Review Article

Acromioclavicular Joint Injuries:

Diagnosis and Management
Abstract
Ryan Simovitch, MD
Brett Sanders, MD
Mehmet Ozbaydar, MD
Kyle Lavery, BS
Jon J. P. Warner, MD

Dr. Simovitch is Attending Surgeon,

Palm Beach Orthopaedic Institute,
Palm Beach Gardens, FL.
Dr. Sanders is Attending Surgeon,
Center for Sports Medicine and
Orthopaedics, Chattanooga, TN.
Dr. Ozbaydar is International Fellow,
Harvard Shoulder Service,
Massachusetts General Hospital,
Boston, MA. Mr. Lavery is Research
Assistant, Harvard Shoulder Service,
Massachusetts General Hospital.
Dr. Warner is Chief, Harvard
Shoulder Service, Massachusetts
General Hospital.
Dr. Warner or a member of his
immediate family has received
royalties from Zimmer, and research
or institutional support from Aircast
(DJ), Arthrex, Mitek, Smith &
Nephew, and Zimmer. None of the
following authors or a member of
their immediate families has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Simovitch,
Dr. Sanders, Dr. Ozbaydar, and
Mr. Lavery.
Reprint requests: Dr. Simovitch,
Palm Beach Orthopaedic Institute,
Suite 500, 3401 PGA Boulevard,
Palm Beach Gardens, FL 33410.
J Am Acad Orthop Surg 2009;17:
207-219
Copyright 2009 by the American
Academy of Orthopaedic Surgeons.

April 2009, Vol 17, No 4

Acromioclavicular joint injuries represent nearly half of all athletic

shoulder injuries, often resulting from a fall onto the tip of the
shoulder with the arm in adduction. Stability of this joint depends
on the integrity of the acromioclavicular ligaments and capsule as
well as the coracoclavicular ligaments and the trapezius and
deltoid muscles. Along with clinical examination for tenderness and
instability, radiographic examination is critical in the evaluation of
acromioclavicular joint injuries. Nonsurgical treatment is indicated
for type I and II injuries; surgery is almost always recommended for
type IV, V, and VI injuries. Management of type III injuries remains
controversial, with nonsurgical treatment favored in most instances
and reconstruction of the acromioclavicular joint reserved for
symptomatic instability. Recommended techniques for stabilization
in cases of acute and late symptomatic instability include screw
fixation of the coracoid process to the clavicle, coracoacromial
ligament transfer, and coracoclavicular ligament reconstruction.
Biomechanical studies have demonstrated that anatomic
acromioclavicular joint reconstruction is the most effective
treatment for persistent instability.

cromioclavicular (AC) joint injuries represent 40% to 50% of

athletic shoulder injuries.1,2 The
treatment of AC instability has been
an ongoing source of controversy.
Long before a three-grade classification of the injury was developed by
Tossy et al3 and Allman4 in the 1960s
and then expanded by Rockwood in
1989,5 surgeons debated the method
and timing of treatment. The greatest
source of dispute has been the issue
of nonsurgical management versus
surgical reconstruction for complete
dislocations.
In the mid 1970s, most residency
program directors in the United
States recommended surgical treatment for type III dislocations (ie, loss
of contact between the clavicle and
the acromion).6 However, by the

early 1990s, 135 of 187 surgeons

preferred nonsurgical treatment
(72.2%).7 A series of comparative
studies has supported this trend.8-12
Today, the tendency in management
is toward minimal intervention.13
However, surgical management,
most commonly in the form of coracoclavicular (CC) fixation14 and/or
ligament reconstruction,15,16 is often
undertaken after consideration of individual patient demands and injury
chronicity.

Joint Anatomy and

Biomechanics
The AC joint is a diarthrodial joint
formed between the lateral end of
the clavicle and the medial end of the

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Acromioclavicular Joint Injuries: Diagnosis and Management

Figure 1

The acromioclavicular (AC) joint. Static stabilizers include the AC capsule

and the coracoclavicular ligaments, consisting of the trapezoid ligament
laterally and the conoid ligament medially.

acromion. This joint has a variable

inclination between nearly vertical
and 50 of obliquity, where the superior edge of the clavicle is more lateral. A fibrocartilaginous disk exists
at the AC joint and has been shown
to involute with age and disintegrate
by age 40 years.17 Innervation of the
AC joint is from the lateral pectoral,
axillary, and suprascapular nerves.
Multiple studies have confirmed that
the clavicle rotates approximately
40 to 45 with full shoulder elevation and abduction.18 However, the
clavicle actually only rotates approximately 5 to 8 relative to the acromion because of synchronous scapuloclavicular (SC) motion.19 This is
the basis for shoulder elevation remaining normal after CC arthrodesis
with a lag screw.20
The AC joint has both static and
dynamic stabilizers (Figure 1). The
static stabilizers include the AC joint
capsule as well as the AC ligaments
that reinforce the capsule. Biomechanical investigations have found
that these structures predominantly
control horizontal motion of the
clavicle.21 Klimkiewicz et al22 demon-

208

strated in cadaveric specimens that

the posterosuperior capsule is essential in preventing excessive posterior
translation of the clavicle and therefore that excessive distal clavicle excision can result in increased posterior clavicle translation.22 The
posterior and superior AC ligaments
contribute most to the horizontal
stability of this joint. Authors of a
recent cadaveric study demonstrated
that a distal 1 cm clavicle resection
results in a 32% increase in posterior
translation compared with the intact
state.23 A resection <1 cm also results
in increased instability. Renfree and
Wright24 demonstrated that a distal
clavicle resection of as little as 2.3
mm in women and 2.6 mm in men
could completely release the clavicular insertion of the AC ligaments in
some patients.
The CC ligaments, which include
the conoid ligament medially and the
trapezoid ligament laterally, also
provide static stabilization and act
predominantly as a restraint to vertical translation of the clavicle.21 Rios
et al25 defined the insertion points of

the CC ligaments on the clavicle in a

cadaveric study. The normal anatomic range of the distance between
the coracoid process and the clavicle
(CC interspace) is 1.1 to 1.3 cm.26
Fukuda et al21 demonstrated that the
conoid ligament restrains vertical
displacement to a greater extent than
does the trapezoid ligament. They
also concluded that the AC joint capsule contributes greater constraint at
small loads and that the CC ligaments provide stability with greater
displacements.
Dynamic stabilization of the AC
joint relies on the origin of part of
the anterior deltoid muscle from the
clavicle and the trapezius muscle
through its fascial insertion over the
acromion. The role of these muscles
in AC joint stability must be appreciated during any AC joint surgical reconstruction.27

Mechanism of Injury
An acute injury to the AC joint can
occur through a direct or an indirect
mechanism. Direct injury results
from a direct force to the acromion
with the shoulder adducted, resulting
in movement of the acromion inferiorly and medially while the clavicle
is stabilized by the sternoclavicular
joint ligaments.25 This mechanism is
involved in most injuries and is usually the result of a fall on the superolateral portion of the shoulder. The
force results in systematic failure of
the stabilizing ligaments with the
propagation of increasing force.20
Failure of the AC ligaments and capsule is followed by failure of the CC
ligaments and deltotrapezial fascia.
An indirect force can result in the
same constellation of injury patterns
but is generated by a fall on an outstretched arm or elbow with a superiorly directed force. Although injury
to the AC and CC ligaments is the
most common pathologic basis for

Journal of the American Academy of Orthopaedic Surgeons

Ryan Simovitch, MD, et al

Table 1
Characterization of Acromioclavicular Joint Injuries by the Rockwood Classification*
AC
Ligaments

CC
Ligaments

Deltopectoral
Fascia

Sprained

Intact

Intact

II
III
IV

Disrupted
Disrupted
Disrupted

Sprained
Disrupted
Disrupted

Intact
Disrupted
Disrupted

Normal (1.1 to
1.3 cm)
<25%
25%-100%
Increased

V
VI

Disrupted
Disrupted

Disrupted
Intact

Disrupted
Disrupted

100%-300%
Decreased

Type

Radiographic CC Radiographic AC
Distance Increase
Appearance

AC Joint
Reducible

Normal

N/A

Widened
Widened
Posterior clavicle
displacement
N/A
N/A

Yes
Yes
No
No
No

* The type of AC injury can be discerned based on the pattern of ligament injury, AC joint position on radiographs, and whether the AC joint
can be reduced on physical examination.
AC = acromioclavicular, CC = coracoclavicular, N/A = not applicable

complete AC joint dislocation and

instability, AC dislocations can occur
in the context of intra- and extraarticular fractures of the base of the
coracoid process. Such an injury is
considered equivalent to a CC rupture. Epiphyseal separation in children and young adults, as well as
distal clavicle fractures, can result in
the appearance of AC dislocation
on radiographs; these are termed
pseudodislocations.20

Classification
The degree of injury to the AC joint
is dependent on the amount of energy transferred to the acromion and
clavicle and their ligamentous stabilizers. Tossy et al3 and Allman4 originally classified AC joint injuries into
three grades. This classification system was subsequently modified by
Rockwood into six types (Table 1).5
In type I injury, there is no visible
deformity. There may be some swelling and tenderness over the AC joint,
but there is no tenderness over the
CC interspace. Radiographs appear
normal.
In type II injury, the distal clavicle
is unstable horizontally and can be
displaced anteriorly or posteriorly.
April 2009, Vol 17, No 4

Although there may be vertical instability, it is usually absent or minimal.

In contrast to type I injuries, there is
tenderness overlying the CC interspace. Radiographically, the AC joint
is disrupted and may be widened,
with a slight vertical displacement
and concomitant increase in the CC
interspace.
The distal clavicle is unstable vertically and horizontally in type III injury. Radiographically, the AC joint
is dislocated, with the acromion displaced inferiorly relative to the clavicle. There is tenderness in the CC
interspace. Pain is typically more severe in type III and higher injuries.
The AC joint is reducible by an upward force placed on the ipsilateral
elbow. Certain injury patterns
mimic, but should be distinguished
from, type III AC injuries. These
variants include Salter-Harris injuries
to the distal clavicular physis resulting from late closure of this physis
(in persons aged 18 to 22 years), and
AC dislocations associated with intact CC ligaments and a fracture of
the coracoid process.
AC joint dislocation with the clavicle displaced posteriorly into or
through the trapezius muscle identifies a type IV injury. Clinically, the

anterior acromion may be prominent. Radiographically, the CC interspace is increased, and posterior
translation of the lateral clavicle is
seen on an axillary lateral view (Figure 2). The AC joint is irreducible on
physical examination. The SC joint
and brachial plexus should be evaluated in all AC injuries, but such evaluation is particularly important in
type IV injuries, given the reports of
bipolar clavicular dislocations (eg,
synchronous AC and SC dislocation).
In a type V injury, in addition to
disruption of all of the stabilizing ligaments (as in a type III or IV injury),
the deltoid and trapezius muscles
and fascia are more extensively detached from the clavicle. Clinically,
the clavicle lies subcutaneously. Occasionally there is so much inferior
displacement of the upper extremity
that the patient develops symptoms
from traction on the brachial plexus.
The AC joint is irreducible.
The rare type VI injury represents
a high-energy variant that usually occurs as a result of hyperabduction
and external rotation. The distal
clavicle typically comes to rest in a
subacromial or subcoracoid position
(Figure 3). Because this injury is usu-

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Acromioclavicular Joint Injuries: Diagnosis and Management

Figure 2

Diagnosis
Clinical Findings

A 33-year-old man presented with shoulder pain and an abrasion over the
superior portion of the shoulder following a fall from a motorcycle.
A, Anteroposterior radiograph with a 10 to 15 cephalic tilt demonstrating an
increase in the coracoclavicular interspace distance (*). B, Axillary lateral
radiograph demonstrating posterior displacement (posteriorly directed arrow),
thereby distinguishing this as a type IV injury. The acromion (A) and the
clavicle (C) are outlined.

Figure 3

Three-dimensional computed tomography scan demonstrating the

subcoracoid variant of a type VI acromioclavicular dislocation.

ally the result of high-energy trauma,

it is often accompanied by multiple
fractures of the clavicle and ribs.

210

Subcoracoid displacement may be associated with brachial plexus or vascular injury.

Injury to the AC joint should be suspected in any patient who has shoulder trauma with pain in the vicinity
of the acromion and clavicle. During
the clinical examination, the patient
should be in the standing or sitting
position without support for the injured arm. The weight of the arm
pulling downward often makes the
deformity more apparent.
On physical examination, findings
related to the severity of the injury,
such as local swelling, deformity,
abrasion, or bruising, may be noted.
The distal end of the clavicle is sometimes displaced enough to tent the
skin. With AC injury, local tenderness is present on palpation over the
AC joint as well as in the CC interspace. AC joint palpation provides
guidance related to the degree and
direction of the displacement of the
clavicle compared with the acromion. The clavicle should also be
carefully palpated to detect possible
fractures. Disruption of the deltotrapezial fascia should be noted if
present. Passive and active motion of
the shoulder produces focal pain at
the injured AC joint. This pain is often accentuated by abduction and
cross-body adduction. The OBrien
active compression test for pain over
the AC joint may be helpful.28
The AC joint should next be assessed for stability. Evaluation of stability is difficult in the acute phase
because of patient discomfort and
guarding. In the subacute phase, after partial resolution of pain, horizontal and vertical instability can be
detected. Because an AC joint injury
occurs by inferior displacement of
the scapula, determining whether the
AC joint is reducible is done by stabilizing the clavicle with one hand
and placing an upward force under
the ipsilateral elbow with the other

Journal of the American Academy of Orthopaedic Surgeons

Ryan Simovitch, MD, et al

hand. A type III AC joint injury can

be differentiated from a type IV or V
joint injury based on whether the AC
joint dislocation can be reduced (Table 1). Once the AC joint is reduced
with this maneuver, the examiner can
grasp with the index finger and
thumb the midshaft of the clavicle
and attempt to translate it anteriorly
and posteriorly to assess horizontal
stability.
The sternoclavicular joint should always be examined for an associated anterior dislocation. The neurologic status of the affected extremity should be
evaluated in all AC injuries to rule out
a brachial plexus injury.

Radiographic Evaluation
Standardized radiographs are essential to diagnose and classify AC joint
injuries. Routine radiographs for AC
joint evaluation include a true anteroposterior and an axillary lateral
view of the shoulder, as well as
Zanca views (10 to 15 cephalic tilt)
taken with the patient in an upright
position without support of the injured arm. Ideally, comparison views
of the uninjured shoulder should be
obtained to provide normative information with regard to the CC distance and relative posterior displacement of the distal clavicle.
Stress views of the AC joint have
been described to differentiate between type II and type III injuries.
However, the weighted stress views
are costly and uncomfortable for the
patient; also, they rarely provide new
information to help diagnose an unstable injury. Thus, they are no
longer routinely used.
Coracoid process fractures should
always be suspected when radiographs reveal AC dislocation in the
presence of a normal CC distance
(1.1 to 1.3 cm). When the coracoid
fracture is not obvious on the axillary view, the Stryker notch view will
almost always demonstrate it.
April 2009, Vol 17, No 4

Treatment
Nonsurgical
Nonsurgical treatment is uniformly
recommended for type I and type II
injuries. Although multiple methods
for clavicle reduction and immobilization have been described, most authors suggest a period of immobilization in a simple sling or shoulder
immobilizer to remove stress from
the injured CC and/or AC ligaments.14,29 Generally, type I injuries
can be treated by use of a simple
sling for 7 to 10 days or until pain
subsides. Type II injuries may require
immobilization for as long as 2
weeks for resolution of symptoms.
Once the shoulder pain has subsided,
an early and gradual rehabilitation
program is instituted, with the focus
on passive- and active-assisted range
of motion (ROM). After symmetric
and painless shoulder ROM is
achieved, an isometric strengthening
program is begun. This is followed
by isotonic strengthening with a
gradual escalation of strengthening
and endurance. Contact sports and
heavy lifting should be avoided for 2
to 3 months to allow for ligament
healing and avoid converting an incomplete injury to a complete type
III injury.
Most studies support nonsurgical
treatment of type III injuries, although this is controversial. Nonsurgical treatment is well accepted, but
mid- and long-term outcomes should
not be ignored. Several studies have
demonstrated persistent disability in
patients treated nonsurgically. Bergfeld et al30 evaluated United States
Naval Academy midshipmen and
found that 30% of patients with type
I and 42% of patients with type II
injuries reported minor symptoms
such as clicking and pain with pushups and dips. An additional 9% and
23% of patients with type I and II
injuries, respectively, reported severe

persistent pain and limitation of activities. Mouhsine et al31 reported

similar results. Of patients with type
I and II AC injuries treated nonsurgically, 27% developed chronic AC
symptoms at a mean of 26 months
after injury and susequently required
surgical intervention. Of the patients
who chose later surgery, a significant
proportion had activity-related pain
and residual anteroposterior instability.
Bannister et al9 conducted a randomized, prospective, controlled
trial comparing acute surgical treatment of Rockwood type III and V
AC joint dislocations using a CC
screw versus 2 weeks of immobilization in a sling. The same rehabilitation protocol was used in both
groups. Patients were stratified according to the severity of AC joint
displacement. Patients with AC displacement <2 cm fared better with
nonsurgical treatment. Among only
those patients with severe AC dislocation (2 cm displacement), 20% of
the nonsurgical group had good or
excellent results, while 70% of the
surgically treated patients had good
or excellent results. The authors concluded that nonsurgical treatment is
appropriate for low-grade injuries
but surgical treatment can be considered for young patients with severe
injuries.
The most concerning sequelae of
lower-energy injuries are the late development of AC joint osteoarthritis,
exhibited in nearly 50% of patients
with AC injury,30 and chronic instability. Current treatment options include arthroscopic distal clavicle resection,32 involving the removal of as
little as 4 to 8 mm of bone, and open
distal clavicle excision. However, no
published prospective, randomized
studies exist that compare both arthroscopic and open methods.
A meta-analysis by Phillips et al12
demonstrated that type III injuries
have similar overall satisfactory out-

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Acromioclavicular Joint Injuries: Diagnosis and Management

Table 2
Surgical Techniques for the Management of Acromioclavicular Joint Dislocation
Technique

Method

Primary acromioclavicular joint

fixation

Kirschner wires, hook-plate

Fixation between the coracoid

process and clavicle

CC screw, suture loop

Dynamic muscle transfer

Ligament reconstruction

Coracoid transfer
Autogenous hamstring, anterior
tibialis allograft, CA ligament
transfer

Features
Limited dissection
Risk of pin migration
Reserved for acute injury
Screw requires staged removal
Suture loop can be inserted arthroscopically
Reserved for acute injuries
Suture loop can cut through the clavicle or coracoid base
Abandoned due to inferior long-term results
Attempts to anatomically reestablish CC ligament anatomy
Provides biologic scaffold for revascularization
Appropriate for acute and chronic reconstructions

CA = coracoacromial, CC = coracoclavicular

come rates whether managed nonsurgically or surgically. Patients treated

nonsurgically returned to work and
preinjury activities sooner and had
more nearly normal strength and
ROM at follow-up. Patients treated
surgically had a higher complication
rate. However, there was no standardization of surgical technique
or nonsurgical treatment method
among the studies reviewed. Wojtys
and Nelson33 reviewed 22 patients
with type III AC dislocations. They
determined that laborers and athletes
can recover adequate strength and
endurance with nonsurgical treatment of type III injuries despite a
slight decrease in both measures.
However, they expressed concern
that the decrease in endurance and
strength, despite not being statistically significant, coupled with persistent pain and soreness, may be worth
considering in developing a treatment plan for patients who depend
on high levels of shoulder strength or
endurance for a job or sport. Multiple other studies have demonstrated
successful short- and mid-term clinical outcomes in patients with type III
injuries treated nonsurgically.34-36
Proper and adequate rehabilitation
may be critical to successful nonsurgical treatment of type III AC injuries. Glick et al37 evaluated 35 unre-

212

duced AC dislocations that were

treated nonsurgically in a professional and competitive recreational
athletic population. None of the patients was disabled. In addition, none
of the patients who had a supervised
rehabilitation program had reports
of pain. These authors concluded
that the predominant reason for persistent pain and disability after a
type III AC injury treated nonsurgically was inadequate rehabilitation.
This conclusion is supported by the
assertion by Gurd38 that the shoulder
can function normally despite an absent clavicle as long as the shoulder
girdle muscles are strengthened and
maintained. Thus, a structured active
rehabilitation program that focuses
on gaining strength of shoulder girdle muscles, including the deltoid,
trapezius, sternocleidomastoid, and
subclavius, as well as the rotator cuff
and periscapular stabilizers, is indicated for patients who are treated
nonsurgically.
Although there is no conclusive evidence of it in the literature, a relative indication for AC surgical stabilization after an acute type III injury
may be young age or a job or sport
that places high demands on the
shoulder. In addition, chronic symptoms of instability and pain following a type III AC dislocation may

warrant delayed surgical reconstruction. Recent reports of successful

nonsurgical treatment of type III AC
injuries in professional baseball players have challenged the relative indication of sport or job type in selecting a management protocol.39
Despite the success of nonsurgical
treatment, late symptomatic sequelae
can develop. Occasionally, distal
clavicle osteolysis or a painful AC
disk injury, akin to a knee meniscal
tear, occurs acutely, or AC arthritis
develops over time. When symptomatic, these conditions can be
treated by steroid injection or distal
clavicle resection with intra-articular
disk excision, as described by Mumford,40 combined with a ligamentous
reconstruction to establish stability.

Surgical
The case can be made for surgical
management of some acute type III
AC joint dislocations. However,
acute type IV, V, and VI AC joint dislocations all require surgical intervention, although there is no consensus on which technique to use.
Surgical techniques can be categorized into three main groups (Table
2), although all have the goal of obtaining and retaining anatomic AC
joint reduction.

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Ryan Simovitch, MD, et al

Primary Fixation of the

Acromioclavicular Joint
Historically, primary fixation of the
AC joint consisted of pin fixation using either smooth or threaded
Kirschner wires after a closed or
open reduction. However, this
method has been abandoned, given
the rare but catastrophic occurrence
of pin migration; the pins have been
found in the heart, lungs, and great
vessels.41,42
An alternative technique commonly used in Europe is the hookplate. After open reduction of the
AC joint, the lateral end of the plate
is inserted deep to the acromion and
levered down on the clavicle to reduce the joint. It is secured to the
clavicle with bicortical screws. Some
surgeons combine hook-plate fixation with ligament reconstruction,43
while others use the hook-plate
alone.44 The plate is removed at 8
weeks. This technique has been successful in treating AC dislocations
and distal clavicle fractures.43 Sim et
al,44 however, reported that 8 of 16
patients experienced complications
(one bent plate, one plate dislocation, six infections).
Fixation Between the Coracoid
Process and Clavicle
Bosworth45 popularized the use of a
screw for CC fixation. The use of
screws and suture loops has been described alone and in combination
with ligament reconstruction. Rockwood et al20 recommended that a CC
screw (Figure 4) be combined with
ligament reconstruction in acute
cases of AC dislocation. Through recent arthroscopic advances, CC fixation can now be accomplished by
less invasive means.
Placement of synthetic loops between the coracoid process and clavicle have been described by several
authors, most often in combination
with a form of CC ligament reconstruction. The main advantage of
April 2009, Vol 17, No 4

Figure 4

A, Intraoperative photograph demonstrating percutaneous placement of a

coracoclavicular (CC) screw under fluoroscopic guidance. The screw is
placed to reduce the CC interspace and anchor the clavicle to the coracoid
process during soft-tissue healing, as demonstrated in an intraoperative
anteroposterior radiograph (B).

this technique is that it does not require staged removal as do CC

screws. Absorbable and nonabsorbable materials can be used. Morrison
and Lemos46 demonstrated the importance of accurate positioning of a
synthetic loop to allow for the most
anatomic reduction possible. Potential complications of this technique
include suture cutout. Good results
have been reported with 6-mm polytetrafluoroethylene surgical tape as a
secondary fixation combined with
coracoacromial (CA) ligament transfer.46 However, cases of aseptic
foreign-body reaction and clavicle
osteolysis that resulted in failure
have been reported.47,48

Coracoid Process Transfer

Transfer of the coracoid process was
first described by Dewar and Barrington.49 It has been used for the
treatment of acute and chronic injuries, with better results in younger
patients. However, reports of residual joint aching led to the proce-

dures being abandoned because of

poor long-term outcomes.50

Ligament Reconstruction
Weaver and Dunn15 first described
the use of the native CA ligament to
reestablish AC joint stability (Figure
5). This technique has since been
modified to include resection of the
distal clavicle to avoid late degenerative changes at the AC joint. The CA
ligament is detached from the deep
surface of the acromion with or
without a chip of bone and is then
transferred to the clavicle. This construct can be augmented with a suture loop that provides protection
while the reconstructed ligament
heals. Recently, Lafosse et al51 described an all-arthroscopic technique
for CA ligament transfer in the setting of acute or chronic AC dislocations.
An alternative technique for ligament reconstruction is the use of a
semitendinosus tendon autograft.
This technique is combined with re-

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Acromioclavicular Joint Injuries: Diagnosis and Management

Figure 5

The modified Weaver-Dunn procedure. The coracoacromial ligament (A) is

transferred to the clavicle to substitute for the ruptured coracoclavicular
ligaments. A suture loop (B) can be used for augmentation.

section of the distal clavicle. Jones

et al52 described the use of a looped
semitendinosus graft around the
coracoid process and clavicle in a revision AC joint reconstruction. Mazzocca et al16 modified this technique,
incorporating a doubled semitendinosus graft inserted in a coracoid
bone tunnel and secured in two separate clavicle bone tunnels. Interference screws were used to approximate the anatomic location of the
trapezoid ligaments. Biomechanical
testing of this construct has been favorable. We have used anterior tibialis tendon allograft in reconstruction
(Figure 6). Good clinical results have
been achieved using hamstring tendons to reconstruct high-grade AC
separations.53 However, future studies must examine the extent to which
two drill holes weaken the clavicle
and how tunnel expansion54 influences the biomechanical and clinical
outcomes of this treatment.
We favor the use of a doubled
semitendinosus autograft or tibialis
anterior allograft looped around the

Figure 6

Intraoperative photographs of a procedure to anatomically reconstruct the coracoclavicular ligaments through bone
tunnels in the clavicle (C) using a semitendinosus allograft. A, A suture passer is passed from medial to lateral around
the coracoid tip (*) and used to retrieve the anterior tibialis allograft around the coracoid process. B, The graft ends are
pulled through two bone tunnels (arrows) in the clavicle to approximate the pull of the conoid and trapezoid ligaments.

214

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Ryan Simovitch, MD, et al

coracoid process or potted in a coracoid bone socket. The graft is fixed

with interference screws through two
separate clavicle bone tunnels that
approximate the normal anatomic
location and orientation of the CC
ligaments. We believe that this best
replicates the injured anatomy. Biomechanical studies have demonstrated the superiority of this construct. We routinely resect the distal
clavicle at the index operation. However, recent interest in the additional
AC stability conferred by not resecting
the distal clavicle and the clinical ramifications of doing so may be compelling. A possible shift in the treatment
paradigm awaits further prospective
clinical and well-designed biomechanical trials.

Distal Clavicle Resection

There has been some interest in primary or delayed excision of the distal clavicle (ie, Mumford procedure)
in a symptomatic AC joint after dislocation. Although there has been
success with this technique done
open as well as arthroscopically, it
must be reserved for patients in
whom the CC ligaments are intact
and there is no concomitant instability. When horizontal or vertical instability exists, results are compromised because this technique does
not address instability and may accentuate it.23,24,55

Biomechanical
Considerations
The goal of AC joint reconstruction,
when indicated, is to achieve an anatomic reconstruction that best restores both the restraint to vertical as
well as anteroposterior translation of
the clavicle at the AC joint. Multiple
studies have examined the biomechanical results of various reconstructive techniques (Table 3), and
several conclusions can be drawn
April 2009, Vol 17, No 4

from them.16,56-63 A study by Jari

et al56 suggests that surgical techniques that preserve the articulating
surface of the clavicle at the AC joint
lead to lower joint contact forces and
are preferred.
CA ligament transfer, which has
long been the most popular method
for treating complete chronic AC dislocations, has just 25% of the
strength of the intact CC complex
and allows far greater primary and
coupled translation than does the intact AC joint.63 Augmentation of this
repair/reconstruction with various
suture loops and suture anchors can
increase the construct strength and
ultimate load to failure while reducing primary and coupled translation.
However, these constructs are biomechanically inferior to the native intact AC and CC capsuloligamentous
unit. Screw fixation may also be considered. Although the bicortical
Rockwood screw has the highest tensile strength and stiffness with the
lowest elasticity, these properties
may also be responsible for its high
complication rate, including screw
breakage and pullout.56
In a recent study of 42 cadaveric specimens, Mazzocca et al16 compared the
stability conferred by three AC joint reconstruction techniques: CA ligament
transfer and distal clavicle resection
with suture loop augmentation, anatomic reconstruction with a doublebundled semitendinosus graft inserted
into a coracoid bone socket, and arthroscopic reconstruction with suture
and titanium screws (ie, suture loop
and CC screw fixation). Only the anatomic CC reconstruction with tendon
graft and suture augmentation provided anterior, posterior, and superior
stability not statistically different from
the intact state. The authors also recognized that a graft offers the advantage of a scaffold for revascularization
compared with the arthroscopic suture
loop, which does not and which can fa-

tigue and fail over time with cyclic

loading.
Costic et al57 demonstrated that the
dislocated clavicle can lose up to
40% of its stiffness, which suggests
that previous biomechanical models
may be flawed, depending on how
the clavicle and scapula were potted
for testing.

Complications
Complications can occur as a result of
nonsurgical and surgical treatment of
AC joint dislocations. The most common complications associated with
nonsurgical treatment are development
of late arthrosis and persistent instability. Distal clavicle osteolysis also has
been described.
Complications following surgical
treatment of AC joint dislocations are
related to the technique chosen. Hardware failure and migration resulting in
injury to the great vessels have been described. In addition, aseptic foreignbody reaction or infection may occur
after the use of implants and synthetic
suture. Depending on the choice of
technique for surgical reconstruction,
early or late fracture of the coracoid
process or clavicle has been reported.
In addition, any technique that passes
a graft or synthetic material medial to
the coracoid process poses a potential
risk to the brachial plexus and axillary
artery. Although reconstructive success
is clinically predicated on alleviating
pain and establishing AC stability, persistent pain and recurrent instability
have been reported with all of the described techniques.

Postoperative
Rehabilitation
After CC fixation with a metallic
screw or suture construct for acute
AC injuries, the shoulder is immobilized in a simple sling and cold therapy device. At 2 weeks, active and

215

Acromioclavicular Joint Injuries: Diagnosis and Management

Table 3
Biomechanical Comparison of Acromioclavicular Joint Reconstruction Techniques
Study

Methodology

Results

Mazzocca
et al16

Biomechanical testing of 42 cadav- All three techniques establish comparable vertical stability and load to failure
eric shoulders for vertical and AP Anatomic CC reconstruction that reconstructs both conoid and trapezoid ligaments allows the least AP translation of the three techniques and best aptranslation of the AC joint after
proximates the intact state
three reconstructive techniques:
modified Weaver-Dunn procedure, arthroscopic suture fixation,
and anatomic CC reconstruction
with semitendinosus graft

Jari et al56

Biomechanical comparison of the

CA ligament transfer, CC sling,
and Rockwood screw

Compared with the intact AC joint state, anterior, posterior, and superior translation increased 110%, 100%, and 360%, respectively, after the CA ligament
transfer. With the CC sling, anterior translation increased by 110% and posterior translation by 330%.
Primary translation was reduced with the Rockwood screw. A significant decrease in posterior translation was noted (60%) compared with the intact
joint. Similar findings were noted for coupled translations (ie, AP).
The Rockwood screw was the most rigid construct and was found to experience forces 30% and 170% greater than the intact AC joint in response to
anterior and posterior loads, respectively.

Costic et al57

Biomechanical comparison of an
intact AC joint with anatomic reconstruction using a semitendinosus graft

Stiffness and ultimate load to failure of the intact CC ligament state was significantly greater than for the anatomic reconstruction complex (P 0.05)
Stiffness of the anatomic reconstruction complex (23.4 N/mm) was 40% of the
stiffness of the intact CC complex (60.8 N/mm)
Anatomic reconstruction complex had clinically insignificant elongation (<3 mm)
after cyclic loading
There is a 40% decrease in bending stiffness of the clavicle after dislocation
that contributes to diminished stiffness of anatomic reconstruction

Deshmukh
et al58

Biomechanical comparison of the Average load to failure of the Weaver-Dunn procedure alone was 177 N comWeaver-Dunn procedure alone
pared with 319 N for augmentation with a variety of suture anchors or suture
with the Weaver-Dunn procedure cerclage
augmented by suture cerclage or The only failure during the 1,000-cycle fatigue test occurred with an unaugsuture anchor fixation
mented Weaver-Dunn procedure
The augmented Weaver-Dunn technique significantly better approximated the
intact state of the AC joint for superior and AP laxity compared with the unaugmented Weaver-Dunn (P = 0.05) The mean superior and AP laxity for the
augmented Weaver-Dunn technique was 7.6 mm and 26.9 mm, respectively,
versus 3.1 mm and 8.8 mm, respectively, for the intact state. The authors
found no significant difference in biomechanical properties depending on suture anchor choice for the augmentation technique

Baker et al59

Biomechanical examination of var- A more anterior drill hole in the clavicle allows more joint congruity and less
ied placement of the drill hole for
anterior displacement of the clavicle with anterior loading
loop fixation of the clavicle after No method of loop fixation approached normal AC joint congruity
AC dislocation in 14 cadaveric
shoulders

Lee et al63

Biomechanical comparison of CA CA ligament transfer was the weakest construct

ligament transfer, Mersilene tape Mersilene tape reconstruction provided superior initial fixation strength compared with CA ligament transfer
reconstruction, and ligament reUltimate load to failure was equivalent among semitendinosus, gracilis, and
construction with semitendinolong toe extensor grafts
sus, gracilis, and long toe extensors

Wilson et al60

Biomechanical comparison of
AC joints were significantly more mobile after Weaver-Dunn reconstruction
Weaver-Dunn reconstruction
alone compared with the intact state (P < 0.005). However, with suture analone compared with Weaverchor augmentation, the reconstructed state approached the intact state in
Dunn augmented with CC suture
terms of anterior, posterior, and superior translation.
anchor fixation

AC = acromioclavicular, AP = anteroposterior, CA = coracoacromial, CC = coracoclavicular

216

Journal of the American Academy of Orthopaedic Surgeons

Ryan Simovitch, MD, et al

Table 3 (continued)
Biomechanical Comparison of Acromioclavicular Joint Reconstruction Techniques
Study

Methodology

Results

Breslow et al61

Biomechanical comparison of suture and suture anchors for the

loop method of stabilizing the
dislocated AC joint

Harris et al62

Biomechanical comparison of ten- CA ligament transfer demonstrated the weakest reconstruction initially
CC slings had high tensile strength but were very elastic and had the highest
sile strength, tensile stiffness,
and elongation at failure with five elongation at failure.
CC screws provided the highest tensile strength and stiffness as well as least
techniques in 19 cadaveric
elasticity, but only with bicortical coracoid purchase
shoulders: CA transfer, CC sling
with 8-mm polyester vascular
prosthesis, 2 CC suture anchors,
unicortical Bosworth screw, and
bicortical Bosworth screw

After 10,000 cycles, laxity of the construct with suture loop was 1.32 0.59
mm compared with 1.33 0.94 mm for the suture anchor loop. The differences were not statistically significant.

AC = acromioclavicular, AP = anteroposterior, CA = coracoacromial, CC = coracoclavicular

passive ROM is initiated and restricted to beneath the shoulder level.

Doing so allows the patient to begin
activities of daily living while avoiding lifting anything heavier than 5
pounds. Once the screw is removed
at 2 to 3 months, full active and
passive ROM is encouraged, with
strengthening limited to light resistance for 6 to 8 weeks. Once full
ROM and strength are obtained, return to athletic competition is permitted.
After AC joint reconstruction with an
autogenous or allograft ligament reconstruction (eg, semitendinosus graft,
modified Weaver-Dunn), the arm is
maintained in a simple sling. At 2
weeks, pendulum exercises are initiated,
followed by light activities of daily living at 4 weeks. With further graft maturation at approximately 8 weeks, active and passive ROM is encouraged
with a therapist, and light resistance can
be initiated after 3 months. Once full
ROM and strength are obtained, return
to athletic competition or manual labor
is permitted.

Summary
Significant recent advances have
been made in the approach to AC
April 2009, Vol 17, No 4

joint injury. There is a consensus that

type I and II AC joint injuries should
be treated nonsurgically, while acute
type IV, V, and VI injuries should be
treated surgically. The correct algorithm for treating type III injuries is
not known; most studies do not
show a significant difference in the
clinical outcome between nonsurgically and surgically treated patients.
Although it has not been sufficiently
demonstrated, it may be that a subset of overhead athletes and heavy
laborers would benefit from surgical
reconstruction of type III injuries.
The idea that adequate rehabilitation
is critical to a successful outcome of
nonsurgical treatment of a type III
injury is worthy of attention and further study. It is often the case that
nonsurgical care translates into benign neglect, and perhaps inadequate
rehabilitation has been responsible
for some of the failures related to
nonsurgical treatment.

P, Bradley J: Prevalence and variance of

shoulder injuries in elite collegiate
football players. Am J Sports Med 2005;
33:1142-1146.
2.

Thorndike AJ: Injuries to the

acromioclavicular joint: A plea for
conservative treatment. Am J Surg 1942;
55:250-261.

3.

Tossy JD, Mead MC, Sigmond HM:

Acromioclavicular separations: Useful
and practical classification for treatment.
Clin Orthop Relat Res 1963;28:111119.

4.

Allman FL Jr: Fractures and ligamentous

injuries of the clavicle and its
articulation. J Bone Joint Surg Am 1967;
49:774-784.

5.

Williams GR Jr, Nguyen VD, Rockwood

CA Jr: Classification and radiographic
analysis of acromioclavicular
dislocations. Appl Radiol 1989;18:2934.

6.

Powers JA, Bach PJ: Acromioclavicular

separations: Closed or open treatment?
Clin Orthop Relat Res 1974;104:213223.

7.

Cox JS: Current method of treatment of

acromioclavicular joint dislocations.
Orthopedics 1992;15:1041-1044.

8.

Larsen E, Bjerg-Nielsen A, Christensen P:

Conservative or surgical treatment of
acromioclavicular dislocation: A
prospective, controlled, randomized
study. J Bone Joint Surg Am 1986;68:
552-555.

9.

Bannister GC, Wallace WA, Stableforth

PG, Hutson MA: The management of
acute acromioclavicular dislocation: A
randomised prospective controlled trial.
J Bone Joint Surg Br 1989;71:848-850.

References
Citation numbers printed in bold type
indicate references published within
the past 5 years.
1.

Kaplan LD, Flanigan DC, Norwig J, Jost

10.

Taft TN, Wilson FC, Oglesby JW:

217

Acromioclavicular Joint Injuries: Diagnosis and Management

Dislocation of the acromioclavicular
joint: An end-result study. J Bone Joint
Surg Am 1987;69:1045-1051.
11.

Galpin RD, Hawkins RJ, Grainger RW:

A comparative analysis of operative
versus nonoperative treatment of grade
III acromioclavicular separations. Clin
Orthop Relat Res 1985;193:150-155.

25.

Rios CG, Arciero RA, Mazzocca AD:

Anatomy of the clavicle and coracoid
process for reconstruction of the
coracoclavicular ligaments. Am J Sports
Med 2007;35:811-817.

12.

Phillips AM, Smart C, Groom AF:

Acromioclavicular dislocation:
Conservative or surgical therapy. Clin
Orthop Relat Res 1998;353:10-17.

26.

Bearden JM, Hughston JC, Whatley GS:

Acromioclavicular dislocation: Method
of treatment. J Sports Med 1973;1:5-17.

13.

Bradley JP, Elkousy H: Decision making:

Operative versus nonoperative treatment
of acromioclavicular joint injuries. Clin
Sports Med 2003;22:277-290.

14.

Lemos MJ: The evaluation and treatment

of the injured acromioclavicular joint in
athletes. Am J Sports Med 1998;26:137144.

15.

Weaver JK, Dunn HK: Treatment of

acromioclavicular injuries, especially
complete acromioclavicular separation.
J Bone Joint Surg Am 1972;54:11871194.

16. Mazzocca AD, Santangelo SA, Johnson

ST, Rios CG, Dumonski ML, Arciero
RA: A biomechanical evaluation of an
anatomical coracoclavicular ligament
reconstruction. Am J Sports Med 2006;
34:236-246.
17.

DePalma AF: The role of the discs of the

sternoclavicular and acromioclavicular
joints. Clin Orthop Relat Res 1959;13:712.

18.

Kennedy JC: Complete dislocation of the

acromioclavicular joint: 14 years later.
J Trauma 1968;8:311-318.

19.

20.

21.

22.

23.

24.

218

Flatow EL: The biomechanics of the

acromioclavicular, sternoclavicular, and
scapulothoracic joints. Instr Course Lect
1993;42:237-245.
Rockwood CA Jr, Williams GR Jr,
Young DC: Disorders of the acromioclavicular joint, in Rockwood CA, Matsen FA (eds): The Shoulder. Philadelphia,
PA: WB Saunders, 1998, pp 483-553.
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;68:434-440.
Klimkiewicz JJ, Williams GR, Sher JS,
Karduna A, Des Jardins J, Iannotti JP:
The acromioclavicular capsule as a
restraint to posterior translation of the
clavicle: A biomechanical analysis.
J Shoulder Elbow Surg 1999;8:119-124.
Corteen DP, Teitge RA: Stabilization of
the clavicle after distal resection: A
biomechanical study. Am J Sports Med
2005;33:61-67.
Renfree KJ, Wright TW: Anatomy and

clavicle: An hitherto undescribed

operation. Ann Surg 1941;113:10941098.

biomechanics of the acromioclavicular

and sternoclavicular joints. Clin Sports
Med 2003;22:219-237.

27.

28.

Lizaur A, Marco L, Cebrian R: Acute

dislocation of the acromioclavicular
joint: Traumatic anatomy and the
importance of deltoid and trapezius.
J Bone Joint Surg Br 1994;76:602-606.
OBrien SJ, Pagnani MJ, Fealy S,
McGlynn SR, Wilson JB: The active
compression test: A new and effective
test for diagnosing labral tears and
acromioclavicular joint abnormality. Am
J Sports Med 1998;26:610-613.

39.

McFarland EG, Blivin SJ, Doehring CB,

Curl LA, Silberstein C: Treatment of
grade III acromioclavicular separations
in professional throwing athletes: Results
of a survey. Am J Orthop 1997;11:771774.

40.

Mumford EB: Acromioclavicular

dislocation: A new operative treatment.
J Bone Joint Surg Am 1941;23:799-802.

41.

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;47:1024-1026.

42.

Sethi GK, Scott SM: Subclavian artery

laceration due to migration of a Hagie
pin. Surgery 1976;80:644-646.

43.

Faraj AA, Ketzer B: The use of a hookplate in the management of

acromioclavicular injuries: Report of ten
cases. Acta Orthop Belg 2001;67:448451.

29.

Nuber GW, Bowen MK:

Acromioclavicular joint injuries and
distal clavicle fractures. J Am Acad
Orthop Surg 1997;5:11-18.

30.

Bergfeld JA, Andrish JT, Clancy WG:

Evaluation of the acromioclavicular joint
following first- and second-degree
sprains. Am J Sports Med 1978;6:153159.

44.

Sim E, Schwarz N, Hcker K,

Berzlanovich A: Repair of complete
acromioclavicular separations using the
acromioclavicular-hook plate. Clin
Orthop Relat Res 1995;314:134-142.

31.

Mouhsine E, Garofalo R, Crevoisier X,

Farron A: Grade I and II
acromioclavicular dislocations: Results
of conservative treatment. J Shoulder
Elbow Surg 2003;12:599-602.

45.

Bosworth BM: Acromioclavicular

separation: New method of repair. Surg
Gynecol Obstet 1941;73:866-871.

46.

Morrison DS, Lemos MJ:

Acromioclavicular separation:
Reconstruction using synthetic loop
augmentation. Am J Sports Med 1995;
23:105-110.

47.

Boldin C, Fankhauser F, Ratschek M,

Haller-Schober EM: Foreign-body
reaction after reconstruction of complete
acromioclavicular dislocation using PDS
augmentation. J Shoulder Elbow Surg
2004;13:99-100.

48.

Stewart AM, Ahmad CS: Failure of

acromioclavicular reconstruction using
Gore-Tex graft due to aseptic foreignbody reaction and clavicle osteolysis: A
case report. J Shoulder Elbow Surg
2004;13:558-561.

49.

Dewar FP, Barrington TW: The

treatment of chronic acromio-clavicular
dislocation. J Bone Joint Surg Br 1965;
47:32-35.

50.

Ferris BD, Bhamra M, Paton DF:

Coracoid process transfer for
acromioclavicular dislocations: A report
of 20 cases. Clin Orthop Relat Res 1989;
242:184-194.

51.

Lafosse L, Baier GP, Leuzinger J:

Arthroscopic treatment of acute and
chronic acromioclavicular joint
dislocation. Arthroscopy 2005;21:1017.

32.

Nuber GW, Bowen MK: Arthroscopic

treatment of acromioclavicular joint
injuries and results. Clin Sports Med
2003;22:301-317.

33.

Wojtys EM, Nelson G: Conservative

treatment of grade III acromioclavicular
dislocations. Clin Orthop Relat Res
1991;268:112-119.

34.

Bjerneld H, Hovelius L, Thorling J:

Acromio-clavicular separations treated
conservatively: A 5-year follow-up study.
Acta Orthop Scand 1983;54:743-745.

35.

Cox JS: The fate of the

acromioclavicular joint in athletic
injuries. Am J Sports Med 1981;9:50-53.

36.

Walsh WM, Peterson DA, Shelton G,

Neumann RD: Shoulder strength
following acromioclavicular injury. Am J
Sports Med 1985;13:153-158.

37.

Glick JM, Milburn LJ, Haggerty JF,

Nishimoto D: Dislocated
acromioclavicular joint: Follow-up study
of 35 unreduced acromioclavicular
dislocations. Am J Sports Med 1977;5:
264-270.

38.

Gurd FB: The treatment of complete

dislocation of the outer end of the

Journal of the American Academy of Orthopaedic Surgeons

Ryan Simovitch, MD, et al

52.

53.

Jones HP, Lemos MJ, Schepsis AA:

Salvage of failed acromioclavicular joint
reconstruction using autogenous
semitendinosus tendon from the knee:
Surgical technique and case report. Am J
Sports Med 2001;29:234-237.

57.

LaPrade RF, Hilger B: Coracoclavicular

ligament reconstruction using a
semitendinosus graft for failed
acromioclavicular separation surgery.
Arthroscopy 2005;21:1277.

54. Yoo JC, Choi NH, Kim SY, Lim TK:

Distal clavicle tunnel widening after
coracoclavicular ligament reconstruction
with semitendinous tendon: A case
report. J Shoulder Elbow Surg 2006;15:
256-259.
55.

RE: Biomechanical function of surgical

procedures for acromioclavicular joint
dislocations. Arthroscopy 2004;20:237245.

Levine WN, Barron OA, Yamaguchi K,

Pollock RG, Flatow EL, Bigliani LU:
Arthroscopic distal clavicle resection
from a bursal approach. Arthroscopy
1998;14:52-56.

56. Jari R, Costic RS, Rodosky MW, Debski

April 2009, Vol 17, No 4

Costic RS, Labriola JE, Rodosky MW,

Debski RE: Biomechanical rationale for
development of anatomical
reconstructions of coracoclavicular
ligaments after complete
acromioclavicular joint dislocations. Am
J Sports Med 2004;32:1929-1936.

58. Deshmukh AV, Wilson DR, Zilberfarb

JL, Perlmutter GS: Stability of
acromioclavicular joint reconstruction:
Biomechanical testing of various surgical
techniques in a cadaveric model. Am J
Sports Med 2004;32:1492-1498.
59.

Baker JE, Nicandri GT, Young DC,

Owen JR, Wayne JS: A cadaveric study
examining acromioclavicular joint
congruity after different methods of
coracoclavicular loop repair. J Shoulder
Elbow Surg 2003;12:595-598.

60.

Wilson DR, Moses JM, Zilberfarb JL,

Hayes WC: Mechanics of
coracoacromial ligament transfer
augmentation for acromioclavicular joint
injuries. J Biomech 2005;38:615-619.

61.

Breslow MJ, Jazrawi LM, Bernstein AD,

Kummer FJ, Rokito AS: Treatment of
acromioclavicular joint separation:
Suture or suture anchors? J Shoulder
Elbow Surg 2002;11:225-229.

62.

Harris RI, Wallace AL, Harper GD,

Goldberg JA, Sonnabend DH, Walsh
WR: Structural properties of the intact
and the reconstructed coracoclavicular
ligament complex. Am J Sports Med
2000;28:103-108.

63.

Lee SJ, Nicholas SJ, Akizuki KH,

McHugh MP, Kremenic IJ, Ben-Avi S:
Reconstruction of the coracoclavicular
ligaments with tendon grafts: A
comparative biomechanical study. Am J
Sports Med 2003;31:648-655.

219