joint
instabilities in GraftRope technique with an additive
horizontal tendon augmentation. Arch Orthop
Trauma Surg 2013;133(6):841–51.
84. Cook JB, Shaha JS, Rowles DJ, et al. Clavicular
bone tunnel malposition leads to early failures in
coracoclavicular ligament reconstructions. Am J
Sports Med 2013;41(1):142–8.
85. Milewski MD, Tompkins M, Giugale JM, et al. Com-
plications related to anatomic reconstruction of the
coracoclavicular ligaments. Am J Sports Med
2012;40(7):1628–34.
86. DiFrancesco A, Zoccali C, Colafarina O, et al. The
use of hook plate in type III and V acromioclavicular
Rockwood dislocations: clinical and radiological
midterm results and MRI evaluation in 42 patients.
Injury 2012;43(2):147–52.
10 Stucken & Cohen
87. Salem KH, Schmelz A. Treatment of Tossy III acro-
mioclavicular joint injuries using hook plates and
ligament suture. J Orthop Trauma 2009;23(8):
565–9.
88. Bergfeld JA, Andrish JT, Clancy WG. Evaluation of
the acromioclavicular joint following first and
second-degree sprains. Am J Sports Med 1978;
6:153–9.
89. Moushine E, Garofalo R, Crevoisier X, et al. Grade I
and II acromioclavicular dislocations: results of
conservative treatment. J Shoulder Elbow Surg
2003;12(6):599–602.