Combination of Surgical Techniques Restores Multidirectional Biomechanical Stability of Acromioclavicular Joint

Published:December 14, 2021DOI:


      To measure the multiaxial stability of the acromioclavicular joint before and after transection of the acromioclavicular capsule and coracoclavicular ligaments and after sequential repair of acromioclavicular and coracoclavicular ligaments.


      Biomechanical testing was performed on fresh-frozen human cadaveric shoulders (N = 6). Translational and rotational stability in the vertical and horizontal planes was measured in intact specimens, after transecting the acromioclavicular and coracoclavicular ligaments, and after sequentially performing the following procedures: single-bundle coracoclavicular repair (CCR), modified Weaver–Dunn procedure (WD), and acromioclavicular stabilization (ACS).


      Resecting the acromioclavicular and coracoclavicular significantly reduced translational stiffness in the inferior and anteroposterior directions, as well as rotational stiffness about the vertical and anteroposterior axes. All 3 surgical procedures increased inferior translational stiffness relative to the intact condition (Intact: 38 ± 9 N/mm, CCR: 54 ± 23 N/mm (P = .03), CCR+WD 52 ± 20 N/mm (P = .07), CCR ± WD+ACS 50 ± 21 N/mm (P = .17)). However, the combination of CCR, modified WD, and ACS resulted in the greatest increase in stiffness in internal rotation (Intact: 12.5 ± 7.4 cNm/deg, CCR: 1.2 ± 1.1 cNm/deg, CCR+WD 7.2 ± 3.0 N∗m/deg [P = .023], CCR+WD+ACS 11.6 ± 4.9 cNm/deg [P = .055]).


      The cumulative stability of CCR, WD reconstruction, and ACS appears to be additive. Our findings provide a biomechanical justification for combining all three techniques. Biomechanical studies assessing the performance of various acromioclavicular repairs and reconstructions should therefore incorporate multiaxial testing in their protocols.

      Clinical Relevance

      Multiple points of fixation that provide multidirectional stability have the potential to improve clinical outcomes and reduce failure rates of acromioclavicular joint repair or stabilization.
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        • Weiser L.
        • Nuchtern J.V.
        • Sellenschloh K.
        • et al.
        Acromioclavicular joint dislocations: Coracoclavicular reconstruction with and without additional direct acromioclavicular repair.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2025-2031
        • Schliemann B.
        • Lenschow S.
        • Schurmann P.
        • et al.
        Biomechanics of a new technique for minimal-invasive coracoclavicular ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1176-1182
        • Wylie J.D.
        • Johnson J.D.
        • DiVenere J.
        • Mazzocca A.D.
        Shoulder acromioclavicular and coracoclavicular ligament injuries: Common problems and solutions.
        Clin Sports Med. 2018; 37: 197-207
        • Granville-Chapman J.
        • Torrance E.
        • Rashid A.
        • Funk L.
        The Rockwood classification in acute acromioclavicular joint injury does not correlate with symptoms.
        J Orthop Surg (Hong Kong). 2018; 26 (2309499018777886)
        • Sandmann G.H.
        • Marteschlager F.
        • Mey L.
        • et al.
        Reconstruction of displaced acromio-clavicular joint dislocations using a triple suture-cerclage: Description of a safe and efficient surgical technique.
        Patient Safety Surg. 2012; 6: 25
        • Stucken C.
        • Cohen S.B.
        Management of acromioclavicular joint injuries.
        Orthop Clin North Am. 2015; 46: 57-66
        • Beitzel K.
        • Obopilwe E.
        • Apostolakos J.
        • et al.
        Rotational and translational stability of different methods for direct acromioclavicular ligament repair in anatomic acromioclavicular joint reconstruction.
        Am J Sports Med. 2014; 42: 2141-2148
        • Dawson P.A.
        • Adamson G.J.
        • Pink M.M.
        • et al.
        Relative contribution of acromioclavicular joint capsule and coracoclavicular ligaments to acromioclavicular stability.
        J Shoulder Elbow Surg. 2009; 18: 237-244
        • Kraus N.
        • Hann C.
        • Gerhardt C.
        • Scheibel M.
        Dynamic instability of the acromioclavicular joint.
        Obere Extremität. 2018; 13: 279-285
        • Scheibel M.
        • Droschel S.
        • Gerhardt C.
        • Kraus N.
        Arthroscopically assisted stabilization of acute high-grade acromioclavicular joint separations.
        Am J Sports Med. 2011; 39: 1507-1516
        • Metzlaff S.
        • Rosslenbroich S.
        • Forkel P.H.
        • et al.
        Surgical treatment of acute acromioclavicular joint dislocations: Hook plate versus minimally invasive reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 1972-1978
        • Debski R.E.
        • Parsons I.M.
        • Woo S.L.
        • Fu F.H.
        Effect of capsular injury on acromioclavicular joint mechanics.
        J Bone Joint Surg Am. 2001; 83: 1344-1351
        • Masionis P.
        • Satkauskas I.
        • Mikelevicius V.
        • et al.
        Biomechanical evaluation of native acromioclavicular joint ligaments and two reconstruction techniques in the presence of the sternoclavicular joint: A cadaver study.
        J Orthop Surg (Hong Kong). 2017; 25 (2309499017730424)
        • Abat F.
        • Sarasquete J.
        • Natera L.G.
        • et al.
        Biomechanical analysis of acromioclavicular joint dislocation repair using coracoclavicular suspension devices in two different configurations.
        J Orthop Traumatol. 2015; 16: 215-219
        • Wellmann M.
        • Kempka J.P.
        • Schanz S.
        • et al.
        Coracoclavicular ligament reconstruction: biomechanical comparison of tendon graft repairs to a synthetic double bundle augmentation.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 521-528
        • Park I.
        • Itami Y.
        • Hedayati B.
        • et al.
        Biomechanical analysis of single-, double-, and triple-bundle configurations for coracoclavicular ligament reconstruction using cortical fixation buttons with suture tapes: A cadaveric study.
        Arthroscopy. 2018; 34: 2983-2991
        • Cho C.H.
        • Kim B.S.
        • Kwon D.H.
        Importance of additional temporary pin fixation combined coracoclavicular augmentation using a suture button device for acute acromioclavicular joint dislocation.
        Arch Orthop Trauma Surg. 2016; 136: 763-770
        • Michlitsch M.G.
        • Adamson G.J.
        • Pink M.
        • Estess A.
        • Shankwiler J.A.
        • Lee T.Q.
        Biomechanical comparison of a modified Weaver-Dunn and a free-tissue graft reconstruction of the acromioclavicular joint complex.
        Am J Sports Med. 2010; 38: 1196-1203
        • Saier T.
        • Venjakob A.J.
        • Minzlaff P.
        • et al.
        Value of additional acromioclavicular cerclage for horizontal stability in complete acromioclavicular separation: a biomechanical study.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 1498-1505
        • Hann C.
        • Kraus N.
        • Minkus M.
        • Maziak N.
        • Scheibel M.
        Combined arthroscopically assisted coraco- and acromioclavicular stabilization of acute high-grade acromioclavicular joint separations.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 212-220
        • Gonzalez-Lomas G.
        • Javidan P.
        • Lin T.
        • Adamson G.J.
        • Limpisvasti O.
        • Lee T.Q.
        Intramedullary acromioclavicular ligament reconstruction strengthens isolated coracoclavicular ligament reconstruction in acromioclavicular dislocations.
        Am J Sports Med. 2010; 38: 2113-2122
        • Martetschläger F.
        • Tauber M.
        • Habermeyer P.
        • Hawi N.
        Arthroscopically assisted acromioclavicular and coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability.
        Arthrosc Tech. 2016; 5: e1239-e1246
        • Schar M.O.
        • Jenni S.
        • Fessel G.
        • Snedeker J.G.
        • Scheibel M.
        • Zumstein M.A.
        Biomechanical comparison of two biplanar and one monoplanar reconstruction techniques of the acromioclavicular joint.
        Arch Orthop Trauma Surg. 2019; 139: 779-786
        • Haber D.B.
        • Golijanin P.
        • Stone G.L.
        • et al.
        Primary acromioclavicular-coracoclavicular reconstruction using 2 allografts, TightRope, and stabilization to the acromion.
        Arthrosc Tech. 2019; 8: e147-e152
        • Dyrna F.G.E.
        • Imhoff F.B.
        • Voss A.
        • et al.
        The integrity of the acromioclavicular capsule ensures physiological centering of the acromioclavicular joint under rotational loading.
        Am J Sports Med. 2018; 46: 1432-1440
        • Seo J.-B.
        • Heo K.
        • Kim S.-J.
        • Jung J.-U.
        • Yoo J.-S.
        Arthroscopic acromioclavicular fixation with suture tape augmentation after coracoclavicular fixation with dog bone button: Surgical technique.
        Arthrosc Tech. 2018; 7: e1197-e1203
        • Weaver J.K.
        • Dunn H.K.
        Treatment of acromioclavicular injuries, especially complete acromioclavicular separation.
        J Bone Joint Surg. 1972; 54: 1187-1194
        • Le Hanneur M.
        • Thoreson A.
        • Delgrande D.
        • et al.
        Biomechanical comparison of anatomic and extra-anatomic reconstruction techniques using local grafts for chronic instability of the acromioclavicular joint.
        Am J Sports Med. 2018; 46: 1927-1935
        • Lee S.J.
        • Nicholas S.J.
        • Akizuki K.H.
        • McHugh M.P.
        • Kremenic I.J.
        • Ben-Avi S.
        Reconstruction of the coracoclavicular ligaments with tendon grafts: A comparative biomechanical study.
        Am J Sports Med. 2003; 31: 648-655
        • Deshmukh A.V.
        • Wilson D.R.
        • Zilberfarb J.L.
        • Perlmutter G.S.
        Stability of acromioclavicular joint reconstruction: Biomechanical testing of various surgical techniques in a cadaveric model.
        Am J Sports Med. 2004; 32: 1492-1498
        • Beitzel K.
        • Sablan N.
        • Chowaniec D.M.
        • et al.
        Sequential resection of the distal clavicle and its effects on horizontal acromioclavicular joint translation.
        Am J Sports Med. 2012; 40: 681-685
        • Spencer H.T.
        • Hsu L.
        • Sodl J.
        • Arianjam A.
        • Yian E.H.
        Radiographic failure and rates of re-operation after acromioclavicular joint reconstruction: A comparison of surgical techniques.
        Bone Joint J. 2016; 98-B: 512-518
        • Choi N.H.
        • Lim S.M.
        • Lee S.Y.
        • Lim T.K.
        Loss of reduction and complications of coracoclavicular ligament reconstruction with autogenous tendon graft in acute acromioclavicular dislocations.
        J Shoulder Elbow Surg. 2017; 26: 692-698
        • Cisneros L.N.
        • Reiriz J.S.
        Unstable acromioclavicular joint injuries: Is there really a difference between surgical management in the acute or chronic setting?.
        J Orthop. 2017; 14: 10-18
        • Salzmann G.M.
        • Walz L.
        • Buchmann S.
        • Glabgly P.
        • Venjakob A.
        • Imhoff A.B.
        Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations.
        Am J Sports Med. 2010; 38: 1179-1187
        • Morikawa D.
        • Mazzocca A.D.
        • Obopilwe E.
        • et al.
        Reconstruction of the acromioclavicular ligament complex using dermal allograft: A biomechanical analysis.
        Arthroscopy. 2020; 36: 108-115
        • Dyrna F.
        • Imhoff F.B.
        • Haller B.
        • et al.
        Primary stability of an acromioclavicular joint repair is affected by the type of additional reconstruction of the acromioclavicular capsule.
        Am J Sports Med. 2018; 46: 3471-3479
        • Banffy M.B.
        • Uquillas C.
        • Neumann J.A.
        • ElAttrache N.S.
        Biomechanical evaluation of a single- versus double-tunnel coracoclavicular ligament reconstruction with acromioclavicular stabilization for acromioclavicular joint injuries.
        Am J Sports Med. 2018; 46: 1070-1076
        • Celik H.
        • Chauhan A.
        • Flores-Hernandez C.
        • et al.
        Vertical and rotational stiffness of coracoclavicular ligament reconstruction: A biomechanical study of 3 different techniques.
        Arthroscopy. 2020; 36: 1264-1270
        • Lee J.
        • El-Daou H.
        • Alkoheji M.
        • Carlos A.
        • Di Mascio L.
        • Amis A.
        Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: A biomechanical study.
        J Shoulder Elbow Surg. 2021; 30: 1251-1256
        • Beitzel K.
        • Obopilwe E.
        • Chowaniec D.M.
        • et al.
        Biomechanical comparison of arthroscopic repairs for acromioclavicular joint instability: Suture button systems without biological augmentation.
        Am J Sports Med. 2011; 39: 2218-2225
        • Beitzel K.
        • Obopilwe E.
        • Chowaniec D.M.
        • et al.
        Biomechanical properties of repairs for dislocated AC joints using suture button systems with integrated tendon augmentation.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1931-1938
        • Fukuda K.
        • Craig E.V.
        • An K.N.
        • Cofield R.H.
        • Chao E.Y.
        Biomechanical study of the ligamentous system of the acromioclavicular joint.
        J Bone Joint Surg Am. 1986; 68: 434-440
        • Murena L.
        • Canton G.
        • Vulcano E.
        • Cherubino P.
        Scapular dyskinesis and SICK scapula syndrome following surgical treatment of type III acute acromioclavicular dislocations.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1146-1150
        • Gumina S.
        • Carbone S.
        • Postacchini F.
        Scapular dyskinesis and SICK scapula syndrome in patients with chronic type III acromioclavicular dislocation.
        Arthroscopy. 2009; 25: 40-45
        • Cisneros L.N.
        • Sarasquete Reiriz J.
        • Besalduch M.
        • et al.
        Horizontal and vertical stabilization of acute unstable acromioclavicular joint injuries arthroscopy-assisted.
        Arthrosc Tech. 2015; 4: e721-729