Eur J Orthop Surg Traumatol (2014) 24:237–242
DOI 10.1007/s00590-013-1186-1
TECHNICAL NOTE
Acromio-clavicular repair using two different techniques
Lorenzo Andreani • Enrico Bonicoli • Paolo Parchi
Nicola Piolanti • Lisanti Michele
Received: 16 January 2013 / Accepted: 4 February 2013 / Published online: 13 February 2013
Ó Springer-Verlag France 2013
Abstract Acromio-clavicular joint (ACJ) injuries repre-
sent nearly half of all athletic shoulder injuries. Stability of
this joint depends on the integrity of the acromio-clavicular
and coracoclavicular ligaments. Although the traumatic
acromioclavicular joint separation is a well-known topic,
there are different classifications, diagnostic procedures,
concepts of intervention, and a great variety of implants. In
this paper, we present an overview of the recent literature
about this issue and the results of a retrospective non-
randomized study with 2 different techniques. At the first
Orthopedic Department of University of Pisa, a retrospec-
tive study was performed starting from January 2007 to
February 2011 in our electronic database. We selected
patient treated with two different techniques (tight-ropeÒ
system and hook plate) by the same senior surgeon with
experience in shoulder surgery. The mean Costant score
was 90 for the tight-ropeÒ system group and 75 for the
hook plate group. At the final follow-up, most of the
patients had returned to their preinjury level of activity.
Two patients had a breakage of the fixating system. The
above-mentioned techniques provided satisfactory results
with no loss of reduction except in two cases. The use of
L. Andreani (&)
E. Bonicoli
P. Parchi
N. Piolanti

L. Michele
Orthopedics and Tramatology I Department, University of Pisa,
via Paradisa 2, 56121 Pisa, Italy
e-mail: l.andreani@hotmail.it
E. Bonicoli
e-mail: enrico.bonicoli@libero.it
P. Parchi
e-mail: parchip@tiscali.it
N. Piolanti
e-mail: nicpio@hotmail.it
L. Michele
e-mail: michele.lisanti@tin.it
•
the hook plate is useful in fracture-dislocation of ACJ, but
this requires another surgery to remove it. On the contrary,
the use of the tight-ropeÒ system does not require a new
surgery or use of expensive synthetic graft or a graft har-
vested from a distant donor site.
Keywords AC joint
Surgery
Technique
Results

Sports injury
Shoulder trauma
Introduction
The acromio-clavicular joint (ACJ) is a robust articulation
that anchors the scapula and the upper extremity of the
clavicle. Even if ACJ injuries represent most of the athletic
shoulder injuries, the true incidence of ACJ injuries is
likely underestimated [1]. Most are minor sprains, with
incidence of subluxations approximately twice as high as
those of dislocations. However, they occur five times more
frequently in men than in women, with the highest inci-
dence in the 20–30 years age group [2].
Depending on the grade of the injury, the treatment
options range from non-surgical measures allowing quick
return to athletic activity to various forms of surgical
reconstruction of the joint. This article reviews the anatomy
and biomechanics of the ACJ and describes the evaluation,
diagnosis, non-surgical and surgical treatment of various
injuries involving the joint adding our experience.
The ACJ is a diarthrodial articulation between the lateral
end of the clavicle and the medial end of acromion. Both
static and dynamic stabilizers ensure the stability of the
ACJ. The static stabilizers include the ACJ capsule rein-
forced with the AC ligaments and the coracoclavicular
(CC) ligaments The CC ligaments include the conoid lig-
ament medially and the trapezoid ligament laterally, both
of which provide vertical stability by preventing superior
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and inferior displacement of the clavicle [3, 4]. Complete
sectioning of the CC ligaments is necessary for complete
ACJ dislocation with either superior or inferior displace-
ment of the entire scapulohumeral complex.
AC injuries are most commonly the result of direct
trauma. For the athlete, the injury is usually due to a direct
hit, either by another player or by contact with the ground
[5]. Direct injury is the consequence of a direct force on the
acromion with the shoulder adducted, resulting in move-
ment of the acromion while the clavicle remains stabilized
by the sterno-clavicular ligaments. The severity of injury is
determined by the magnitude of the force.
Different classification systems are in use: Allman,
Tossy, and the most widely accepted is the Rockwood
system which puts in six different degrees (1990s) [6, 7].
Surgical treatment is advocated for types IV, V, and VI and
in some cases type III where there is complete ACJ dis-
location. Since the first reported procedure for ACJ repair
by Cooper in 1861 [8], numerous techniques have been
used to treat AC dislocation. The techniques have tended to
fall into five groups: primary fixation of the ACJ, second-
ary stabilization linking the distal clavicle and the corac-
oids, distal clavicle excision, dynamic stabilization or
combined approach. Despite such attention, the lack of a
dominant procedure suggests that the ideal repair is yet to
be found [9]. Timing from the trauma seems to be funda-
mental for achieving better [10]. Our experience involves
primary fixation of the ACJ using two different techniques.
Materials and methods
This retrospective comparative study was approved by the
local institutional review board and all patients gave
written informed consent.
Between January 2007 and February 2011, twenty-eight
consecutive cases of acute ACJ dissociation were assessed
in our trauma center. All patients had type IV, V, or VI
ACJ injuries according to Rockwood classification; sur-
geries were performed within a maximum of 3 weeks of
injury by the same experience surgeon. We did not con-
sider grade I to III because we believe, according to the
majority of the literature, that in this case, the conservative
management is the treatment of choice. Injuries occurred
predominantly during sporting activities: cycling/moto-
cycling (n = 12), team sports (n = 10), alpine sports
(n = 2), other trauma (n = 4). Injury mechanism was a
direct trauma to shoulder (n = 24) or an indirect trauma to
the elevated arm (n = 4). All patients gave their written
consent before undergoing the surgery. Inclusion criteria
were as follows: acute lesion (\3 weeks after trauma),
high-grade ACJ injury Rockwood type IV to VI, patients
age [18, and monotrauma. The exclusion criteria were:
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Eur J Orthop Surg Traumatol (2014) 24:237–242
chronic ACJ separations, previous ACJ injuries, and a
disease process that would preclude accurate evaluation
(e.g., neuromuscular, rheumatic, significant psychiatric, or
metabolic disorders). There were 22 men and 6 women.
The average age at the time of surgery was 32.3 (range
19–60) years. The duration between the time of injury and
the date of surgery varied between 2 and 21 days, with an
average of 7.2 days. The non-dominant side was affected
in 8 cases. Sixteen patients were injured while participating
in sports. Injuries were documented by preoperative plain
X-rays of the affected shoulder in the anteroposterior (AP)
standing, axillary views, and AP in stress mode. The AP
view was obtained with a 50 % decrease in penetrance with
the X-ray beam tilted cephalad by 10°–15°. The decrease in
penetrance prevents overexposure, and the 15° cephalic tilt
helps to remove the scapula from being superimposed onto
the acromioclavicular joint. The axillary radiograph helps
to show the position of the clavicle relative to the acro-
mion. The stress-mode AP radiographs were obtained with
a 10-kg weight suspended from the affected arm with wrist
straps (Fig. 1). The degree of displacement of the ACJ was
evaluated and compared with the contralateral side. The
coracoclavicular distance was measured in each side and
the increase of height on the operated side was compared to
the unaffected side and calculated in percent. Ossifications
were classified as absent, minor, or major; minor ossifica-
tions represented spots or small ossicles located in the
coracoclavicular ligaments, whereas major ossifications
were considered as almost complete bridging between the
clavicle and the coracoid process. Patients were pre- and
postoperatively evaluated using the University of Califor-
nia Los Angeles (UCLA) and Costant scoring systems. In
Table 1 is summarized the classification of our case series
according to Rockwood.
Nineteen patients were treated with the tight-ropeÒ
system (ArthrexTM, Naples, Florida) and 9 patients using
hook plate (SynthesTM, Bettlach, Switzerland). The tight-
ropeÒ system is a device that consists in two buttons, one
round clavicle button and one oblong coracoid button.
The buttons are joined by a continuous loop of 5-0
FiberWireÒ. The clavicle is drilled, the system is passed
through it and then is opened (Fig. 2). We added 2 K-
wires when we used the tight-ropeÒ system that we left in
place for just 3 weeks. The hook plate was used to fix
ACJ dislocation and distal clavicular fracture; then, a
second surgery was performed in 3 cases to remove the
plate following patient request without loosening of
reduction. The hook plate is positioned through a standard
surgical incision; we perform temporary fixation of the
fracture using bone-holding forceps. The shaft of the plate
is fixed onto the superior aspect of the clavicle and the
end of the hook is in contact with the underside of the
acromion. We are used to perform a ligament and capsule
Eur J Orthop Surg Traumatol (2014) 24:237–242
Fig. 1 a Standard X-ray,
b stress mode X-ray
Table 1 Rockwood classification
IV grade V grade VI grade
4/28 (14.28 %) 18/28 (64.28 %) 6/28 (21.42 %)
reconstruction with a PDS suture wire (Fig. 3). To eval-
uate the results of reduction of the AC joint after surgery,
we analyzed the anteroposterior radiographs. The vertical
distance of the inferior border of the acromion and the
clavicle was measured and categorized into 4 groups:
anatomic: \2 mm, slight loss of reduction: 2–4 mm,
partial loss of reduction: 4–8 mm, dislocation [8 mm for
clinical evaluation of the horizontal stability of the AC
joint; the lateral clavicle was fixed between the fingers of
one hand of the examiner, while the other fixed the
acromion. The extent of dorsal shift of the lateral clavicle
against the acromion was evaluated and differentiated into
horizontal stable or unstable [11].
The average follow-up was 24 (range 48–6) months; we
performed radiological, clinical, and functional evaluation.
In the postoperative care, 26 patients were placed in an
arm-pouch sling for 3 weeks during which light use of the
hand and only passive motion up to a flexion and abduction
of 45° were allowed. From the 4th week, patients per-
formed active-assistive motions up to a flexion and
abduction of 45°–60° in week 5 and 6. From the 7th week,
a free motion was allowed. Only 2 patients were placed in a
Desault bandage for 4 weeks. The sport activities were not
allowed for 2 months.
This study was conducted according to the principles
established in Helsinki conference.
239
Results
A limitation of this study is that these two groups cannot be
statistically compared.
All of our patients could be reviewed and examined
during the follow-up study. Participants were examined at
least at 3 weeks and at 3 months. The follow-up evaluations
were performed in a standardized fashion by two indepen-
dent examiners. Clinical assessment consisted of a struc-
tured interview including evaluation of patient’s
satisfaction, two scales for functional results, and a physical
examination. The mean Costant score was 90 (range 74–99)
for the tight-ropeÒ system group while for the hook plate
group was 75 (range 65–85). Results according to the
UCLA score showed a significant improvement in pain,
function, active forward elevation, strength of forward
flexion, and patient satisfaction. The mean total score
improved from 52 to 95 in the tight-ropeÒ system group,
while in the hook plate group, it was from 33 to 80. Most of
the patients returned to their preinjury activity level, but we
have to underline that we observed two cases of breakage of
the tight-ropeÒ system without any significant new trauma.
Postoperative radiographs confirmed anatomic reduction in
18 patients and residual asymptomatic slight loss of
reduction in 8 patients. None showed deltoid atrophy or
detachment, and none suffered of pain or paresthesia over
the clavicular buttons. One patient had hypertrophic scars.
In the investigated patients, there were no clinical signs
indicating rotator cuff disease, impingement syndrome, or
other concomitant pathologies of the shoulder joint.
In the patient with the longest follow-up (10 case
with more than 36 months of F-U), the coracoclavicular
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Fig. 2 a–c Technical steps of tight-ropeÒ system, d, e pre- and postoperative X-ray, f 1 month X-ray control
calcifications have appeared in a low percentage of cases,
but showed no correlation to our clinical results. Two
patients developed at 2 years postoperatively roentgeno-
graphic evidence of asymptomatic AC arthritis.
Discussion
Injuries to the ACJ are among the most commonly occur-
ring problems in the athletic population. However, the
choice of the best operative technique for the treatment of
the ACJ dislocation is a controversial issue. Studies pub-
lished over the past three decades remain inconclusive in
establishing the ideal method of acromioclavicular joint
surgery [11, 12]. Reviewing the literature, there are over
100 operative methods to reconstruct the ACJ. However,
never anatomic techniques are being adopted to reduce
complication and improve the outcome by using both
biological [13] and artificial tissue for treatment [14, 15].
The treatment for grade I and II is certain to be non-
operative, as it is for acute, uncomplicated, grade III ACJ
dislocation [16]. Indeed, comparative studies have reported
similar results for conservative and surgical treatment, and
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Eur J Orthop Surg Traumatol (2014) 24:237–242
meta-analysis failed to find any significant benefit in a
surgical approach. Moreover, the incidence of complica-
tions in terms of infection, revision surgery, osteoarthritis,
and unsightly scars is clearly higher in surgically treated
patients [17, 18]. Our personal approach is to treat a type
III AC injury conservatively, with surgical stabilization
considered only if the athlete specifically requests it. One
of the most important factors seems to be the timing of
surgery. In fact, acute reduction of the AC joint is easier
when surgery is performed within the first 2–3 weeks after
injury. Early repair of acute ACJ dislocation provides
overall good clinical results independent of the surgical
method [19].
The use of the tight-ropeÒ system is quite easy and is
minimal invasive both in arthroscopic than in open tech-
nique. Obviously, the reduction must be anatomic and the
meniscus must be reduced in the right place. We are used
to adding 2 K-wire trans acromion-clavicle left in place for
3 weeks to reach a better fixation and to allow a better
healing and scaring of residual ligaments.
Sometimes an osteolysis area around the clavicle and/or
coracoidal buttons can be observed, but most of the time it
is asymptomatic. Using this system, we were able to reach
Eur J Orthop Surg Traumatol (2014) 24:237–242
Fig. 3 a Fracture-dislocation of ACJ, b, c intraoperative images of hook plate, d postoperative X-ray
Fig. 4 a Postoperative X-ray,
b 1 month X-ray control
showing rupture of tight-ropeÒ
system
a good reduction in most of the patients, but we have to
underline the fact that in 2 cases, we have the breakage of
the implant without any significant new trauma. These
failures were probably caused by an initial poor reduction,
deficient reconstruction of the deltotrapezoidal fascia, cla-
vicular movement, and inadequate healing of the injured
ligaments (Fig. 4).
The hook plate is useful in case of fracture of clavicle
and dislocation of ACJ. The main concern using the hook
241
plate is the subacromial impingement, but some studies,
like in our, did not find this complication [20, 21]. Once the
fracture has healed, it is possible but not mandatory to
remove the hook plate. We performed it in 3 cases, and we
did not found any loss of reduction as instead was descri-
bed by Scheibel et al. [22].
This study showed a high level of patient satisfaction; the
difference between the two groups must probably be added
to the fact that we used the hook plate for the worst case.
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Conclusions
The ACJ injuries are very frequent. The damage must be
identified using the Rockwood classification, while the
surgical approach for type IV, V, VI must be performed
within 3 weeks after injury. Further investigations with an
increased sample size, identical follow-up periods, and a
prospective study design are required to answer the ques-
tion which technique is superior. The surgeon should
choose the techniques which he/she knows better and feels
much more self-confident at.
Conflict of interest No benefits or funds were received in support
of this study. None of the authors has any conflict of interest to
disclose.
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