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AC Joint Stabilisation

Surgical reconstruction for high-grade AC joint dislocation (Rockwood III-VI).

123 citationsUpdated Oct 2026

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Overview

Acromioclavicular (AC) joint separation results from progressive disruption of ligamentous support, beginning with capsular ligaments and progressing to coracoclavicular (CC) ligaments, typically following direct trauma such as a fall on the point of the shoulder [8]. Indirect injuries are rare [8]. The injury spectrum ranges from Type I and II separations, which involve AC ligament sprain or rupture with intact CC ligaments, to high-grade Types III through VI, characterized by CC ligament disruption and varying degrees of clavicular displacement [8]. Evaluation of capsuloligamentous integrity is reproducible and provides additional information on injury severity that may influence treatment decisions [10].

Nonsurgical treatment is recommended for Type I and II injuries, with most patients regaining full shoulder function within 4 to 6 weeks [8]. While good functional outcomes are expected, patients face an increased risk of painful AC joint arthritis, and 30% to 50% of young, very active patients will experience mild to moderate residual pain [8]. For Type III separations, management is controversial and depends on patient age and activity level; meta-analyses demonstrate similar outcomes for nonsurgical and surgical management, though nonsurgical treatment resulted in quicker recovery and return to work compared to surgical treatment [8]. Surgery is indicated for most acute Type IV, V, and VI separations, as nonsurgical treatment likely results in substantial residual pain and limited function for these high-grade injuries [8].

Operative intervention for selected Type III separations is considered in younger, physically active patients, manual laborers, those with cosmetic concerns, or patients with chronic injuries who have persistent symptoms [8]. Surgical techniques vary, including anatomic reconstruction, arthroscopic stabilization, and combined AC and CC fixation, which provide equivalent clinical scores when early or delayed [6]. While radiographic alignment is improved with surgical repair, there is no clear evidence that operative treatment improves short-term outcome for complete AC joint dislocations [7]. Radiological failures were observed in 41% of cases, indicating that surgical results must still be improved [21].

Anatomy & Pathophysiology

Bony Anatomy and Joint Structure

The acromioclavicular (AC) joint is a diarthrodial joint that serves as a primary link between the axial skeleton and the upper extremity [40]. It is not a rigid structure but is movable in all planes [40]. The clavicle facilitates shoulder function by suspending it away from the axial skeleton to optimize motion, muscle action vectors, and position [20]. Under 70-N loads, the normal AC joint is capable of translating 4 to 6 mm in the anterior, posterior, and superior planes [40]. The joint accommodates rotary motion of 5° to 8° during scapulothoracic motion [40] and 40° to 45° with shoulder abduction and elevation [40]. The AC joint and its stabilizing ligaments are part of the superior shoulder suspensory complex (SSSC), a bone and ligament ring structure described by Goss in 1993 [140]. The integrity of the SSSC is essential to maintain the stability and biomechanics of the shoulder [140]. Lesions affecting two or more points of the SSSC compromise the integrity of the ring and can lead to complications such as delayed union, loss of strength, and degenerative arthritis [140].

Ligamentous Anatomy and Stabilizers

The AC joint possesses both dynamic and static stabilizers [40]. The static stabilizers are the AC and coracoclavicular (CC) ligaments, while the dynamic stabilizers are the deltoid and trapezius muscles [40]. The complex ligamentous structure of the AC joint is critical to the normal function of the shoulder girdle [40]. The main ligaments of the AC joint are superior, inferior, anterior, and posterior ligaments that reinforce the capsule surrounding the joint [40]. Horizontal plane stability of the clavicle is provided by the AC ligaments, specifically the posterior and superior portions [33]. The AC ligaments offer the weakest resistance to forces that push the acromion inferiorly and medially [26]. Stronger resistance to inferior and medial forces on the acromion is afforded by the intact clavicle and sternoclavicular joint (SCJ) [26]. The CC ligaments act as an extremely strong buffer after force advances through the AC joint [26]. If the integrity of the CC ligaments is overcome, remaining forces are likely to be dissipated at the attachment sites of the deltoid and trapezius muscles [26]. The AC and coracoclavicular ligaments play a role in torque transduction and horizontal and vertical stability [130]. The scapula and clavicle are linked into a single segment referred to as the “claviscapula” [130].

Pathophysiology of Injury

Injury to the AC joint results in progressive disruption of the ligamentous support, beginning with the capsular ligaments and progressing to the CC ligaments [8]. The most common mechanism for AC joint injury is a direct force applied to the superior aspect of the acromion process, such as a fall onto the outer aspect of the shoulder with the upper limb in an adducted position [26]. Indirect mechanisms of AC joint injury are exceedingly rare [26]. An indirect mechanism involves a fall onto the adducted upper limb driving the humeral head into the inferior aspect of the acromion [26]. An inferiorly directed force acting upon the superior lateral clavicle can cause an inferior dislocation of the clavicle beneath the coracoid process when the upper limb is abducted and the scapula is retracted [26]. The extent of injury to the AC and CC ligaments as well as the amount and direction of clavicle displacement often determines the severity of AC joint separation [68]. Kinematic changes in the shoulder with AC joint dislocation could be a potential source of pain and dysfunction [98]. Scapular and clavicular kinematics are affected in AC separation models [99]. There are large kinematic differences between the intact state and a Rockwood V lesion during humerothoracic movements [128] and during scapulothoracic movements [128]. Decoupling the claviscapular segment has deleterious effects on the functional integrity of the AC joint complex within scapulohumeral rhythm [130]. A coracoid process fracture can result in superior displacement of the clavicle with an intact CC distance, creating a functionally equivalent AC joint separation [8]. In AC joint dislocation associated with a coracoid process fracture, tensile forces transmitted by the CC ligaments cause a fracture in the coracoid process instead of ligament rupture [140].

Degenerative Pathophysiology

Osteoarthritis of the AC joint is more common with advanced age following degeneration of the intra-articular disk [33]. Arthritic deterioration of the AC joint starts in early middle age [33]. Osteoarthritis of the AC joint is more common in patients engaged in repetitive overhead or lifting activities [33]. Previous low-grade AC joint separations can result in painful arthritis [33]. The radiographic severity of AC joint arthritis does not always correlate with patient symptoms [33]. Distal clavicle osteolysis involves localized hyperemia of the distal clavicle resulting in inflammation, bone resorption, microfractures, and secondary arthritis of the AC joint [33]. Distal clavicle osteolysis is associated with heavy lifting or repetitive motions [33].

Classification

Rockwood Classification System

The Rockwood classification is the most widely used system for acromioclavicular (AC) joint dislocation [59]. Initially described in 1963 with types I, II, and III, it was expanded in 1984 to include types IV, V, and VI [29]. This purely radiographic classification relies on comparative examination of bilateral anterior–posterior stress radiographs to evaluate the coracoclavicular (CC) distance relative to the uninjured side for vertical instability [59, 42].

Type I: Involves AC ligament sprain with intact CC ligaments and no radiographic abnormality [8, 29, 59]. Type II: Involves complete rupture of the AC ligament with sprained but intact CC ligaments and an increase in CC distance of less than 25% compared with the contralateral shoulder [8, 29, 59]. Type III: Involves disruption of both AC and CC ligaments with an increase in CC distance of 25% to 100% compared with the contralateral shoulder [8, 29, 59]. A modification proposes type IIIA (horizontally stable) and type IIIB (horizontally unstable) [8]. Rockwood type III is the most common injury, constituting 55.7% of cases in a prospective urban cohort study [118]. Type IV: Involves disruption of AC and CC ligaments with posterior displacement of the clavicle into the trapezius muscle [8, 29, 59]. Type V: Involves disruption of AC and CC ligaments with superior displacement of the clavicle greater than 100% (or 100% to 300%) compared with the contralateral shoulder [8, 29, 59]. Type VI: Involves inferior displacement of the clavicle into the subcoracoid space [8, 29, 59].

Limitations and Reliability

The Rockwood classification does not assess horizontal instability except for Type IV injuries [42]. Combined posterior–superior dislocation of the clavicle may lead to an unpredictable effect on radiographic CC distance due to projection, potentially underestimating the CC distance [42]. The reliability of using the Rockwood grade as a decision-making tool in the management of acute AC joint dislocation is unclear because it does not correlate with symptoms [117]. The Kraus classification system was slightly more reliable than the Rockwood system for classifying AC joint injuries both between assessor groups and overall [92]. The ISAKOS Upper Extremity Committee has issued a consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries [59].

Radiographic Parameters

The AC-DC (acromial centre line to dorsal clavicle) measurement and use of the Alexander view provides a more realistic appreciation of true AC joint displacement [45]. The AC-DC measurement may better inform decision-making regarding management options, especially in defining watershed cases such as IIIA/IIB/IV [45]. Radiographic evaluation should include a bilateral Zanca view, which visualizes the ipsilateral and contralateral AC joints on a single x-ray cassette while maintaining the same orientation of the x-ray beam [59].

Clinical Presentation

Mechanism and Epidemiology

The most common mechanism of injury for the acromioclavicular (AC) joint is a direct force applied to the superior aspect of the acromion process, such as a fall onto the outer aspect of the shoulder with the upper limb in an adducted position [26]. These injuries are more common in male patients less than 30 years of age and are associated with contact sports or athletic activity involving a direct blow to the lateral aspect of the shoulder [20]. AC joint injuries occur five times more frequently in men than in women, with the highest incidence in the 20- to 30-year-old age group [40]. In many contact sports, AC joint injuries account for 40% to 50% of shoulder injuries [40].

Physical Examination

Inspection reveals localized bruising, swelling, and tenderness in acute AC joint injuries [8]. Higher grade injuries result in prominence of the distal clavicle [8]. During palpation, the AC joint is assessed for point tenderness and crepitus on motion [86]. The sternoclavicular joint must also be evaluated for swelling, deformity, and tenderness [8]. Ligament instability is evaluated by manual manipulation of the clavicle and acromion in the inferior-superior and anterior-posterior directions; increased translation compared with the uninvolved side is a positive finding [86]. Dynamic joint stability is assessed by visual observation of bone and joint motion with arm motion in flexion and abduction, noting if the acromion displaces around the clavicle [86]. The ability to reduce the deformity with manual pressure is important and can help differentiate nonsurgical versus surgical treatment for higher grade injuries [8].

Imaging

Plain radiographs for AC joint evaluation include an AP view of the clavicle, a caudal tilt view, and an axillary view [8]. A Zanca view, a modified underpenetrated AP view with a cephalic tilt of 10° to 15°, provides excellent detail of the distal clavicle [8]. Radiographic evaluation should include a bilateral Zanca view to visualize the ipsilateral and contralateral AC joints on a single x-ray cassette while maintaining the same orientation of the x-ray beam [59]. The normal coracoclavicular distance between the superior aspect of the coracoid and the inferior clavicle should be between 11 to 13 mm [8]. The AC-DC measurement and use of the Alexander view provide a more realistic appreciation of true AC joint displacement, especially in defining watershed cases (type IIIA/IIB/IV) [45].

Classification

The Rockwood classification is a purely radiographic classification system based on the increasing severity of injury to the stabilizing structures of the AC joint complex [59].

Type I: Involves AC ligament sprain with intact CC ligaments and normal radiographic CC distance [8]. Type II: Involves AC ligament rupture with sprained but intact CC ligaments and normal radiographic CC distance [8]. The CC distance is increased by less than 25% compared with the contralateral shoulder [29]. Type III: Involves disruption of the AC and CC ligaments, characterized by increased CC distance, superior displacement of the clavicle of up to 100% of the clavicle width, and a reducible deformity [8]. The CC distance is increased 25% to 100% compared with the contralateral shoulder [29]. Type IV: Involves disruption of the AC and CC ligaments with posterior displacement of the clavicle, increased CC distance, and a non-reducible deformity where the distal clavicle is herniated into or through the deltotrapezial fascia [8]. Type V: Involves disruption of the AC and CC ligaments with greater than 100% displacement of the clavicle superiorly, markedly increased CC distance, and a deformity usually not reducible due to herniation through the deltotrapezial fascia [8]. The CC distance is increased by more than 100% compared with the contralateral shoulder because of disruption of the deltotrapezial fascia [29]. Type VI: Involves disruption of the AC and CC ligaments with inferior clavicle displacement, resulting in the distal clavicle lying under the acromion or coracoid process [8].

Investigations

Clinical Examination

The mechanism of injury for AC joint separation is usually direct trauma resulting from a fall on the point of the shoulder [8]. Physical examination must evaluate the sternoclavicular joint for swelling, deformity, and tenderness [8]. Range of motion and rotator cuff strength are typically normal in chronic AC joint injuries but may be limited in acute injuries secondary to pain [8]. Scapular motion should be carefully assessed as scapular dyskinesis can be seen with AC joint injury [8].

Imaging

Plain radiography: The anterior aspect of the clavicle should lie in the same plane as the anterior aspect of the acromion on radiographs [8]. A Zanca view, defined as a modified, underpenetrated AP view with a cephalic tilt of 10° to 15°, gives excellent detail of the distal clavicle [8]. Weighted views are rarely indicated and often are not clinically helpful [8]. The Rockwood classification relies on comparative radiographs of the contralateral shoulder to determine each type [29]. In type V injuries, the CC distance is increased by more than 100% compared with the contralateral shoulder [29]. The Rockwood classification system does not assess horizontal instability except for Type-4 injuries [42]. The AC-DC measurement and use of the Alexander view provides a more realistic appreciation of true AC joint displacement, especially in defining watershed cases (ie, IIIA/IIB/IV) [45].

Classification

Type I: Involves AC ligament sprain without injury to the CC ligaments, with no AC joint widening or clavicular displacement [29]. Type II: Consists of complete rupture of the AC ligament, CC ligament sprain, widening of the AC joint, and an increase in the CC distance by less than 25% compared with the contralateral shoulder [29]. Type III: Involves disruption of the AC and CC ligaments, widening of the AC joint, and an increase in the CC distance by 25% to 100% compared with the contralateral shoulder [29]. Type IV: Diagnosed when the distal clavicle is displaced posteriorly into the trapezius muscle [29]. Type V: Involves disruption of the deltotrapezial fascia and tenting of the overlying skin, with a CC distance increased by more than 100% compared with the contralateral shoulder [29]. Type VI: Rare and involves inferior displacement of the clavicle into the subcoracoid space [29].

Diagnostic Assessment

Evaluating the integrity of the capsuloligamentous structures stabilizing the AC joint is reproducible and gives additional information on the severity of the injury, which might also influence the treatment decision [10].

Treatment

Non-Operative

Nonsurgical treatment is recommended for type I and II acromioclavicular joint injuries [8]. Sling immobilization is typically used for approximately 1 week for type I injuries, while type II injuries require 2 to 3 weeks [37]. Most patients with type I or II injuries regain full shoulder function within 4 to 6 weeks [8]. However, between 30% and 50% of young, very active patients will have mild to moderate residual pain at the acromioclavicular joint following type I or II injuries [8]. Retrospective studies have reported persistent symptoms in up to 40% to 50% of patients at 1, 6, and 10 years after type I or II injury [37].

For type III separations, nonsurgical treatment resulted in quicker recovery and return to work compared to surgical treatment [8]. A prospective randomized trial of type III and V injuries showed better results with nonsurgical treatment when clavicle displacement was less than 2 cm [8]. Nonoperative treatment of Rockwood types III and V dislocations produced more prominent or unstable and radiographically wider acromioclavicular joints than operative treatment, but clinical results were equally good at 18- to 20-year follow-up [28]. In patients with chronic severe acromioclavicular joint dislocation, a trial of conservative treatment may be attempted, as time from injury to eventual conversion to anatomic coracoclavicular ligament reconstruction had no significant influence on postoperative clinical outcomes [138]. Non-operative reduction and stabilization of high-grade acromioclavicular joint separations seems to be a valuable treatment option [1].

Operative

Indications: Surgical treatment is recommended for most patients with type IV, V, and VI acromioclavicular joint injuries [8]. Surgery is indicated for most acute type IV, V, and VI acromioclavicular joint separations [8]. Surgery is often recommended for patients with type IIIB (horizontally unstable) acromioclavicular joint separations [8]. A prospective randomized trial of type III and V injuries showed better results with surgical management when the clavicle was displaced more than 2 cm [8]. Early surgical repair of type III acromioclavicular joint injuries with or without augmentation seems to result in better patient satisfaction and clinical outcomes compared with delayed reconstruction [37]. Superior functional outcomes were found in the early surgical group compared with delayed surgery for complete acromioclavicular joint dislocation involving mostly type III injuries [37]. Partial dislocations or redislocations were found in 26% of cases in the early treatment group compared with 38.1% of cases in the delayed group [37]. The rates of complication were 12.5% in the early surgical group and 17.7% in the delayed surgical group, although the differences did not reach statistical significance [37]. Early and delayed surgical interventions of high-grade acromioclavicular joint dislocation provide equivalent clinical scores when combined coracoclavicular and acromioclavicular joint fixation is used for stabilization [6].

Surgical Approach / Technique: Acute fixation within 3 to 4 weeks of injury of high-grade acromioclavicular joint separations can be successfully performed with various fixation options and without the use of tendon graft [33]. Delayed reconstruction of acromioclavicular joint separations requires biologic augmentation, either ligament transfer or tendon grafting, in addition to coracoclavicular stabilization [33]. Anatomic acromioclavicular joint reconstructions are biomechanically superior to nonanatomic techniques, such as the Weaver-Dunn procedure [33]. Anatomic acromioclavicular joint reconstruction was associated with functional and radiologic benefits and better restored the stability compared to arthroscopic assisted fixation [4]. Combined stabilization of the acromioclavicular capsule and coracoclavicular ligaments demonstrated the greatest capacity to restore native stability against translational and rotational loads [5]. Acute acromioclavicular joint dislocation requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint [23, 31]. Only combined acromioclavicular and coracoclavicular reconstruction can adequately reestablish physiological horizontal acromioclavicular joint stability [39]. The reconstruction of the acromioclavicular ligaments along with the coracoclavicular ligaments provides a stronger reconstruction that may better maintain reduction of the acromioclavicular joint and lead to fewer failures [52]. Consideration should be given to reconstruction of the acromioclavicular joint capsular ligament for complete anterior-posterior stability in high-grade and horizontally unstable acromioclavicular joint injuries [49]. Anatomic techniques that address both coracoclavicular ligaments and the acromioclavicular capsule are recommended to restore horizontal and vertical stability while allowing physiological rotation [16].

Implant Selection: Both single and double TightRope systems are effective in treating acromioclavicular joint dislocation, but the double TightRope system is more reliable for reduction maintenance [3]. Reconstruction of acromioclavicular dislocations with one or two TightRopes leads to stable results with higher stiffness than native joints [34]. Similar stability can be achieved for coracoclavicular fixation with suture anchors or with sutures placed around the base of the coracoid for the treatment of acromioclavicular joint separations [19]. Arthroscopic stabilization for acute acromioclavicular joint dislocations offers satisfactory clinical and radiographic outcomes, and the arthroscopic technique is reliable in the long run [11]. The described arthroscopic technique using a single button over the clavicle and a FiberTape with modified cinch loop through the coracoid provides acromioclavicular joint stability, allowing early rehabilitation and minimizing fixation failure [2]. The described technique of cerclage augmentation offers an attractive alternative in acromioclavicular joint stabilization, with good to excellent results [14]. A new method of temporary acromioclavicular joint stabilization is an easy-to-perform and low-cost procedure with a low complication rate [17]. Temporary pin fixation for the acromioclavicular joint provides early postoperative stability when performing coracoclavicular fixation using a suture button device [48]. Ensuring good initial recovery of the coracoclavicular distance and precise placement of the acromioclavicular joints was important in maintaining the proper acromioclavicular position at the final follow-up [22]. The Gracilis graft appears to restore optimum stability and is strong enough to withstand forces across the acromioclavicular joint [36]. The arthroscopic reconstruction of the acromioclavicular separation is a low-morbidity, safe, and reproducible operation that provides adequate fixation and stability combined with the use of a soft tissue graft to promote sound biologic healing [38]. Risk of fracture is minimized and additional stability is provided via augmentation of the acromioclavicular joint using the Infinity-Lock Button System with allograft augmentation [25]. The described surgical technique using 2 allografts, TightRope, and stabilization to the acromion results in anatomic reconstruction of the acromioclavicular joint [85]. The described technique of arthroscopic coracoclavicular reconstruction combined with open acromioclavicular reconstruction using knot hiding clavicular implants is a stable solution [112]. Patients with acute high-grade acromioclavicular joint injuries managed arthroscopically with a non-rigid coracoclavicular fixation seem to have a better quality of life than patients managed with a hook plate [115]. Hook plate fixation with coracoclavicular augmentation is preferable for acute unstable acromioclavicular joint dislocations [132]. Both TightRope and hook plate techniques offered effective outcomes in relieving the pain of dislocation and improving function of the acromioclavicular joint [157]. The described technique of arthroscopic acromioclavicular joint reconstruction using the TightRope device with allograft augmentation is an arthroscopic method of restoring joint stability that allows for a minimally invasive, low-profile fixation construct with excellent biomechanical stability [53]. The described technique of arthroscopically assisted acromioclavicular joint dislocation repair using suture anchors aims to restore optimal biomechanics by providing both anatomic acromioclavicular joint reduction and physiological horizontal stabilization [51]. The described technique of proximal extension of the deltopectoral approach with a 'bra-strap' incision offers a safe and efficient solution for acromioclavicular joint stabilization by combining the reliability of a well-established technique with improved visualization and reduced soft tissue trauma [13]. The described technique of arthroscopic coracoclavicular reconstruction using Endobutton fixation provides an ideal approach for clinical treatment of acromioclavicular joint dislocations with advantages including easy operation, little trauma, low cost, reliable effectiveness, fewer complications, and no need for a second surgery [83]. The described technique of free tissue graft reconstruction of the acromioclavicular joint resulted in all patients being satisfied with their surgery and demonstrating good reduction of the acromioclavicular joint on radiographs, although follow-up periods were less than 1 year [12]. The described technique of arthroscopic Weaver-Dunn procedure for acute or chronic acromioclavicular joint dislocation involves coracoacromial ligament transfer and lateral portion of the clavicle removal to reconstruct the torn coracoclavicular ligaments [111]. The described technique of under-coracoid-around-clavicle loop in type II distal clavicle fractures avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results [131]. The described technique of the acromioclavicular-distal clavicle 3-dimensional all-suture stabilization technique is a true "all-suture technique" with no use of metallic hardware such as endobutton or cortical button [109]. The described technique of arthroscopic coracoclavicular fixation using multiple low-profile devices in acute acromioclavicular joint dislocation requires ensuring good initial recovery of the coracoclavicular distance and precise placement of the acromioclavicular joints to maintain proper position [22]. The described technique of arthroscopic stabilization of acromioclavicular joint dislocation using the AC graftrope system is a low-morbidity, safe, and reproducible operation that provides adequate fixation and stability combined with the use of a soft tissue graft to promote sound biologic healing [38]. The described technique of arthroscopic coracoclavicular reconstruction using a single adjustable-loop-length suspensory fixation device in acute acromioclavicular joint dislocation resulted in satisfactory clinical outcomes [32]. The described technique of arthroscopic acromioclavicular joint reconstruction using the Infinity-Lock Button System with allograft augmentation minimizes risk of fracture and provides additional stability via augmentation of the acromioclavicular joint [25]. The described technique of primary acromioclavicular-coracoclavicular reconstruction using 2 allografts, TightRope, and stabilization to the acromion results in anatomic reconstruction of the acromioclavicular joint [85]. The described technique of acute high-grade acromioclavicular joint injuries treatment with arthroscopic non-rigid coracoclavicular fixation provides better quality of life outcomes than hook plate open reduction and internal fixation [115]. The described technique of coracoclavicular augmentation additional to hook plate fixation is preferable for acute unstable acromioclavicular dislocations [132]. The described technique of TightRope versus clavicular hook plate for Rockwood III–V acromioclavicular dislocations offers effective outcomes in relieving the pain of dislocation and improving function of the acromioclavicular joint [157]. The described technique of free tissue graft reconstruction of the acromioclavicular joint resulted in all patients being satisfied with their surgery and demonstrating good reduction of the acromioclavicular joint on radiographs, although follow-up

Complications

General Complication Profiles: Surgical management of acromioclavicular (AC) joint injuries carries a relatively high complication profile and common loss of reduction, though the revision surgery rate remains low [47]. Meta-analyses and systematic reviews demonstrate that surgical treatment increases complications compared to nonsurgical treatment for type III separations [8]. While open and arthroscopic reconstruction techniques show no differences in loss of reduction, complication rates, or revision rates based on available literature [137], good to excellent outcomes are reported only in patients without complications [163]. Surgical intervention improves joint reduction but adds the risk of surgical complications [183]. Arthroscopically assisted treatment of acute dislocation provides good clinical results with few complications [41], and the goal of arthroscopic reconstruction using knotless coracoclavicular fixation and soft-tissue anatomic ligament reconstruction is to achieve good to excellent outcomes with lower complication rates than other open and arthroscopic techniques [151]. All three AC joint reconstruction techniques evaluated in one study showed similar complication rates [84].

Loss of Reduction and Fixation Failure: After primary AC joint reconstruction, loss of reduction (13.4% at 2 years) and distal clavicle fractures (15.7% at 2 years) were frequently reported, with a 3.9% revision reconstruction rate within 2 years [174]. Anatomic AC joint reconstruction resulted in a 16% mechanical failure rate in one series [173], while the rate of revision AC joint stabilization was 14.3% in another [79]. Although radiological assessment showed statistically significant immediate superior clavicular displacement after hardware removal, with increased incidence in the first year, this may not negatively influence clinical results [35]. Ensuring good initial recovery of the coracoclavicular distance and precise placement of the AC joint is important for maintaining proper position at final follow-up [22]. In one study, 3 patients (10%) in the TightRope group experienced complete loss of reduction at 1 year but showed satisfactory clinical outcomes at final follow-up and were treated nonoperatively [148]. AC joint reconstruction with LARS ligament revealed 2% failures (re-dislocations) at 2-year minimum follow-up [80]. Recurrent AC joint instability occurred in 7 patients (12%) at a mean of 3 years’ follow-up, defined as subluxation of 50% of the clavicle shaft width in the vertical or horizontal plane [90]. One study noted a high percentage of radiographic redisplacement and clinical failure, stating the technique cannot be recommended for AC joint injuries in their population [78]. These findings should be considered when selecting an appropriate implant for fixation of AC joint dislocation [67]. Secondary stabilization techniques, such as suture fixation, may obviate the need for subsequent hardware removal but carry risks of suture failure and erosion [167]. The rate of recurrence and postoperative loss of reduction requires better definition of indications and improvement of surgical implants and technique [41]. Double-bundle constructs provide improved maintenance of reduction compared to single-bundle constructs, though clinical outcomes are comparable [162]. Both surgical methods are effective in treating AC joint dislocation, but the DT system is more reliable for reduction maintenance [3].

Hardware-Related Complications: Postoperative complications in the clavicular hook plate group included 3 superficial wound infections, 1 nerve palsy, and 1 plate breakage [148]. The superficial radial nerve palsy resolved spontaneously without treatment [148]. One patient in the clavicular hook plate group fell after surgery, causing plate breakage, and was treated with secondary surgery using the clavicular hook plate [148]. Patients should abide by a strict policy of limited range of motion until the hook plate is removed to avoid complications [170]. The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook [56]. Risk of fracture is minimized and additional stability is provided via augmentation of the AC joint when using the Infinity-Lock Button System with allograft augmentation [25]. CT scan analysis showed that the clavicular tunnel was positioned too anterior in 9 cases (15%), whereas it was well centered or slightly posterior in 48 cases (85%) [90]. The coracoid tunnel was well centered in 37 cases (65%), whereas it was too lateral in 20 cases (35%); no coracoid tunnel was too medial [90]. Enlargement of the clavicular tunnel was observed in 44 cases (77%), whereas the coracoid tunnel was enlarged in 3 cases [90]. Complications such as mechanical impingement, aseptic loosening, instability, and failure of the implant are common after constrained shoulder replacements, and the rates of reoperation are unacceptably high [141]. Persistent shoulder pain, wound infection, delayed wound healing, and arthritis can occur postoperatively after clavicular hook plate fixation [148]. Considering its less morbidity, excellent cosmetics, no need to remove an implant, and minimal complications from breakage or migration of metal implants, the arthroscopic technique offers an attractive alternative in acromioclavicular joint stabilization [175]. Considering its less morbidity, excellent cosmesis, no need of hardware removal, and minimal complications from breakage or migration of metal implants, the arthroscopic technique offers an attractive alternative in acromioclavicular joint stabilization [177].

Infection: Three cases were reported in which nonabsorbable tape or suture was directly related to a postoperative infection after surgical repair of acromioclavicular separations [144]. The superficial wound infection resolved with oral antibiotics and daily dressing [148]. No intraoperative or postoperative complications, such as fracture, infection, or implant failure, occurred in any of the patients in the acute type V dislocation cohort [91]. There were no infections or fractures in patients who were included in the study using autogenous semitendinosus tendon graft and endobutton technique [95].

Bony Complications: Clavicle and coracoid process periprosthetic fractures are late post-operative complications in arthroscopically assisted acromioclavicular joint stabilization [171]. This needs to be considered when planning for surgical intervention in acute AC joint disruption, especially in a high-risk population [171]. Female sex is associated with higher fracture risk after acromioclavicular joint reconstruction [174]. There were 2 (8.7%) patients in Group A with acromial osteolysis on the latest radiographs, which included a 38-year-old woman and a 45-year-old man [95]. Their constant scores were 59 and 55, respectively, and moderate shoulder pain and limited range of motion were reported by both of them [95].

Other Considerations: Heterotopic ossification can occur after acute acromioclavicular joint dislocation, with mild ossification observed in the conoid ligament area, conoid and trapezoid ligament areas, or mainly in the trapezoid ligament area [50]. A concomitant glenohumeral injury was observed during diagnostic arthroscopy in 25% of cases in group 1 and 28% of cases in group 2 [50]. The early results from the initial experience of arthroscopic Weaver-Dunn in chronic acromioclavicular joint dislocation have been excellent, with no complications [150]. The described technique of cerclage augmentation offers an attractive alternative in AC joint stabilization, with good to excellent results [14]. The described technique for chronic AC joint dislocations is an excellent procedure with minimal morbidity, no need for autologous tendon transfer or hardware removal, and promising short-term results [77]. Satisfactory clinical outcomes were obtained after CC fixation using the single adjustable-loop-length suspensory fixation device for acute AC joint dislocation [32]. The described technique provides AC joint stability, allowing early rehabilitation and minimizing fixation failure [2]. Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation [82]. Excellent results were obtained and maintained over long-term follow-up using continuous loop double endobutton reconstruction [172]. This study demonstrates that the AC joint fixation anatomically with double-bundle titanium acquired excellent outcomes in terms of the recovery of shoulder joint function and radiographic outcomes [76]. The objective of this note is to describe the technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts [9]. They state that the procedure is easily reproducible, applicable for the vast majority of revision AC joint reconstructions, and has good results [179]. Delayed surgical management of AC joint injuries using a modern device has comparable functional outcomes and is not associated with a higher incidence of fixation failure or major complications [180]. By analysing a large cohort of patients across multiple centres and providers, this study provides valuable insight into the recent complication profiles of AC joint reconstruction, allowing surgeons to appropriately counsel patients on the risks of these procedures [161]. The authors support arthroscopic double-bundle reconstruction using flexible fixation as it better replicates normal anatomy and affords better stability, though longer-term studies are needed to determine if differences in long-term CC interval ratios impact clinical outcomes and complications [181]. This newer and unproven surgery, once proven with needed RCTs, may become the new standard in the ever-changing story of the Type V AC joint injury [182]. The level of evidence was low and due to methodological heterogeneity between studies, subgroup analyses of return to sport outcomes were not feasible [176]. Clinical patient outcome studies are ongoing to validate long-term effectiveness of AC joint reconstruction using peroneus brevis tendon allograft [165]. Although the follow-up periods are less than 1 year, all patients are satisfied with their surgery and demonstrate good reduction of the AC joint on radiographs [12]. A steady state of excellent quality-of-life and functional outcomes was noted from 12 months follow-up on for this short-term case series [81]. The only factor associated with recurrence was multidirectional instability, but even excluding these patients, the failure rate remained high at 43.3% [169]. No further episodes of instability have been reported by any of our patients to date [164]. The author urges clinicians to err on the conservative side when possible until better evidence defines when surgery is necessary [168]. Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint [15]. These differences were quantitatively small, so that the clinical relevance of the stabilization effect of combined AC ligaments and DTF injuries is questionable [62]. The AC joint capsule is a robust anatomical structure that contributes significantly to the AC joint stability, especially in the AP plane [18]. Anatomic AC joint reconstruction was associated with functional and radiologic benefits and better restored the stability [4]. The described technique of open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translations for type V acromioclavicular joint dislocation and minimizes the incidence of persistent postoperative AC joint subluxation [178].

Recovery

Light activity (weeks): The evidence does not specify a defined week range for the initiation of desk work, driving, or light activities of daily living. While early rehabilitation is noted to minimize fixation failure [2] and early functional rehabilitation is compared against bracing [102], specific timelines for these light activities are not provided in the source text.

Full activity (months): The evidence does not specify a defined month range for the return to manual work, sport, or full range of motion and strength. Although high rates of return to sport are reported at long-term follow-up [121, 160] and in active-duty military populations [121], specific timelines for achieving full activity are not provided in the source text.

Complete recovery / outcome plateau (months): The evidence does not specify a defined month range for the stabilization of pain, strength, and final functional outcomes. While a steady state of excellent quality-of-life and functional outcomes is noted from 12 months follow-up onward [81], and sustained improvements are observed at long-term follow-up [121], these are observation periods rather than defined recovery plateaus.

Rehabilitation protocol: There is substantial variability in publicly accessible AC joint rehabilitation protocols, including a wide range in recommendations for appropriate time to return to sport [60]. No sustainably improved reduction of the ACJ resulted from bracing when compared to early functional rehabilitation, questioning its utility in Rockwood type III and V injuries [102]. Arthroscopic AC joint fixation using a single button over the clavicle and a FiberTape with modified cinch loop through the coracoid allows early rehabilitation and minimizes fixation failure [2].

Functional milestones: CC ligament reconstruction results in excellent functional outcomes irrespective of surgical approach or technique, with high patient satisfaction, high return to pre-injury level of sport, and low rates of recurrence and reoperation at a minimum 5-year follow-up [160]. Outcomes after arthroscopic CC reconstruction for chronic, type V AC dislocations in an active-duty military patient population show sustained and statistically significant improvements in functional outcomes as well as high rates of return to sport and maintenance of active-duty military status at long-term follow-up [121]. A steady state of excellent quality-of-life and functional outcomes was noted from 12 months follow-up on for a short-term case series of arthroscopic Bankart repair [81].

Other Considerations: Non-operative reduction and stabilization of high-grade AC joint separations is a valuable treatment option [1]. Surgical repair improves radiographic alignment but does not clearly improve short-term outcome for complete AC joint dislocations compared to non-operative treatment [7]. Conservative participants demonstrated extensive ACJ instabilities, potentially implying inferior kinematic outcomes compared to the surgical group [75]. In a young, active population with Type V ACJ dislocation treated acutely, a high percentage lost reduction yet still returned to duty [136]. At final follow-up, the average patient's AC joint was left with 43% subluxation, no instability to cross-body adduction, minimal symptoms, and a satisfactory outcome following percutaneous coracoclavicular fixation [58]. Patients undergoing free tissue graft reconstruction of the AC joint are satisfied with their surgery and demonstrate good reduction of the AC joint on radiographs, though follow-up periods are less than 1 year [12]. Arthroscopic stabilization for acute AC joint dislocations offers satisfactory clinical and radiographic outcomes and is reliable in the long run [11]. The rate of revision ACJ stabilization was 14.3% after arthroscopically-assisted anatomic coracoclavicular reconstruction for Type III and V AC joint injuries [79]. AC joint reconstruction with LARS ligament did not reveal differences in clinical outcomes between professional and non-professional athletes, with 2% of failures (re-dislocations) at 2-year minimum follow-up [80].

Key Evidence

• [L4] Non-operative reduction and stabilization of high-grade AC joint separations seems to be a valuable treatment option. [1] (10.1007/s00402-020-03630-0)
• [L5] The described technique provides AC joint stability, allowing early rehabilitation and minimizing fixation failure. [2] (10.1016/j.eats.2024.103363)
• [L3] Both surgical methods are effective in treating AC joint dislocation, but the DT system is more reliable for reduction maintenance. [3] (10.1016/j.jse.2020.10.002)
• [L4] Anatomic AC joint reconstruction was associated with functional and radiologic benefits and better restored the stability. [4] (10.1016/j.jor.2020.04.007)
• [L5] Combined stabilization of the AC capsule and CC ligaments demonstrated the greatest capacity to restore native stability against translational and rotational loads. [5] (10.1177/0363546518807908)
• [L3] Early and delayed surgical interventions of high-grade AC joint dislocation provide equivalent clinical scores when combined CC and AC joint fixation is used for stabilization. [6] (10.1016/j.jse.2020.06.026)
• [L1] While radiographic alignment is improved with surgical repair, there is no clear evidence that operative treatment improves short-term outcome for complete AC joint dislocations. [7] (10.1016/j.jse.2012.12.051)
• [Paper] The objective of this note is to describe the technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts. [9] (10.1016/j.eats.2020.10.055)
• [L1] Evaluating the integrity of the capsuloligamentous structures stabilizing the AC joint is reproducible and gives additional information on the severity of the injury, which might also influence the treatment decision. [10] (10.1016/j.jse.2020.10.026)
• [L3] Arthroscopic stabilization for acute AC joint dislocations offers satisfactory clinical and radiographic outcomes, and the arthroscopic technique is reliable in the long run. [11] (10.5397/cise.2023.01060)
• [L4] Although the follow-up periods are less than 1 year, all patients are satisfied with their surgery and demonstrate good reduction of the AC joint on radiographs. [12] (10.1097/bte.0b013e31818a5dd9)
• [L5] By combining the reliability of a well-established technique with improved visualization and reduced soft tissue trauma, this muscle-sparing, cost-effective approach offers a safe and efficient solution for AC joint stabilization. [13] (10.1016/j.xrrt.2025.06.010)
• [L4] The described technique of cerclage augmentation offers an attractive alternative in AC joint stabilization, with good to excellent results. [14] (10.1016/j.jse.2010.08.007)
• [L5] Future research should focus on addressing horizontal and rotational instability, to restore native physiological and biomechanical properties of the AC joint. [15] (10.1186/s12891-022-05935-0)
• [L5] Anatomic techniques that address both coracoclavicular ligaments and the AC capsule are recommended to restore horizontal and vertical stability while allowing physiological rotation. [16] (10.1016/j.arthro.2019.01.038)
• [L4] A new method of temporary ACJ stabilization described herein is an easy-to-perform and low-cost procedure with a low complication rate. [17] (10.1097/bte.0000000000000005)
• [L5] The AC joint capsule is a robust anatomical structure that contributes significantly to the AC joint stability, especially in the AP plane. [18] (10.1016/j.jse.2008.08.003)
• [L5] Similar stability can be achieved for coracoclavicular fixation with suture anchors or with sutures placed around the base of the coracoid for the treatment of AC joint separations. [19] (10.1067/mse.2002.123904)
• [L4] Surgery for AC dislocations is difficult with radiological results that must still be improved, as radiological failures were observed in 41% of cases. [21] (10.1016/j.otsr.2015.09.012)
• [L4] Ensuring good initial recovery of the CCD and precise placement of the AC joints was important in maintaining the proper AC position at the final follow-up. [22] (10.1016/j.arthro.2018.07.007)
• [L2] This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. [23] (10.1016/j.otsr.2015.09.003)
• [L4] The authors recommend this procedure for the treatment of chronic complete AC dislocations. [24] (10.1016/j.injury.2010.09.023)
• [Paper] Risk of fracture is minimized and additional stability is provided via augmentation of the AC joint. [25] (10.1016/j.eats.2020.08.030)
• [L2] Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good in the study groups at 18- to 20-year follow-up. [28] (10.1177/2325967114560130)
• [Case_report] Arthroscopic reconstruction for traumatic AC joint dislocation has yielded good results, but caution is recommended when considering surgical stabilization for voluntary AC joint dislocation as outcomes in this case and others in the literature are poor. [30] (10.1016/j.jse.2019.03.039)
• [L2] This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromio-clavicular joint. [31] (10.1016/j.arthro.2016.03.056)
• [L4] Satisfactory clinical outcomes were obtained after CC fixation using the single adjustable-loop-length suspensory fixation device for acute AC joint dislocation. [32] (10.1016/j.arthro.2014.11.013)
• [L5] Reconstruction of AC dislocations with one or two TightRopes leads to stable results with higher stiffness than native joints. [34] (10.1007/s00167-015-3920-1)
• [L4] Although radiological assessment showed a statistically significant immediate superior clavicular displacement after this rarely required procedure, with an increased incidence in the first year following stabilization, this may not negatively influence the results of ACJ stabilization in a clinically relevant way. [35] (10.1007/s00167-022-06978-5)
• [L4] The Gracilis graft appears to restore optimum stability and is strong enough to withstand forces across the AC joint. [36] (10.1016/j.arthro.2008.04.012)
• [L4] The arthroscopic reconstruction of the AC separation is a low-morbidity, safe, and reproducible operation that provides adequate fixation and stability combined with the use of a soft tissue graft to promote sound biologic healing. [38] (10.1016/j.jse.2009.12.014)
• [L5] The results suggest that only combined AC and CC reconstruction can adequately reestablish physiological horizontal ACJ stability. [39] (10.1007/s00167-014-2895-7)
• [L4] [40] (10.1302/2058-5241.3.170027)
• [L4] [41] (10.1016/j.otsr.2010.10.004)
• [L5] [42] (10.1007/s00167-017-4579-6)
• [L4] The AC-DC measurement and use of the Alexander view provides the clinician with a more realistic appreciation of true AC joint displacement, especially in defining watershed cases (ie, IIIA/IIB/IV) and may better inform the decision-making process regarding management options and recommendations. [45] (10.1016/j.jse.2019.12.014)
• [L4] Surgical management of AC joint injuries is associated with a relatively high complication profile and common loss of reduction, though the revision surgery rate is low. [47] (10.1016/j.jse.2023.03.019)
• [L4] These results support evidence indicating that temporary pin fixation for the AC joint provides early postoperative stability when performing CC fixation using a suture button device. [48] (10.1007/s00402-016-2437-5)
• [L5] Consideration should be given to reconstruction of the ACJ capsular ligament for complete AP stability in high-grade and horizontally unstable ACJ injuries. [49] (10.1016/j.jse.2020.09.006)
• [L3] [50] (10.1177/23259671251408491)
• [Paper] The described technique aims to restore optimal biomechanics by providing both anatomic AC joint reduction and physiological horizontal stabilization, which will ultimately determine the quality of AC ligament biological healing. [51] (10.1016/j.eats.2020.10.004)
• [L2] The reconstruction of the AC ligaments along with the CC ligaments provides a stronger reconstruction that may better maintain reduction of the AC joint and lead to fewer failures. [52] (10.1177/17585732211068322)
• [Paper] AC joint reconstruction with the TightRope device with allograft augmentation is an arthroscopic method of restoring joint stability that allows for a minimally invasive, low-profile fixation construct with excellent biomechanical stability. [53] (10.1016/j.eats.2015.02.012)
• [L5] The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. [56] (10.1016/j.injury.2009.12.012)
• [L4] At final follow-up, the average patient's AC joint was left with 43% subluxation, no instability to cross-body adduction, minimal symptoms and a satisfactory outcome. [58] (10.1111/j.1758-5740.2011.00113.x)
• [L5] [59] (10.1016/j.arthro.2013.11.005)
• [L4] There was substantial variability in publicly accessible AC joint rehabilitation protocols, including a wide range in the recommendations for appropriate time to return to sport. [60] (10.1016/j.asmr.2020.10.007)
• [L4] Additional AC fixation on horizontal plane is not a prerequisite for all injuries, there is no significant association between horizontal instability and clinical outcomes and indications of an additional AC fixation needs to be determined. [61] (10.1016/j.jseint.2022.10.001)
• [L5] These differences were quantitatively small, so that the clinical relevance of the stabilization effect of combined AC ligaments and DTF injuries is questionable. [62] (10.1007/s00402-015-2389-1)
• [L4] These findings should be taken into consideration when selecting an appropriate implant for fixation of ACJ dislocation. [67] (10.1016/j.jseint.2024.06.011)
• [L4] By transferring the coracoid process, the AC joint regained stability after chronic joint separation. [71] (10.1016/j.jseint.2022.09.012)
• [L4] Conservative participants demonstrated extensive ACJ instabilities, potentially implying inferior kinematic outcomes compared to the surgical group. [75] (10.1177/2325967123s00080)
• [L4] This study demonstrates that the AC joint fixation anatomically with double-bundle titanium acquired excellent outcomes in terms of the recovery of shoulder joint function and radiographic outcomes. [76] (10.1186/s13018-021-02442-1)
• [L4] The described technique is an excellent procedure for chronic AC joint dislocations with minimal morbidity, no need for autologous tendon transfer or hardware removal, and promising short-term results. [77] (10.1007/s00167-008-0633-8)
• [L4] We noted a high percentage of radiographic redisplacement and clinical failure, and this technique cannot be recommended to treat AC joint injuries in our population. [78] (10.1016/j.jse.2012.01.018)
• [L4] The rate of revision ACJ stabilization was 14.3%. [79] (10.1177/2325967125s00150)
• [L2] AC joint reconstruction with LARS ligament did not reveal differences in clinical outcomes between professional and non-professional athletes, with 2% of failures (re-dislocations) at 2-year minimum follow-up. [80] (10.1007/s00167-014-3231-y)
• [L4] A steady state of excellent quality-of-life and functional outcomes was noted from 12 months follow-up on for this short-term case series. [81] (10.1016/j.arthro.2017.08.039)
• [L3] Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. [82] (10.1007/s00167-014-3294-9)
• [L4] This surgical method provides an ideal approach for clinical treatment of AC joint dislocations with advantages including easy operation, little trauma, low cost, reliable effectiveness, fewer complications, and no need for a second surgery. [83] (10.1007/s00402-014-2117-2)
• [L4] All three ACJ reconstruction techniques showed similar complication rates. [84] (10.1016/j.jse.2019.03.005)
• [Paper] The described surgical technique results in anatomic reconstruction of the AC joint. [85] (10.1016/j.eats.2018.10.006)
• [L4] [86] (10.1016/j.arthro.2016.08.023)
• [L4] [90] (10.1016/j.arthro.2018.11.058)
• [L4] [91] (10.1016/j.jse.2017.05.032)
• [L3] The Kraus system was slightly more reliable than the Rockwood system for classifying AC joint injuries both between assessor groups and overall. [92] (10.1177/23259671221149391)
• [L1] [95] (10.2147/tcrm.s81829)
• [L5] The kinematic changes could be a potential source of pain and dysfunction in the shoulder with AC joint dislocation. [98] (10.1177/0363546512458571)
• [L5] Scapular and clavicular kinematics were affected in AC separation models. [99] (10.1016/j.jse.2013.01.004)
• [L3] However, no sustainably improved reduction of the ACJ resulted from bracing, when compared to early functional rehabilitation, thus questioning its utility. [102] (10.1016/j.jse.2024.08.040)
• [L5] [109] (10.1002/atn2.70185)
• [L4] [111] (10.1097/bte.0b013e3181d56229)
• [L4] [112] (10.1016/j.asmr.2021.08.002)
• [L4] Patients with acute high-grade ACJ injuries managed arthroscopically with a non-rigid CC fixation seem to have a better QoL than patients managed with a hook plate. [115] (10.1016/j.otsr.2015.10.007)
• [L4] Therefore, the reliability of using the Rockwood grade as a decision-making tool in the management of acute AC joint dislocation is unclear. [117] (10.1177/2309499018777886)
• [L3] Rockwood type III was the most common type of AC joint dislocation constituting 55.7% of the injuries. [118] (10.1177/17585732221123314)
• [L4] Outcomes after arthroscopic CC reconstruction for chronic, type V AC dislocations in an active-duty military patient population show sustained and statistically significant improvements in functional outcomes as well as high rates of return to sport and maintenance of active-duty military status at long-term follow-up. [121] (10.1016/j.arthro.2025.05.008)
• [L5] There are large kinematic differences between the intact state and a Rockwood V lesion not only during humerothoracic, but also during scapulothoracic movements. [128] (10.1016/j.jse.2022.01.096)
• [L5] [130] (10.5435/jaaos-d-24-00360)
• [L4] This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results. [131] (10.1302/0301-620x.95b7.31316)
• [L1] HP fixation with CC augmentation is preferable for acute unstable ACJ dislocations. [132] (10.1186/s12891-022-05142-x)
• [L3] In a young, active population with Type V ACJ dislocation treated acutely, a high percentage lost reduction yet still returned to duty. [136] (10.1177/2325967124s00051)
• [L1] Open and arthroscopic AC joint reconstruction techniques have no differences in loss of reduction, the complication rate, and the revision rate based on the available literature. [137] (10.1177/0363546518795147)
• [L4] In patients with chronic severe ACJ dislocation, a trial of conservative treatment may be attempted, as time from injury to eventual conversion to ACCR had no significant influence on postoperative clinical outcomes. [138] (10.1007/s00167-020-06159-2)
• [L4] [140] (10.1016/j.jseint.2020.02.007)
• [L4] [144] (10.1016/s1058-2746(96)80021-8)
• [L5] The independent acromioclavicular ligament repair, disregarding the routinely reconstructed coracoclavicular ligaments, demonstrated significant translational stability in both the anterior–posterior and superior–inferior planes, restoring stability to a state comparable to the native ligaments of the intact joint. [146] (10.1177/1758573219857685)
• [L2] [148] (10.1080/08941939.2017.1305022)
• [L4] The early results from the initial experience have been excellent, with no complications. [150] (10.1097/00132589-200609000-00007)
• [Paper] The goal is to achieve good to excellent clinical outcomes with lower complication rates than previously associated with other open and arthroscopic surgical techniques. [151] (10.1016/j.eats.2016.08.035)
• [L1] Both TightRope and hook plate techniques offered effective outcomes in relieving the pain of dislocation and improving function of ACJ. [157] (10.1111/os.12724)
• [L4] No long term disability results from the loss of the coraco-acromial ligament from its normal site. [159] (10.1016/s0020-1383(80)80045-3)
• [L4] CC ligament reconstruction results in excellent functional outcomes irrespective of surgical approach or technique, with high patient satisfaction, high return to pre-injury level of sport, and low rates of recurrence and reoperation at a minimum 5-year follow-up. [160] (10.1177/03635465261457302)
• [L4] By analysing a large cohort of patients across multiple centres and providers, this study provides valuable insight into the recent complication profiles of ACJR, allowing surgeons to appropriately counsel patients on the risks of these procedures. [161] (10.1007/s00167-016-4206-y)
• [L5] Double-bundle constructs provide improved maintenance of reduction compared to single-bundle constructs, but clinical outcomes are comparable. [162] (10.1016/j.arthro.2024.04.014)
• [L4] Good to excellent outcomes could only be reported in those patients who did not have a complication. [163] (10.1177/0363546513502459)
• [L4] No further episodes of instability have been reported by any of our patients to date. [164] (10.1097/bte.0000000000000127)
• [L4] Clinical patient outcome studies are ongoing to validate long-term effectiveness. [165] (10.1016/j.arthro.2006.09.006)
• [L5] Secondary stabilization techniques, such as suture fixation, may obviate the need for subsequent hardware removal but carry risks of suture failure and erosion. [167] (10.1016/s0278-5919(03)00005-x)
• [L5] The author urges clinicians to err on the conservative side when possible until better evidence defines when surgery is necessary. [168] (10.1016/j.arthro.2018.03.022)
• [L4] The only factor associated with recurrence was multidirectional instability, but even excluding these patients, the failure rate remained high at 43.3%. [169] (10.1016/s1058-2746(95)80141-3)
• [L4] Patients should abide by a strict policy of limited ROM until the hook plate is removed to avoid complications. [170] (10.1016/j.jse.2009.09.004)
• [L4] This needs to be considered when planning for surgical intervention in acute ACJ disruption, especially in a high-risk population. [171] (10.1007/s00167-019-05482-7)
• [L4] Excellent results were obtained and maintained over long-term follow-up. [172] (10.1177/0363546515596409)
• [L4] Anatomic AC joint reconstruction resulted in a 16% mechanical failure rate in this series. [173] (10.1016/j.jse.2014.06.017)
• [L3] After primary AC joint reconstruction, loss of reduction (2 years, 13.4%) and distal clavicle fractures (2 years, 15.7%) were frequently reported complications in the postoperative period, with a 3.9% revision reconstruction rate within 2 years. [174] (10.1002/ars2.70063)
• [Abstract] Considering its less morbidity, excellent cosmetics, no need to remove an implant, and minimal complications from breakage or migration of metal implants, this new technique offers an attractive alternative in acromioclavicular joint stabilization. [175] (10.1016/j.jse.2007.02.103)
• [L4] However, the level of evidence was low and due to methodological heterogeneity between studies, subgroup analyses of return to sport outcomes were not feasible. [176] (10.1007/s00167-019-05528-w)
• [L4] Considering its less morbidity, excellent cosmesis, no need of hardware removal, and minimal complications from breakage or migration of metal implants, this new technique offers an attractive alternative in acromioclavicular joint stabilization. [177] (10.1007/s00402-005-0073-6)
• [L4] This novel surgical technique using a free graft and braided suture for simultaneous coracoclavicular ligament and AC joint capsular reconstruction successfully controls superior and posterior translations after type V AC joint dislocation and minimizes the incidence of persistent postoperative AC joint subluxation. [178] (10.1007/s00167-017-4509-7)
• [L5] They state that the procedure is easily reproducible, applicable for the vast majority of revision ACJ reconstructions, and has good results. [179] (10.1097/bte.0000000000000190)
• [L3] Delayed surgical management of ACJ injuries using a modern device has comparable functional outcomes and is not associated with a higher incidence of fixation failure or major complications. [180] (10.1016/j.jse.2022.05.020)
• [L5] The authors support arthroscopic double-bundle reconstruction using flexible fixation as it better replicates normal anatomy and affords better stability, though longer-term studies are needed to determine if differences in long-term CC interval ratios impact clinical outcomes and complications. [181] (10.1016/j.arthro.2022.10.019)
• [L5] This newer and unproven surgery, once proven with needed RCTs, may become the new standard in the ever-changing story of the Type V AC joint injury. [182] (10.1016/j.injury.2026.113201)
• [L1] While surgical intervention is able to improve joint reduction, it adds the risk for surgical complications. [183] (10.1530/eor-2024-0077)

See Also

• Distal Clavicle Osteolysis
• Rotator Cuff
• Fractures
• Internal Fixation

References

[1] Can an acute high-grade acromioclavicular joint separation be reduced and stabilized without surgery? A surgeon’s experience. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03630-0

[2] Arthroscopic Acromioclavicular Joint Fixation in Acute High‐Grade Injuries Using a Single Button Over the Clavicle and a FiberTape With Modified Cinch Loop Through the Coracoid With Acromioclavicular Reduction Using a Hohmann Retractor. Arthroscopy Techniques. 2024. DOI: 10.1016/j.eats.2024.103363

[3] Comparison of single versus double TightRope system in the treatment of acute acromioclavicular joint dislocation. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.002

[4] High grade acromioclavicular injury: Comparison of arthroscopic assisted acromioclavicular joint fixation and anatomic acromioclavicular joint reconstruction. Journal of Orthopaedics. 2020. DOI: 10.1016/j.jor.2020.04.007

[5] Primary Stability of an Acromioclavicular Joint Repair Is Affected by the Type of Additional Reconstruction of the Acromioclavicular Capsule. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518807908

[6] Early and delayed acromioclavicular joint reconstruction provide equivalent outcomes. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.026

[7] Operative vs. Non-Operative Treatment of Acute Dislocations of the Acromio-Clavicular Joint: Results of a Multi-Centre Randomized, Prospective Clinical Trial. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.12.051

[8] Aaos Comprehensive Orthopaedic Review 3. Disorders of the Acromioclavicular Joint > II. Traumatic Conditions of the AC Joint.

[9] Treatment of a Failed Type V Acromioclavicular Separation Due to Coracoid Fracture: Revision of Acromioclavicular‐Coracoclavicular Reconstruction and Coracoid Fixation. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2020.10.055

[10] The ligamentous injury pattern in acute acromioclavicular dislocations and its impact on clinical and radiographic parameters. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.026

[11] Long-term clinical and radiographic outcomes of arthroscopic acromioclavicular stabilization for acute acromioclavicular joint dislocation. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2023.01060

[12] Free Tissue Graft Reconstruction of the Acromioclavicular Joint. Techniques in Shoulder & Elbow Surgery. 2008. DOI: 10.1097/bte.0b013e31818a5dd9

[13] Proximal extension of the deltopectoral approach with ‘bra-strap’ incision: a technical note on a classic technique for acromioclavicular stabilization with step-by-step insights and surgical tips. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.06.010

[14] Acromioclavicular and coracoclavicular cerclage reconstruction for acute acromioclavicular joint dislocations. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.08.007

[15] Current concepts in acromioclavicular joint (AC) instability – a proposed treatment algorithm for acute and chronic AC-joint surgery. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05935-0

[16] Editorial Commentary: Why We Have To Respect The Anatomy In Acromioclavicular Joint Surgery And Why Clinical Shoulder Scores Might Not Give Us The Information We Need!. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.01.038

[17] Evaluation of the Surgical Treatment of Acromioclavicular Joint Dislocation With a New Option for Temporary Fixation of the Acromioclavicular Joint. Techniques in Shoulder & Elbow Surgery. 2013. DOI: 10.1097/bte.0000000000000005

[18] Relative contribution of acromioclavicular joint capsule and coracoclavicular ligaments to acromioclavicular stability. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.08.003

[19] Treatment of acromioclavicular joint separation: Suture or suture anchors?. Journal of Shoulder and Elbow Surgery. 2002. DOI: 10.1067/mse.2002.123904

[20] Rockwood and Green's Fractures in Adults. 2019.

[21] Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.09.012

[22] Arthroscopic Coracoclavicular Fixation Using Multiple Low‐Profile Devices in Acute Acromioclavicular Joint Dislocation. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.07.007

[23] Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.09.003

[24] Surgical treatment of chronic acromioclavicular dislocation: Comparison between two surgical procedures for anatomic reconstruction. Injury. 2010. DOI: 10.1016/j.injury.2010.09.023

[25] Arthroscopically Assisted Acromioclavicular Joint Reconstruction Using the Infinity‐Lock Button System With Allograft Augmentation. Arthroscopy Techniques. 2020. DOI: 10.1016/j.eats.2020.08.030

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[28] Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114560130

[29] Orthopaedic Knowledge Update Sports Medicine 6. Disorders of the Acromioclavicular Joint, Sternoclavicular Joint, and Clavicle > AC Joint Injuries > Classification.

[30] Voluntary acromioclavicular joint dislocation: a case report and literature review. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.039

[31] Is Coraco‐Clavicular Stabilisation Alone Sufficient for the Endoscopic Treatment of Severe Acromio‐Clavicular Separation (Rockwood Types III, IV, and V)?. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.056

[32] Complications After Arthroscopic Coracoclavicular Reconstruction Using a Single Adjustable–Loop‐Length Suspensory Fixation Device in Acute Acromioclavicular Joint Dislocation. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.11.013

[33] Aaos Comprehensive Orthopaedic Review 3. Disorders of the Acromioclavicular Joint > III. Atraumatic and Degenerative Conditions of the AC Joint.

[34] Acromioclavicular joint dislocations: coracoclavicular reconstruction with and without additional direct acromioclavicular repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3920-1

[35] Low rate of substantial loss of reduction immediately after hardware removal following acromioclavicular joint stabilization using a suspensory fixation system. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06978-5

[36] Reconstruction of the Coracoclavicular Ligament for AC Joint Dislocation (SS‐11). Arthroscopy. 2008. DOI: 10.1016/j.arthro.2008.04.012

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[38] Arthroscopic stabilization of acromioclavicular joint dislocation using the AC graftrope system. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.12.014

[39] Value of additional acromioclavicular cerclage for horizontal stability in complete acromioclavicular separation: a biomechanical study. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-2895-7

[40] Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures. EFORT Open Reviews. 2018. DOI: 10.1302/2058-5241.3.170027

[41] Endoscopically assisted reconstruction of acute acromioclavicular joint dislocation using a synthetic ligament. Outcomes at 12 months. Orthopaedics & Traumatology: Surgery & Research. 2011. DOI: 10.1016/j.otsr.2010.10.004

[42] New quantitative radiographic parameters for vertical and horizontal instability in acromioclavicular joint dislocations. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4579-6

[45] Improved identification of unstable acromioclavicular joint injuries in a clinical population using the acromial center line to dorsal clavicle radiographic measurement. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.12.014

[47] Complications after operative treatment of high-grade acromioclavicular injuries. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.03.019

[48] Importance of additional temporary pin fixation combined coracoclavicular augmentation using a suture button device for acute acromioclavicular joint dislocation. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-016-2437-5

[49] Ligamentous and capsular restraints to anterior-posterior and superior-inferior laxity of the acromioclavicular joint: a biomechanical study. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.006

[50] Heterotopic Ossification After Acute Acromioclavicular Joint Dislocation—Effect on Radiographic and Clinical Outcomes. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251408491

[51] Arthroscopic‐Assisted Acromioclavicular Joint Dislocation Repair: A Modified Technique for Horizontal Stabilization Using Suture Anchors. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2020.10.004

[52] Anatomic Acromioclavicular Joint Reconstruction with and without Acromioclavicular Ligament Reconstruction: A Comparative Biomechanical Study. Shoulder & Elbow. 2022. DOI: 10.1177/17585732211068322

[53] Arthroscopic‐Assisted Acromioclavicular Joint Reconstruction Using the TightRope Device With Allograft Augmentation: Surgical Technique. Arthroscopy Techniques. 2015. DOI: 10.1016/j.eats.2015.02.012

[56] Subacromial morphometric assessment of the clavicle hook plate. Injury. 2010. DOI: 10.1016/j.injury.2009.12.012

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[60] Publicly Accessible Rehabilitation Protocols for Acromioclavicular Joint Reconstruction Are Widely Variable. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2020.10.007

[61] Clinical and anatomical outcomes of isolated coracoclavicular fixation after acromioclavicular joint injury: is it stable enough or is additional horizontal fixation necessary?. JSES International. 2023. DOI: 10.1016/j.jseint.2022.10.001

[62] The biomechanical influence of the deltotrapezoid fascia on horizontal and vertical acromioclavicular joint stability. Archives of Orthopaedic and Trauma Surgery. 2016. DOI: 10.1007/s00402-015-2389-1

[67] Fixation failure and early loss of reduction with the use of suture anchors for surgical repair of acromioclavicular joint dislocation: a case series. JSES International. 2024. DOI: 10.1016/j.jseint.2024.06.011

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[71] Coracoid process transfer and distal clavicle resection for chronic acromioclavicular separation. JSES International. 2023. DOI: 10.1016/j.jseint.2022.09.012

[75] Paper 55: Kinematic Abnormalities in the Shoulder Girdle after Conservative or Surgical Treatment of the High-grade Acromioclavicular Joint Disruption. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/2325967123s00080

[76] Acute high-grade acromioclavicular joint dislocation patients treated with titanium cable insertion under a homemade guider. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02442-1

[77] Arthroscopic reconstruction of chronic AC joint dislocations by transposition of the coracoacromial ligament augmented by the Tight Rope device: a technical note. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0633-8

[78] Early failures with single clavicular transosseous coracoclavicular ligament reconstruction. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2012.01.018

[79] Poster 39: Minimum 10-Year Outcomes After Arthroscopically-Assisted Anatomic Coracoclavicular Reconstruction for the Treatment of Type III and V Acromioclavicular Joint Injuries. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/2325967125s00150

[80] Acromioclavicular joint reconstruction with the LARS ligament in professional versus non‐professional athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3231-y

[81] Paper #50: How Satisfied Are Patients with Arthroscopic Bankart Repair? A Two‐Year Follow‐Up On Quality‐Of‐Life Outcome. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.08.039

[82] Surgical treatment of acute acromioclavicular joint dislocations: hook plate versus minimally invasive reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3294-9

[83] Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation. Archives of Orthopaedic and Trauma Surgery. 2014. DOI: 10.1007/s00402-014-2117-2

[84] Surgical management of chronic high-grade acromioclavicular joint dislocations: a systematic review. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.03.005

[85] Primary Acromioclavicular‐Coracoclavicular Reconstruction Using 2 Allografts, TightRope, and Stabilization to the Acromion. Arthroscopy Techniques. 2019. DOI: 10.1016/j.eats.2018.10.006

[86] Treatment of Symptomatic Acromioclavicular Joint Instability by a Docking Technique: Clinical Indications, Surgical Technique, and Outcomes. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.08.023

[90] All‐Arthroscopic Reconstruction of Severe Chronic Acromioclavicular Joint Dislocations. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2018.11.058

[91] Surgical treatment of acute type V acromioclavicular joint dislocations in professional athletes: an anatomic ligament reconstruction with synthetic implant augmentation. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.05.032

[92] The Reliability of Acromioclavicular Joint Dislocation Classification Systems: A Comparison Between the Rockwood and Kraus Classifications. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671221149391

[95] Treatment of Rockwood type III acromioclavicular joint dislocation using autogenous semitendinosus tendon graft and endobutton technique. Therapeutics and Clinical Risk Management. 2016. DOI: 10.2147/tcrm.s81829

[98] The Function of the Acromioclavicular and Coracoclavicular Ligaments in Shoulder Motion. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512458571

[99] Acromioclavicular joint ligamentous system contributing to clavicular strut function: a cadaveric study. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.004

[102] Noninvasive bracing of acromioclavicular joint dislocations is not superior to early functional rehabilitation and not inferior to surgical stabilization in Rockwood type III and V injuries. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.08.040

[109] The Acromioclavicular‐Distal Clavicle 3‐Dimensional All‐Suture Stabilization Technique Without Need for Fluoroscopy and Without Metallic Hardware. Arthroscopy Techniques. 2026. DOI: 10.1002/atn2.70185

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[112] Arthroscopic Coracoclavicular Reconstruction Combined with Open Acromioclavicular Reconstruction Using Knot Hiding Clavicular Implants Is a Stable Solution. Arthroscopy, Sports Medicine, and Rehabilitation. 2021. DOI: 10.1016/j.asmr.2021.08.002

[115] Acute high-grade acromioclavicular joint injuries treatment: Arthroscopic non-rigid coracoclavicular fixation provides better quality of life outcomes than hook plate ORIF. Orthopaedics & Traumatology: Surgery & Research. 2016. DOI: 10.1016/j.otsr.2015.10.007

[117] The Rockwood classification in acute acromioclavicular joint injury does not correlate with symptoms. Journal of Orthopaedic Surgery. 2018. DOI: 10.1177/2309499018777886

[118] Rockwood type III is the most common type of acromioclavicular joint dislocation: A prospective cohort study investigating the incidence and epidemiology of acute acromioclavicular joint dislocations in an urban population. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221123314

[121] Arthroscopic Coracoclavicular Ligament Reconstruction With Double‐Bundle Soft Tissue Allograft for Chronic Type V Acromioclavicular Dislocations Shows Excellent Patient Outcomes and Return to Duty and Sport at Minimum 10‐Year Follow‐Up. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.05.008

[128] Kinematic Alterations In The Shoulder Complex In Rockwood V Acromioclavicular Dislocations During Humerothoracic And Scapulothoracic Movements. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.096

[130] Effect of Acromioclavicular Joint Injuries on the Acromioclavicular Joint Complex and Scapulohumeral Rhythm: A Functional and Mechanical Perspective. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00360

[131] Under-coracoid-around-clavicle (UCAC) loop in type II distal clavicle fractures. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b7.31316

[132] Does coracoclavicular augmentation additional to hook plate fixation provide benefits in acute unstable acromioclavicular dislocation? A meta-analysis. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05142-x

[136] Paper 39: Overreduction of Type V Acromioclavicular Joint Dislocations During Acute Fixation is Associated with Improved Postoperative Rockwood Classification. Orthopaedic Journal of Sports Medicine. 2024. DOI: 10.1177/2325967124s00051

[137] Current Concepts in the Operative Management of Acromioclavicular Dislocations: A Systematic Review and Meta-analysis of Operative Techniques. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518795147

[138] Conversion to anatomic coracoclavicular ligament reconstruction (ACCR) shows similar clinical outcomes compared to successful non‐operative treatment in chronic primary type III to V acromioclavicular joint injuries. Knee Surgery, Sports Traumatology, Arthroscopy. 2020. DOI: 10.1007/s00167-020-06159-2

[140] Acromioclavicular joint dislocation associated with a coracoid process fracture: report of 2 cases. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.007

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[148] Comparison of the Tight Rope Technique and Clavicular Hook Plate for the Treatment of Rockwood Type III Acromioclavicular Joint Dislocation. Journal of Investigative Surgery. 2017. DOI: 10.1080/08941939.2017.1305022

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[151] Arthroscopic Acromioclavicular Joint Reconstruction Using Knotless Coracoclavicular Fixation and Soft‐Tissue Anatomic Coracoclavicular Ligament Reconstruction. Arthroscopy Techniques. 2017. DOI: 10.1016/j.eats.2016.08.035

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[161] Early complications of acromioclavicular joint reconstruction requiring reoperation. Knee Surgery, Sports Traumatology, Arthroscopy. 2016. DOI: 10.1007/s00167-016-4206-y

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[171] Clavicle and coracoid process periprosthetic fractures as late post‐operative complications in arthroscopically assisted acromioclavicular joint stabilization. Knee Surgery, Sports Traumatology, Arthroscopy. 2019. DOI: 10.1007/s00167-019-05482-7

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[174] Loss of Reduction and Clavicle Fractures Commonly Occur in Patients Undergoing Acromioclavicular Joint Reconstruction and Female Sex Is Associated With Higher Fracture Risk. Arthroscopy, Sports Medicine, and Rehabilitation. 2026. DOI: 10.1002/ars2.70063

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[178] Open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translation for type V acromioclavicular joint dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4509-7

[179] A Surgical Technique for Revision of Failed Acromioclavicular Joint Reconstruction. Techniques in Shoulder & Elbow Surgery. 2020. DOI: 10.1097/bte.0000000000000190

[180] Delayed acromioclavicular joint reconstruction using a modern suspensory device does not increase the risk of fixation failure or major complications. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.05.020

[181] Editorial Commentary : Coracoclavicular Joint Reconstruction for Acromioclavicular Dislocation: Double‐Bundle Techniques Are Anatomically and Biomechanically Favored. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.10.019

[182] Should Type V Acromioclavicular joint injuries have surgery?. Injury. 2026. DOI: 10.1016/j.injury.2026.113201

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