J Shoulder Elbow Surg (2010) 19, 37-46

www.elsevier.com/locate/ymse

The anatomic coracoclavicular ligament reconstruction:

Surgical technique and indications
Brad C. Carofino, MD*, Augustus D. Mazzocca, MS, MD

Department of Orthopaedic Surgery, University of Connecticut Health Center, New England Musculoskeletal Institute,
Farmington, CT

The anatomic coracoclavicular ligament reconstruction (ACCR) is a surgical procedure to address acrio-
mioclavicular joint instability. The coracoclavicular ligaments are reconstructed using a semitendinosus
allograft passed beneath the coracoid and through bone tunnels in the clavicle. The graft is secured
with interference screw fixation, and the acromioclavicular joint is retained. Here we describe the authors’
surgical technique, indications, and rehabilitation protocol. Also, a preliminary case series of seventeen
patients is presented. Patients demonstrated significant improvement in pain levels and function.
The mean ASES score increased from 52 preoperatively to 92. The Constant Murley rose from 66.6 to
94.7. There were three failures in this series, and two required revision surgery.
Level of Evidence: Review Article.
Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.

Acromioclavicular (AC) joint injuries are amongst the
most common traumatic conditions affecting the shoulder
girdle. A recent study reported that these are the third most
common injuries affecting Division I NCAA hockey
players.22 Most patients will achieve an acceptable result;
however, some experience significant disability which
impairs their ability to work and return to sports. Despite
the frequency of these injuries, many aspects of their
treatment remain unresolved. There is variability in oper-
ative indications, surgical techniques, nonoperative
management, and rehabilitation protocols.
Here, we present the University of Connecticut treat-
ment protocol for AC separations, with a particular
emphasis on the surgical technique for the anatomic cor-
acoclavicular ligament reconstruction (ACCR). The
anatomy and biomechanics of the AC joint, as they pertain
*Reprint requests: Brad C. Carofino, MD, University of Connecticut
Health Center, Department of Orthopaedic Surgery, 263 Farmington
Avenue, Farmington, CT 06030.
to the surgical technique, is reviewed. Surgical indications
and nonoperative treatment strategies are also described.
History
In an effort to understand modern treatments, it is important
to study what has been done in the past. Surgical treatment of
AC separations has been performed since 1861, when Cooper
reduced and secured the joint with silver wire.14 To date, over
60 surgical procedures have been described to treat AC
separations, which reflects a general dissatisfaction with
treatment options. Many of the early techniques relied on
metallic implants to maintain their reduction. In 1940,
Murray transfixed the AC joint with kirschner wires.39 The
following year, Bosworth famously used a percutaneously
inserted coracoclavicular (CC) screw and some Soviet
authors even employed external fixators.3,6 Unfortunately,
these techniques were often associated with hardware related
complications that required implant removal.

1058-2746/2010/$36.00 - see front matter Ó 2010 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2010.01.004
38
A multitude of soft tissue surgeries have been described,
which aim to recreate the function of the disrupted CC and/
or AC ligaments. These include ligamentoplasty proce-
dures,12,40,50 muscle transfers,2,4,18,20,31,49 and ligament
reconstruction with autologous, allogeneic, or synthetic
materials.1,5,10,11,13,19,21,25,27,30,35,36,41,44,45,48,52 Ligamento-
plasty is the transfer of a portion of an existing ligament,
most commonly the coracoacromial (CA) ligament. This
was first performed by Cadenat in 1917 when he transferred
the posterior portion of the CA ligament from the acromion
onto the clavicle to mimic the CC ligaments.12 The
Weaver-Dunn procedure incorporates a similar transfer of
the CA ligament to the clavicle. The primary challenge
facing these operations has been maintenance of reduction.
This is likely because the transferred ligaments are not as
strong as the native CC ligaments and do not reproduce
their normal anatomy. This has led to the development of
the ACCR, which aims to recreate the anatomy of the CC
ligaments utilizing stronger graft materials.
Management of the distal clavicle in the setting of AC
separations has also evolved. Many of the early techniques
featured closed reduction and fixation of the joint, such as
with the Bosworth screw. In these situations, the distal
clavicle was retained. On the other hand, Mumford’s publi-
cation in 1941 popularized the isolated distal clavicle exci-
sion (DCE) for the treatment of AC separations.38 This
technique ultimately yielded poor results because it failed to
address the instability.42 However, the DCE has been incor-
porated into many subsequent procedures for AC instability
to remove a potential pain generator and prevent AC joint
arthrosis. The ACCR technique described in this paper
retains the distal clavicle, because it is felt to contribute to the
stability of the repair based on the anatomy.
Anatomy
The primary static stabilizers of the AC joint are the AC
ligaments (anterior, posterior, superior, and inferior), CC
ligaments (conoid and trapezoid), and, to a lesser extent, the
CA ligament. The deltoid, trapezius, and serratus anterior are
secondary dynamic stabilizers. The AC ligamentsdin
particular, the superior and posterior ligamentsdcontrol
motion in the anterior-posterior plane. The superior ligament
provides 56% of the resistance to posterior translation, and
the posterior ligament contributes 25%. Horizontal insta-
bility can cause posterior abutment of the clavicle and
scapular spine, resulting in significant clinical disability.
The CC ligaments are the primary restraint to inferior
translation of the sacpulohumeral complex, or superior
migration of the clavicle. The conoid ligament provides
approximately 60% of the strength in this dimension.23
These ligaments also have a role as secondary restraints
to resist anteroposterior translation. Furthermore, Debski et
al showed that when the AC ligaments are injured, there is
an increase in the load borne by the CC ligaments in
B.C. Carofino, A.D. Mazzocca
response to anteroposterior stress.17 The CC ligaments
originate posterior to the pectoralis minor insertion on the
coracoid and insert on the undersurface of the clavicle. The
conoid inserts onto the posterior aspect of the clavicle, 46
mm medial to the AC joint. The trapezoid inserts 26 mm
medial to the joint and is located more centrally in the
anteroposterior dimension.
Treatment approach
Nonoperative protocol
The majority of AC separations encountered by the senior
author are managed with a nonoperative rehabilitation
protocol, which is explained in detail elsewhere.16 The
specifics of the rehabilitation treatment are based on the
extent of injury, and are designed to restore stability by
compensating for the damaged structures. However, there
are also some general aspects of our rehabilitation protocol
that are applied across all grades of injury. Treatment is
approached in a stepwise fashion.24 Phase 1 focuses on the
elimination of pain and protection of the AC joint with
sling immobilization. Patients may discontinue use of
a sling when they are pain free with the arm at their side
and during self-care activities. Phase 2 emphasizes range
of motion exercises and gradually introduces isotonic
strengthening. Motions that provoke pain and stress the AC
joint are avoided. Phase 3 involves advanced strengthening
of the dynamic stabilizers of the AC joint. Finally, phase 4
prepares patients to return to sport by incorporating sports
specific training.
The specific prescribed exercises are dictated by the
severity of the injury and the anatomic structures damaged.
A Grade I separation is a ligament sprain without clavicle
displacement and theoretically does not compromise joint
stability; therefore, there is no need to immobilize during
a healing phase. Early initiation of range of motion is
encouraged, which assists in reducing pain and inflamma-
tion. Motions that increase stress on the AC joint, such as
cross arm adduction, behind the back internal rotation, and
end range forward elevation, are approached cautiously and
within the patient’s tolerance. In Grade II separations, the
AC ligaments are torn, resulting in anterior-posterior
instability. For this reason, scapular exercises are initiated
early, emphasizing retraction in an effort to provide
dynamic stability to the AC joint. In the early post injury
period, we begin with closed chain scapular exercises that
are easily tolerated within the patient’s comfort zone. As
symptoms abate, patients progress to rowing exercises with
tubing or cable resistance to integrate combined motions. In
Grade III separations, there is additional loss of the CC
ligaments, resulting in superior displacement of the clav-
icle. This results in significant alterations in the attachments
of the scapula to the clavicle. In this regard, treatment
directed towards scapular stabilization is essential.
Anatomic coracoclavicular ligament reconstruction 39

At 6 weeks, patients who demonstrate little or no

response are offered surgery, while those who have had
a significant reduction in symptoms are allowed to resume
sport or work specific activity and encouraged to continue
rehab for up to 12 weeks.

Surgical indications

In general, AC joint reconstruction with the ACCR proce-

dure is offered acutely to patients with high grade separa-
tions or more accurately dislocations (Grades IV-VI), as
well as patients with Grade III separations who do not
respond to a trial of conservative management. However, it
is important to note that these are not strict rules. We feel
there is a spectrum of injury, as well as a spectrum of
patients’ responses to injury. Some will compensate and do Figure 1 Patient positioning. Note the far lateral position of the
very well with non surgical management of ‘‘high grade’’ patient, the small bump of blue towels beneath scapula, and head
separations, while others do very poorly with seemingly turned toward the contra lateral direction.
lesser injuries. We treat all individually and do not jump to
any treatment. The physical exam and patient’s pain will
dictate our treatment much more than the radiographic
results.

Surgical technique

Set-up

A standard operating room table is set up in a beach chair

position at 60 of flexion. The patient is positioned as far
lateral as is safely possible. The medial border of the
scapula should come to the edge of the table, allowing the
arm to fall into extension without hitting the table. A small
bump is placed beneath the medial border of the scapula.
This serves to stabilize the scapula, and also raises the
shoulder away from the table thereby improving access to
the clavicle, which is critical for drilling bone tunnels.
Access to the clavicle is further improved by turning the
patient’s head slightly in the opposite direction and making
sure that it can be re-positioned intraoperatively if neces-
sary (Figure 1). However, it should be remembered that
overly aggressive twisting of the patient’s head could cause
a brachial plexus stretch injury.
The patient is secured with a safety belt and 3-in. cloth
tape around the chest. The operative field is draped from
the sternoclavicular joint medially to the ear laterally and
several inches behind the posterior aspect of the clavicle.
Prior to prepping, the miniature C-arm is pre-positioned to
ensure that the appropriate intra-operative images can be
obtained (Figure 2).
Surgical approach
The incision begins at the posterior edge of the clavicle
approximately 3.5 cm medial to the AC joint and extends
Figure 2 The mini-C-arm is pre-positioned to ensure that
appropriate images can be obtained.
inferiorly towards the coracoid following Langer’s lines
(Figure 3). The incision may be extended posterior if further
access is needed. This incision is medial to the approach
typically used for the Weaver-Dunn reconstruction.
A scalpel is used to cut skin, and then needle tip electro-
cautery is used to obtain hemostasis and dissect down to the
deltotrapezial fascia. Generous skin flaps are raised above
the fascia to improve visualization. This is well tolerated
about the shoulder due to the vascularity of the region.
The deltotrapezial fascia is then elevated off of the clav-
icle as full thickness flaps. The fascia is incised in line with
the natural demarcation between the trapezius insertion onto
the posterior aspect of the clavicle and the deltoid origin on
the anterior clavicle. This incision extends medially beyond
to conoid ligament insertion. Needle tip electrocautery is
used to begin raising flaps off of bone before using an
elevator. Maintaining full thickness flaps at this point is
critical to obtaining a good closure. It is important to note that
40
Figure 3 Incision begins 3.5 cm medial to the AC joint and
extends toward the coracoid.
Figure 4 Full thickness flaps are elevated off of the clavicle.
Tagging stitches facilitate later closure.
the deltoid has an insertion on the undersurface of the clav-
icle, and care should be made to ensure that the deltoid is not
violated. Additionally, tagging stitches are placed in the flaps
to facilitate accurate re-approximation at closure (Figure 4).
Gelpi retractors are used to retract the flaps. The exposure is
completed by freeing the clavicle and AC joint of soft tissues
that are preventing joint reduction. The clavicle may need to
be released from the trapezium fascia in a type IV separation
or from beneath the coracoid or acromion. A trial reduction is
performed by pushing up on the elbow to elevate the scap-
ulohumeral complex. Visual inspection is usually adequate
for assessing reduction; however, a mini-C-arm is used
intraoperatively to confirm the reduction. In chronic cases,
there is significant scar tissue inferior to the AC joint. This is
B.C. Carofino, A.D. Mazzocca
Figure 5 Guide pins are placed in the position of the CC liga-
ment tunnels. Trapezoid tunnel is placed 20-25 mm lateral to the
conoid tunnel.
incised in line with its fibers to gain access to the native joint
and preserved for later for use in the reconstruction if needed.
Clavicle preparation
The clavicle is prepared by drilling bone tunnels in the
anatomic locations of the coracoclavicular ligaments. The
conoid ligament tunnel is placed 45-mm medial to the AC
joint and at the posterior aspect of the clavicle. Addition-
ally, the conoid tubercle can be palpated on the undersur-
face of the clavicle and used as a secondary reference. After
placement of the guide pin, a 5-mm tunnel is made using
a cannulated reamer. A ‘‘ream-in, pull out’’ technique is
used. The reamer is advanced in under power and then
disconnected and pulled out. This prevents eccentric
reaming during removal and ensures a perfect circle. If
a wider graft is being used, it may be necessary to ream up
by 0.5-mm increments until graft passage is possible. The
goal is to make the tunnel as small as possible while still
allowing for graft passage, and therefore it should be
somewhat difficult to pass the graft. A secure fit between
the graft and tunnel is a critical aspect of the procedure.
Oversizing of the tunnel impairs fixation and, anecdotally,
is a cause of failure. Next, the trapezoid ligament tunnel is
prepared in the same manner. It is placed at the anterior
aspect of the clavicle and 20 - 25 mm lateral to the center of
the conoid tunnel (Figure 5).
A potential pitfall of this technique is to ‘‘blow out’’ the
posterior or anterior cortex when preparing the poster-
omedial and anterolateral tunnels. To prevent this, the guide
wire should be placed far enough away from the cortex to
allow for half the diameter of the anticipated reamer and
a remaining cortical bridge. Additionally, to prevent frac-
tures, there should be a 20- to 25-mm distance between the 2
tunnels; and the trapezoid tunnel should not be placed any
closer than 15 mm from the end of the clavicle. This is the
‘‘flat’’ end of the clavicle, and purchase can sometimes be
compromised. In the event that cortical ‘‘blowout’’ does
Anatomic coracoclavicular ligament reconstruction
Figure 6 High strength suture whipstitches are placed in the
tendon ends and used to bullet the tip.
Figure 7 Curved suture passing device.
occur, the limbs of the graft could be passed around the
clavicle and then sutured to themselves on top of the clavicle.
Graft preparation and passage
Graft options include a semitendinosus allograft or auto-
graft and anterior tibialis allograft. We prefer to use an
allograft, because it avoids the donor site morbidity as well
as the positioning and set-up issues involved with har-
vesting the semitendinosus. However, autograft is a possi-
bility in patients who object to use of an allograft.
High strength non-absorbable suture is used to place
whipstitches in the end of the graft. The stitch should also
‘‘bullet’’ the end of the graft by making the distal diameter
as small as possible. This will facilitate graft passage
through a small tunnel and prevent fraying of the graft
edges (Figure 6). The graft is passed beneath the coracoids,
either using a shuttling stitch and a curved clamp such as
41
Figure 8 Graft limbs pass beneath the coracoid and cross before
entering bone tunnels.
the Stanitsky aortic cross clamp or a curved suture passing
device (Figure 7). A number 2, high strength, nonabsorb-
able suture is passed with the graft to provide additional
nonbiologic fixation. The graft may be passed from either
medial to lateral or vice versa. We chose to pass from
medial to lateral under direct visualization.
After passing beneath the coracoid, the limbs of the graft
are crossed before being shuttled through the bone tunnels.
The Hewson suture passer is used to shuttle the graft
beginning with the posteromedial tunnel. The graft is then
loaded cyclically by pulling up on both ends in order to
remove any slack, and see-sawed back and forth to ensure
easy passage. The graft is arranged so that a shorter limb of
approximately 2 cm exits the conoid tunnel. The remaining
length of the graft exits the trapezoid tunnel. This longer
limb will be used later to reinforce the AC joint and
recreate the superior and anterior AC ligaments (Figure 8).
Reduction of posterior displacement
If there is posterior displacement of the clavicle and an
anterior force is needed to obtain reduction, then the position
of the bone tunnels can be used to facilitate this reduction.
In this instance, both tunnels are placed posteriorly, and the
42
Figure 9 The longer limb of the graft exits the trapezoid tunnel
and will be used to reconstruct the AC ligaments.
2 ends of the graft are not crossed before being shuttled
through the clavicle. When the graft is tightened it will help
to pull the clavicle anteriorly (Figure 9).
Graft fixation
The AC joint is then reduced by pushing up on the elbow
to elevate the scapulohumeral complex. Prior to fixation,
the quality of reduction is examined visually and radio-
graphically. Anatomical reduction of the AC joint is
critical. While an assistant maintains the reduction, the
grafts are secured with interference screws. The graft
exiting the posteromedial (conoid ligament) tunnel is
secured first using a 5.5 x 8-mm PEEK screw. The screw is
placed in the anterior aspect of the tunnel and tension is
maintained on the graft during fixation. The other limb of
the graft exiting the trapezoid tunnel is again tensioned
cyclically to remove any slack, before being secured with
a second interference screw. Once again, tension is held as
the screw is placed in the anterior aspect of the tunnel. The
#2 high strength nonabsorbable suture that accompanied
the graft is now tied on the superior aspect of the clavicle for
additional security.
The shorter limb of graft exiting the conoid tunnel is sewn
into the longer limb. The AC joint capsule and ligaments
are repaired with figure-of-eight stitches using absorbable
suture. The longer limb of graft exiting the lateral tunnel is
then looped over the top of the AC joint in order to reinforce
this repair (Figure 10). The superior and posterior AC liga-
ments are recreated using this excess graft material. High
strength nonabsorbable suture is used to take the lateral limb
(trapezoid) and suture it into the most posterior tissue on the
acromial side of the joint. Generally, we will use a free
‘‘mayo’’ needle and tie this as a horizontal mattress, grabing
persiosteum and old AC ligament to make this a ‘‘tight and
snug’’ band across the top part of the joint. The remaining
graft is then taken posteriorly and sutured to the trapezial
fascia, creating the posterior AC ligament.
B.C. Carofino, A.D. Mazzocca
Figure 10 The graft is secured in bone tunnels with PEEK
anchors, and the AC ligaments have been reconstructed with the
remaining graft exiting the trapezoid tunnel.
Closure
The deltotrapezial fascia is closed with interrupted nonab-
sorbable sutures. This is a critical step and great care must
be used. Both attachments of the anterior deltoid fascia and
the trapezius fascia are brought together with interrupted
stitches. The knots are placed on the posterior side of the
flap to minimize skin irritation. Occasionally, simple
sutures are used to bury knots that appear prominent. The
deep dermal layer is closed with buried 3.0 vicryl sutures,
and a running subcuticular closure is used on skin.
Postoperative rehabilitation
During the first 6-8 weeks, patients wear a brace which
provides support and protects the surgical repair against the
pull of gravity such as the Lerman Shoulder Brace (DJO
Inc., Vista, CA.) or a Gunslinger Shoulder Orthosis (Hanger
Prosthetics & Orthotics, Inc., Bethesda, MA) (Figure 11).
The brace may be removed for grooming and supine range
of motion exercises only. After 8 weeks, the graft has
obtained sufficient stability to begin upright range of
motion exercises. At 12 weeks, if there is a pain free range
of motion, strengthening exercises are begun. These should
target the scapular stabilizers, which help retract the
scapula and, thereby, decrease loads across the AC joint.
Weight training may begin at 3-5 months post-op. Full
contact athletics are allowed at 6 months, but it, generally,
Anatomic coracoclavicular ligament reconstruction
Figure 11 Postoperative brace supports the arm to protect the
repair. Here, the brace is being fitted to a patient pre-operatively.
requires 9 months to a year for patients to regain peak
strength, particularly with pressing activities or lifting from
the floor as in a dead lift.
Pearls and pitfalls
1) Patient positioning should maximize access to the
clavicle. This is critical to successfully drilling bone
tunnels. 2) Full thickness deltoid and trapezius flaps are
maintained for closure. 3) Clavicle fractures can be pre-
vented by spacing bone tunnels 20-25 mm apart. Further-
more, do not place lateral tunnel closer than 10-15 mm to
the lateral edge of the clavicle. 4) A tight fit between tunnel
and graft can be achieved by reaming the smallest possible
tunnel. No fractures have been reported with tunnels of
5 mm. 5) Postoperatively, a supportive brace should be
used to protect repair for 6 weeks (Figure 13).
Case series
All AC joint dislocations treated by the senior author
have been collected in a registry, since the inception of his
practice in 2002. A total of 106 AC joint separations were
treated between August 2002 and February 2008. There
were 34 patients with either a Grade III or V separation.
43
Patients were offered surgery if they had a Grade III or
V separation that was recalcitrant to 6-12 weeks of
conservative management, as described above (Figure 12).
Surgical management would also be offered for Grade IV
and VI separations, but none were encountered during this
time period. Twenty-two ACCRs were performed on 21
patients. There were 4 women and 17 men (mean age, 44
þ/ 14). There were 14 Grade III separations and 8 Grade
V separations. Sixteen patients were available for follow-up
examinations and completion of surveys. Average follow-
up for this series is 21 months (range, 6-61). Of the
patients lost to follow-up, 1 has been incarcerated, 1 has
been included as a failure because he required a subsequent
distal clavicle excision, and 1 reports that he is doing well,
but is unwilling to return for examination.
All patients underwent ACCR using the technique
described above with a 2-bundle semitendinosus allograft
and interference screw fixation in the clavicle. A concom-
itant distal clavicle excision was performed in 2 patients, 1
of whom also underwent subacromial decompression.
Patients were evaluated pre- and postoperatively with
the American Shoulder and Elbow Surgeons Score (ASES),
the Simple Shoulder Test (SST) and the Constant Murley
score. We also recorded the Self Assessment Numeric
Evaluation score (SANE) and reported pain with a posterior
directed force, forward elevation, and horizontal adduction.
Radiographically, the coracoclavicular distance (CCD) was
measured as the distance between the tip of the coracoid
and the undersurface of the clavicle. These measurements
were recorded from bilateral Zanca radiographs, and the
difference between the operative and nonoperative sides
were calculated. These radiographs were not magnification
controlled; however, in each case, the nonoperative side
served as an internal control.
There were significant differences (P < .001) between
the mean pre- and postoperative scores for all 3 outcome
measures: ASES (52 þ/ 15 to 92 þ/ 5), SST (7.1þ/ 2.9
to 11.8 þ/ .4), and Constant Murley (66.6 þ/ 12.7 to
94.7 þ/5.02). The mean postoperative SANE score was
94.4. All patients reported no pain with a posterior directed
force, forward elevation, and horizontal adduction. On
radiographic analysis the mean side to side difference in
CCD was .96 mm.
There were 3 failures (3/17) in this series. One patient
has had persistent pain localized to the AC joint. A
subsequent distal clavicle excision was performed, but
without improvement. A second patient developed a
chronic infection, requiring removal of the allograft and
a lattissimus flap for soft tissue coverage. Finally, a third
patient is included as a failure due to loss of reduction.
Discussion
The surgical technique described in this paper is based on
an understanding of the anatomy and history of previous
44 B.C. Carofino, A.D. Mazzocca

All patients in a single surgeon’s practice

with AC joint pathology from 1//2003 to
2/2008.
N = 106

Inclusion Criteria Exclusion Criteria

•Grade III -VI AC Joint Separation • Grade I or II AC Joint Separation
•Traumatic etiology • Chronic etiology
N = 34 • Concomitant chronic disease
N = 72

Conservative Management-6 weeks

• Restoration of range of motion
• Strengthening of periscapular muscles

Success of C.M. ACCR

• Relief of pain • Continued pain
• Return to prior level of fn. • Failure to return to prior level of activity
N=13 N = 21

Lost to Follow Up
N=5

Data Reported
N=16

Figure 12 Flow sheet of AC separations proceeding to ACCR.

patient did have persistent postoperative pain, but failed to

Figure 13 Postoperative radiographs following right ACCR.
operations to address AC separations. The ACCR includes
an anatomic reconstruction of the coracoclavicular (CC)
ligaments using a free tendon graft, and conserves the AC
joint because it is felt to contribute to the stability of the
repair. The decision to retain the AC joint is somewhat
controversial and deserves explanation, as many authors
advocate removal of the distal clavicle as a potential pain
generator.
A study of the early surgical techniques that retained the
distal clavicle demonstrates that AC joint arthrosis and pain
were rarely causes of failure.6-8,39 In these series where the
joint was retained and, in some instances, even violated
with hardware, acceptable results were often obtained.
While failure was commonly due to hardware complica-
tions, it was not attributed to AC joint symptoms. The
results from our series further support this observation. The
distal clavicle was retained in the majority of our patients
(only 2 underwent a concomitant DCE) and we did not find
AC joint arthrosis to be a cause of failure in this series. One
improve with a DCE, thus indicating that the AC joint was
not the pain generator.
Presently, there is not strong evidence to support or
refute routinely performing a concomitant DCE. Park
et al41 found that the retained distal clavicle may cause pain
in some patients. Yet Browne et al reported no additional
improvement resulted from concomitant DCE.9 Weinstein
et al reported that when the AC joint is preserved, some
patients will experience symptomatic arthritis requiring
future treatment; however, this observation was not repro-
duced in our series.51
The greatest challenge to reconstructive procedures for
AC separation has been loss of reduction. In the case of
Weaver-Dunn, this occurs in up to 24% of patients and is
associated with inferior clinical results.47,50,51 This may be
occurring because the CA ligament possesses only 20% of
the ultimate strength of the CC ligaments. Jari et al eval-
uated the biomechanical properties of a coracoacromial
transfer and found that the stiffness of this repair is
significantly less than that of the native CC ligaments.28
Furthermore, the vector of attachment of the transferred
ligament does not reproduce the vector of the native CC
ligaments.33,37 Surgeons have attempted to address these
shortcomings by augmenting the CA ligament transfer with
a heavy suture or biologic graft passed beneath the coracoid
and over the top of the clavicle. Still, loss of reduction
remains an issue.29,32,43
This has led to the development of the ACCR, which
aims to recreate the anatomy of the CC ligaments and
utilize stronger graft materials. Multiple biomechanical
Anatomic coracoclavicular ligament reconstruction
studies have shown that anatomic reconstructions with free
tendon grafts have greater stability and load to failure than
the traditional Weaver-Dunn procedure, and also more
closely reproduce the function of the native CC liga-
ments.15,26,33,34 More importantly, this improvement in
biomechanical properties may result in better clinical
outcomes. Tauber et al prospectively compared the tradi-
tional Weaver-Dunn reconstruction and a coracoclavicular
reconstruction with semitendinosus allograft in 24 patients
with Grade III and V separations.46 The CC ligament
reconstruction resulted in significantly better clinical and
radiographic outcomes. Our case series represents a single
reconstructive technique and does not allow for direct
comparisons. However, there was only 1 loss of reduction
during this time period, which compares favorably with
previous publications.
Surgically recreating the human bodies’ natural anatomy
has been a successful tenant for orthopaedic surgeons in the
past. The ACCR technique is an attempt to recreate the
important CC and AC anatomy and allow for better patient
outcomes.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
article.
Supplementary data
Supplementary data associated with this article can be
found, in the online version, at doi:10.1016/j.jse.2010.01.
004.
References
1. Appell AA. Acromioclavicular dislocations. Can Med Assoc J 1940;
43:23-5.
2. Bailey RW, Metten CF, O’Connor GA, Titus PD, Baril JD,
Moosman DA. A dynamic method of repair for acute and chronic
acromioclavicular disruption. Am J Sports Med 1976;4:58-71.
3. Bartonicek J, Slavik M, Kofranek I. Akromioklavikularni Kloub.
Acta Chir Orthopaedicae et Traumatologie Cechoslovaca 1985;52:
285-95.
4. Berson BL, Gilbert MS, Green S. Acromioclavicular dislocations:
Treatment by transfer of the conjoined tendon and distal end of the
coracoid process to the clavicle. Clin Orthop 1978;135:157-64.
5. Birkett AN. The result of operative repair of severe acromioclavicular
dislocation. Br J Surg 1944-1945;32:103-5.
6. Bosworth B. Acromioclavicular separation: new method of repair.
Surg Gynecol Obstet 1941;73:866-71.
7. Bosworth BM. Complete acromioclavicular dislocation. N Engl J Med
1949;241:221-5.
45
8. Bosworth BM. Acromioclavicular dislocation: End-results of screw
suspension treatment. Ann Surg 1948;127:98-111.
9. Browne JE, Stanley RF, Tullos HS. Acromioclavicular joint disloca-
tions: Comparative results following operative treatment with and
without primary distal clavisectomy. Am J Sports Med 1977;5:258-63.
10. Bunnell S. Fascial graft for dislocation of the acromioclavicular joint.
Surg Gynecol Obstet 1928;46:563-4.
11. Burri C, Neugebauer R. Carbon fiber replacement of the ligaments of
the shoulder girdle and the treatment of lateral instability of the ankle
joint. Clin Orthop 1985;196:112-7.
12. Cadenat F. The treatment of dislocations and fractures of the outer end
of the clavicle. Int Clin 1917;1:145-69.
13. Carrell WB. Dislocation at the outer end of the clavicle. J Bone Joint
Surg 1928;10:314-5.
14. Cooper E. New method of treating long standing dislocations of the
scapuloclavicular articulation. Am J Med Sci 1861:41.
15. Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical
rationale for development of anatomical reconstructions of cor-
acoclavicular ligaments after complete acromioclavicular joint dislo-
cations. Am J Sports Med 2004;32:1929-36.
16. Cote M, Mazzocca AD. Rehabilitation of acromioclavicular joint
separations operative and non-operative considerations. Clin Sports
Med (in press).
17. Debski RE, Parsons IMIV, Woo SL, Fu FH. Effect of capsular injury
on acromioclavicular joint mechanics. J Bone Joint Surg Am 2001;83-
A:1344-51.
18. Dewar FP, Barrington TW. The treatment of chronic acromio-
clavicular dislocation. J Bone Joint Surg Br 1965;47:32-5.
19. Eikenbary CF, LeCocq JF. The operative treatment of acromiocla-
vicular dislocations. Surg Clin North Am 1933;13:1305-14.
20. Ferris BD, Bhamra M, Paton DF. Coracoid process transfer for acro-
mioclavicular dislocations. A report of 20 cases. Clin Orthop Relat
Res 1989;42:184-94.
21. Fleming RE, Tornberg DN, Kiernan H. An operative repair of acro-
mioclavicular separation. J Trauma 1978;18:709-12.
22. Flik K, Lyman S, Marx RG. American collegiate men’s ice hockey: an
analysis of injuries. Am J Sports Med 2005;33:183-7.
23. Fukuda K, Craig EV, An KN, Cofield RH, Chao EY. Biomechanical
study of the ligamentous system of the acromioclavicular joint. J Bone
Joint Surg Am 1986;68:434-40.
24. Gladstone JN, Wilk KE, Andrews JR. Nonoperative treatment of
acromioclavicular joint injuries. Oper Tech Sports Med 1997;5:78-87.
25. Goldberg JA, Viglione W, Cumming WJ, et al. Review of cor-
acoclavicular ligament reconstruction using Dacron graft material.
Aust N Z J Surg 1987;57:441-5.
26. Grutter PW, Petersen SA. Anatomical acromioclavicular ligament
reconstruction: a biomechanical comparison of reconstructive tech-
niques of the acromioclavicular joint. Am J Sports Med 2005;33:
1723-8.
27. Henry MO. Acromioclavicular dislocations. Minn Med 1929;12:
431-3.
28. Jari R, Costic RS, Rodosky MW, Debski RE. Biomechanical function
of surgical procedures for acromioclavicular joint disorders. Arthros-
copy 2004;20:237-45.
29. Jones HP, Lemos MJ, Schepsis AA. Salvage of failed acromiocla-
vicular joint reconstruction using autogenous semitendinosus tendon
from the knee. Surgical technique and case report. Am J Sports Med
2001;29:234-7.
30. Kappakas GS, McMaster JH. Repair of acromioclavicular separation
using a dacron prosthesis graft. Clin Orthop Relat Res 1978:247-51.
31. Katznelson A, Nerubay J, Oliver S. Dynamic fixation of the avulsed
clavicle. J Trauma 1976;16:841-4.
32. LaPrade RF, Hilger B. Coracoclavicular ligament reconstruction using
a semitendinosus graft for failed acromioclavicular separation surgery.
Arthroscopy 2005;21:1277.
33. Lee SJ, Nicholas SJ, Akizuki KH, McHugh MP, Kremenic IJ,
Ben-Avi S. Reconstruction of the coracoclavicular ligaments with
46
tendon grafts: a comparative biomechanical study. Am J Sports Med
2003;31:648-55.
34. Mazzocca AD, Santangelo SA, Johnson ST, Rios CG, Dumonski ML,
Arciero RA. A biomechanical evaluation of an anatomical coraco-
clavicular ligament reconstruction. Am J Sports Med 2006;34:
236-46.
35. Meyerding HW. The treatment of acromioclavicular dislocation. Surg
Clin North Am 1937;17:1199-205.
36. Millbourn E. On injuries to the acromio-clavicular joint. Treatment
and results. Acta Orthop Scand 1950;19:349-82.
37. 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.
38. Mumford E. Acromioclavicular dislocation. J Bone Joint Surg Am
1941;23:799-802.
39. Murray G. Fixation of the acromioclavicular joint and rupture of the
coracoclavicular ligaments. Can Med Assoc J 1940;43:270-3.
40. Neviaser JS. Acromioclavicular dislocation treated by transference of
the coraco-acromial ligament. A long-term follow-up in a series of 112
cases. Clin Orthop Relat Res 1968;58:57-68.
41. Park JP, Arnold JA, Coker TP, et al. Treatment of acromioclavicular
separations. A retrospective study. Am J Sports Med 1980;8:251-6.
42. Rockwood CAJ, Guy DK, Griffin JL. Treatment of chronic, complete
acromioclavicular dislocation. Orthop Trans 1988;12:735.
B.C. Carofino, A.D. Mazzocca
43. Rokito AS, Oh YH, Zuckerman JD. Modified Weaver-Dunn procedure
for acromioclavicular joint dislocations. Orthopedics 2004;27:21-8.
44. Roper BA, Levack B. The surgical treatment of acromioclavicular
dislocations. J Bone Joint Surg 1982;64B:597-9.
45. Schneider CC. Acromioclavicular dislocation. Autoplastic recon-
struction. J Bone Joint Surg 1933;15:957-62.
46. Tauber M, Gordon K, Koller H, Fox M, Resch H. Semitendinosus
tendon graft versus a modified Weaver-Dunn procedure for acromio-
clavicular joint reconstruction in chronic cases: a prospective
comparative study. Am J Sports Med 2009;37:181-90.
47. Tienen TG, Oyen JF, Eggen PJ. A modified technique of reconstruc-
tion for complete acromioclavicular dislocation: a prospective study.
Am J Sports Med 2003;31:655-9.
48. Toumey JW. Surgery of the acromioclavicular joint. Surg Clin North
Am 1949;29:905-12.
49. Vargas L. Repair of complete acromioclavicular dislocation, utilizing
the short head of the biceps. J Bone Joint Surg 1942;24:772-3.
50. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries,
especially complete acromioclavicular separation. J Bone Joint Surg
Am 1972;54:1187-94.
51. Weinstein DM, McCann PD, McIlveen SJ, Flatow EL, Bigliani LU.
Surgical treatment of complete acromioclavicular dislocations. Am J
Sports Med 1995;23:324-31.
52. Zaricznyj B. Late reconstruction of the ligaments following acro-
mioclavicular separation. J Bone Joint Surg Am 1976;58:792-5.