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AC Joint Stabilisation

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

115 citationsUpdated Sep 2026

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Overview

Acromioclavicular (AC) joint separation results from progressive ligamentous disruption, typically following a fall on the point of the shoulder [8]. The injury spectrum ranges from Type I and II sprains, which are managed nonsurgically with good functional outcomes and full recovery within 4 to 6 weeks [8], to high-grade separations (Types IV, V, and VI) that require surgical intervention due to substantial residual pain and limited function if treated conservatively [8]. While nonsurgical treatment is preferred for Type III injuries in many cases, surgical management is indicated for acute Type IV, V, and VI separations, as well as for selected Type III patients who are physically active, have cosmetic concerns, or present with chronic symptoms [8].

Surgical stabilization aims to restore native stability against translational and rotational loads, with combined AC capsule and CC ligament fixation demonstrating the greatest capacity to achieve this [5]. Various techniques, including anatomic reconstruction, arthroscopic stabilization with TightRope or button systems, and cerclage augmentation, offer effective options for restoring joint congruity [2, 3, 4, 16]. Although radiographic alignment is improved with surgical repair, evidence for superior short-term clinical outcomes compared to nonsurgical treatment remains inconclusive for complete dislocations [7]. However, early and delayed surgical interventions provide equivalent clinical scores when adequate reduction and stabilization are achieved [6].

Complication rates and long-term stability vary by technique; for instance, radiological failures were observed in 41% of cases in one series, while revision rates for arthroscopically-assisted anatomic reconstruction were 14.3% [22, 49]. Ensuring precise placement of the AC joint and recovery of the coracoclavicular distance is critical for maintaining proper position at final follow-up [13]. Specific considerations include the risk of poor outcomes in voluntary dislocations and the potential for increased fracture risk, which can be mitigated by using augmentation systems like the Infinity-Lock Button with allograft [24, 29]. Detailed classification, evaluation protocols, and specific operative techniques are addressed in subsequent sections.

Anatomy & Pathophysiology

Joint Structure and Biomechanics

The acromioclavicular (AC) joint is a diarthrodial joint that serves as a primary link between the axial skeleton and the upper extremity [38]. It is movable in all planes and is not a rigid structure [38]. The clavicle facilitates shoulder function by suspending it away from the axial skeleton, optimizing motion, muscle action vectors, and position [21]. The AC and coracoclavicular (CC) ligaments function as static stabilizers of the AC joint, while the deltoid and trapezius muscles act as dynamic stabilizers [38]. These ligaments contribute to torque transduction and horizontal and vertical stability within the scapulohumeral rhythm [124]. Decoupling the claviscapular segment has deleterious effects on the functional integrity of the AC joint complex within scapulohumeral rhythm [124].

Under 70-N loads, the normal AC joint is capable of translating 4 to 6 mm in the anterior, posterior, and superior planes [38]. The joint accommodates rotary motion of 5° to 8° during scapulothoracic motion and 40° to 45° with shoulder abduction and elevation [38]. Kinematic changes resulting from AC joint dislocation can be a potential source of pain and dysfunction in the shoulder [97]. Scapular and clavicular kinematics are affected in AC separation models [98]. Large kinematic differences exist between the intact state and a Rockwood V lesion during both humerothoracic and scapulothoracic movements [122, 128].

Ligamentous Anatomy and Stability

The AC ligaments provide horizontal plane stability to the clavicle, specifically through the posterior and superior portions [32]. However, they offer the weakest resistance to forces that push the acromion inferiorly and medially [18]. The intact clavicle and sternoclavicular joint (SCJ) provide stronger resistance than the AC ligaments to these forces [18]. The coracoclavicular (CC) ligaments act as an extremely strong buffer after the AC ligaments are disrupted [18]. 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 [18]. The coracoacromial ligament contributes to muscular balance and stabilization of the shoulder girdle [144]. On an AP radiograph, the normal coracoclavicular distance should be between 11 and 13 mm [8, 32].

Mechanism of Injury

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 [18]. This is also described as direct contact applied over the superolateral border of the shoulder while the humerus is in the adducted position [136]. AC joint injuries are often caused by direct trauma to the shoulder or a fall on an outstretched hand [69]. A falling object or a deliberate blow striking the superior acromion is a rarer mechanism of direct AC joint injury [18].

Indirect mechanisms of AC joint injury are exceedingly rare [18]. An indirect mechanism involves a fall onto the adducted upper limb, which drives the humeral head into the inferior aspect of the acromion [18]. 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 [18].

Pathoanatomy and Injury Progression

AC joint injury results in progressive disruption of the ligamentous support, beginning with the capsular ligaments and progressing to the CC ligaments [8]. The extent of injury to the AC and CC ligaments, as well as the amount and direction of clavicle displacement, determines the severity of AC joint separation [69]. Injuries to the AC joint constitute 9% of shoulder injuries [69, 136]. AC joint injuries occur five times more frequently in men than in women [38, 136]. The highest incidence of AC joint injuries is in the 20- to 30-year-old age group [38], with the majority of AC injuries (44%) occurring in people in their twenties [136]. AC joint injuries represent 15%, 20%, and 41% of shoulder injuries in hockey, skiing, and American football, respectively [136].

A coracoid 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, allowing vertical displacement of the clavicle [133]. The AC joint and its stabilizing ligaments are part of the superior shoulder suspensory complex (SSSC), a bone and ligament ring structure essential for maintaining shoulder stability and biomechanics [133]. 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 [133].

Degenerative Pathophysiology

Osteoarthritis of the AC joint is more common with advanced age following degeneration of the intra-articular disk [32]. Arthritic deterioration of the AC joint starts in early middle age [32]. Osteoarthritis of the AC joint is more common in patients engaged in repetitive overhead or lifting activities [32]. Previous low-grade AC joint separations can result in painful arthritis [32]. The radiographic severity of AC joint arthritis does not always correlate with patient symptoms [32].

Distal clavicle osteolysis involves localized hyperemia of the distal clavicle, resulting in inflammation, bone resorption, microfractures, and secondary arthritis of the AC joint [32]. Distal clavicle osteolysis is more common in males and younger patients associated with heavy lifting or repetitive motions [32].

Classification

Rockwood Classification System

The Rockwood classification is the most widely used system for AC joint dislocation, though it remains a purely radiographic classification system [60]. Initially described in 1963 with types I, II, and III, the system was expanded in 1984 to include types IV, V, and VI [28]. Determination of each type relies on comparative radiographs of the contralateral shoulder [28].

Type I: Involves AC ligament sprain with intact CC ligaments and normal radiographic CC distance [8, 28]. Type II: Involves AC ligament rupture with sprained but intact CC ligaments [8]. This injury is characterized by widening of the AC joint and an increase in the CC distance by less than 25% compared with the contralateral shoulder [28]. Type III: Involves disruption of both AC and CC ligaments [8]. It is defined by an increase in the CC distance of 25% to 100% compared with the contralateral shoulder [28], resulting in superior displacement of the clavicle up to 100% of the clavicle width [8]. The deformity is reducible [8, 28]. Type IV: Involves disruption of AC and CC ligaments with posterior displacement of the clavicle into or through the deltotrapezial fascia [8]. This injury is characterized by increased CC distance and a non-reducible deformity [8]. Type V: Involves disruption of AC and CC ligaments with an increase in the CC distance of 100% to 300% compared with the contralateral shoulder [28]. This results in greater than 100% superior displacement of the clavicle [8]. The deformity is usually not reducible due to herniation through the deltotrapezial fascia [8]. Type VI: Involves disruption of AC and CC ligaments with inferior displacement of the clavicle beneath the acromion or coracoid process [8]. This rare injury involves inferior displacement of the clavicle into the subcoracoid space [28].

Epidemiology and Mechanism

Rockwood type III is the most common type of AC joint dislocation, constituting 55.7% of injuries in an urban population cohort [113]. 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 adducted [18].

Limitations and Reliability

The Rockwood classification does not assess horizontal instability except for Type IV injuries [40]. 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 [112]. The Kraus classification system was slightly more reliable than the Rockwood system for classifying AC joint injuries both between assessor groups and overall [91]. The ISAKOS Subclassification of Rockwood Type III AC Joint Dislocations into a stable Type A and an unstable Type B is not clinically relevant in a cohort primarily treated non-surgically [73]. The presence of scapular dyskinesis was associated with an inferior result in patients with Rockwood Type III dislocations [73].

Clinical Presentation

Mechanism and Epidemiology

Acromioclavicular joint injury most commonly results from 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 [18]. Indirect mechanisms of injury are exceedingly rare [18]. 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 [21]. In many contact sports, acromioclavicular joint injury accounts for 40% to 50% of shoulder injuries [38]. The incidence is five times higher in men than in women, with the highest frequency in the 20- to 30-year-old age group [38].

Physical Examination

Higher grade acromioclavicular injuries present with prominence of the distal clavicle [8]. Acute injuries are characterized by localized bruising, swelling, and tenderness [8]. During the physical examination, the sternoclavicular joint must be evaluated for swelling, deformity, and tenderness [8]. Range of motion and rotator cuff strength are typically normal in chronic injuries but may be limited in acute injuries secondary to pain [8]. The ability to reduce the deformity with manual pressure is a critical finding that helps differentiate nonsurgical versus surgical treatment for higher grade injuries [8]. Evaluating the integrity of the capsuloligamentous structures stabilizing the acromioclavicular joint is reproducible and provides additional information on injury severity that may influence treatment decisions [11].

Imaging

Plain radiographs for acromioclavicular joint evaluation include an AP view of the clavicle, a caudal tilt view, and an axillary view [8]. The normal coracoclavicular distance between the superior aspect of the coracoid and the inferior clavicle should be between 11 to 13 mm [8]. A Zanca view, defined as a modified, underpenetrated AP view with a cephalic tilt of 10° to 15°, provides excellent detail of the distal clavicle [8]. Weighted views include bilateral AP views with a weight tied to the wrists in relaxed standing and help distinguish between type II and type III separations [8]. Fracture of the base of the coracoid process should be ruled out, as it can result in superior displacement of the clavicle with an intact coracoclavicular distance, creating a functionally equivalent acromioclavicular joint separation [8]. The AC-DC measurement and use of the Alexander view provide a more realistic appreciation of true acromioclavicular joint displacement, especially in defining watershed cases such as IIIA/IIB/IV [42].

Classification

The Rockwood classification is a purely radiographic classification system based on increasing severity of injury to stabilizing structures [60]. The specific types are defined as follows:

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]. In these injuries, the CC distance is increased by less than 25% compared with the contralateral shoulder [28]. Type III: Involves disruption of the AC and CC ligaments, increased CC distance, superior displacement of the clavicle of up to 100% of the clavicle width, and a reducible deformity [8]. In type III injuries, the CC distance is increased 25% to 100% compared with the contralateral shoulder [28]. Type IV: Involves disruption of the AC and CC ligaments with posterior displacement of the clavicle, increased CC distance, and a non-reducible deformity [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 that is usually not reducible [8]. In type V injuries, the CC distance is increased by more than 100% compared with the contralateral shoulder because of disruption of the deltotrapezial fascia [28]. Type VI: Involves disruption of the AC and CC ligaments with inferior clavicle displacement, where the distal clavicle lies 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]. In acute injuries, localized bruising, swelling, and tenderness are present [8]. Higher grade AC joint injuries result in prominence of the distal clavicle [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]. The sternoclavicular joint should be evaluated for swelling, deformity, and tenderness during the physical examination of the AC joint [8].

Imaging

Plain radiography: Plain radiographs for AC joint evaluation include an AP view of the clavicle, a caudal tilt view, and an axillary view [8]. 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].

Classification: The Rockwood classification relies on comparative radiographs of the contralateral shoulder to determine each type [28]. Type I injury involves AC ligament sprain without injury to the CC ligaments, with no AC joint widening or clavicular displacement [28]. Type II injury 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 [28]. Type III injury involves disruption of the AC and CC ligaments, widening of the AC joint, and an increase in the CC distance 25% to 100% compared with the contralateral shoulder [28]. Type IV AC joint separation is diagnosed when the distal clavicle is displaced posteriorly into the trapezius muscle [28]. Type V injury 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 [28]. In type V injuries, the CC distance is increased by more than 100% compared with the contralateral shoulder [28].

Limitations and Advanced Measurements: The Rockwood classification system does not assess horizontal instability except for Type-4 injuries [40]. The combined posterior–superior dislocation of the clavicle with respect to the acromion may lead to an unpredictable effect on the radiographic CC distance due to projection [40]. Underestimation of the CC distance due to projection may inappropriately influence non-operative management of potential high grade injuries [40]. The AC-DC measurement and use of the Alexander view provides a more realistic appreciation of true AC joint displacement [42]. The AC-DC measurement and Alexander view are useful in defining watershed cases such as IIIA/IIB/IV [42]. The AC-DC measurement and Alexander view may better inform the decision-making process regarding management options [42]. Grading acute AC joint lesions by performing a digital measurement is recommended over a sole visual diagnosis due to higher intra- and interobserver reliability [150].

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 [11]. Evaluation of capsuloligamentous integrity might influence the treatment decision [11].

Treatment

Non-Operative

Nonsurgical management is the standard of care for Rockwood type I and II acromioclavicular (AC) joint injuries [8]. Sling immobilization is typically maintained for approximately 1 week for type I injuries and 2 to 3 weeks for type II injuries [36]. Most patients regain full shoulder function within 4 to 6 weeks [8]. However, between 30% and 50% of young, very active patients with type I or II injuries experience mild to moderate residual pain at the AC joint [8]. Retrospective data indicate persistent symptoms in up to 40% to 50% of patients at 1, 6, and 10 years post-injury [36].

For type III injuries, nonsurgical treatment results in quicker recovery and return to work compared to surgical intervention [8]. Meta-analyses and systematic reviews demonstrate similar outcomes for type III separations managed nonsurgically versus surgically [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]. While nonoperative treatment of Rockwood types III and V dislocations produces more prominent or unstable and radiographically wider AC joints than operative treatment [27], clinical results were equally good between operative and nonoperative groups at 18- to 20-year follow-up [27]. Conservative treatment was successful in a majority of patients with Type V AC dislocations [132]. The average time to return to duty for Type V dislocations was not improved by acute versus delayed surgical intervention [132]. In patients with chronic severe AC joint dislocation, a trial of conservative treatment may be attempted, as time from injury to eventual conversion to anatomic coracoclavicular reconstruction had no significant influence on postoperative clinical outcomes [66]. Non-operative reduction and stabilization of high-grade AC joint separations remains a valuable treatment option [1].

Operative

Indications: Surgery is indicated for most acute type IV, V, and VI AC separations [8]. Surgical treatment is recommended for most patients with these injuries because nonsurgical treatment likely results in substantial residual pain and limited function [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 AC joint injuries with or without augmentation seems to result in better patient satisfaction and clinical outcomes compared with delayed reconstruction [36]. A 2016 systematic review found superior functional outcomes in the early surgical group compared with delayed surgery for complete AC joint dislocation [36]. 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 [36]. 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 [36]. Early and delayed surgical interventions of high-grade AC joint dislocation provide equivalent clinical scores when combined coracoclavicular and AC joint fixation is used for stabilization [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].

Surgical Approach / Technique: Acute fixation of high-grade AC joint separations within 3 to 4 weeks of injury can be successfully performed with various fixation options and without the use of tendon graft [32]. Healing of the coracoclavicular ligaments is reliable without the need for graft augmentation if adequate reduction and stabilization are achieved in acute surgery less than 3 to 4 weeks following injury [8]. Arthroscopic stabilization for acute AC joint dislocations offers satisfactory clinical and radiographic outcomes, and the arthroscopic technique is reliable in the long run [12]. Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation [50]. Patients with acute high-grade AC 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 [111]. Both TightRope and hook plate techniques offered effective outcomes in relieving the pain of dislocation and improving function of the AC joint [149]. Hook plate fixation with coracoclavicular augmentation is preferable for acute unstable AC joint dislocations [126].

The described technique of arthroscopic AC joint fixation using a single button over the clavicle and a FiberTape with modified cinch loop through the coracoid provides AC joint stability, allowing early rehabilitation and minimizing fixation failure [2]. Both single and double TightRope systems are effective in treating AC joint dislocation, but the double TightRope system is more reliable for reduction maintenance [3]. Ensuring good initial recovery of the coracoclavicular distance and precise placement of the AC joints was important in maintaining the proper AC position at final follow-up [13]. The described technique of cerclage augmentation offers an attractive alternative in AC joint stabilization, with good to excellent results [16]. Satisfactory clinical outcomes were obtained after coracoclavicular fixation using the single adjustable-loop-length suspensory fixation device for acute AC joint dislocation [31]. 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 [37]. The arthroscopically assisted AC joint reconstruction using the Infinity-Lock button system with allograft augmentation minimizes risk of fracture and provides additional stability via augmentation of the AC joint [24]. Arthroscopic coracoclavicular fixation using multiple low-profile devices is a technique for acute AC joint dislocation [13]. The described technique of arthroscopic coracoclavicular reconstruction by Endobutton fixation 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]. The described technique of arthroscopically assisted AC joint dislocation repair using suture anchors aims to restore optimal biomechanics by providing both anatomic AC joint reduction and physiological horizontal stabilization [51]. Arthroscopic AC 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 proximal extension of the deltopectoral approach with ‘bra-strap’ incision offers a safe and efficient solution for AC joint stabilization by combining the reliability of a well-established technique with improved visualization and reduced soft tissue trauma [15]. The described technique of arthroscopic coracoclavicular reconstruction combined with open AC reconstruction using knot hiding clavicular implants is a stable solution [109]. The described technique of the AC-distal clavicle 3-dimensional all-suture stabilization technique without need for fluoroscopy and without metallic hardware is a true “all-suture technique” with no use of metallic hardware such as endobutton or cortical button [107]. 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 [20]. These results support evidence indicating that temporary pin fixation for the AC joint provides early postoperative stability when performing coracoclavicular fixation using a suture button device [46]. The described technique of arthroscopic AC joint dislocation repair using a modified technique for horizontal stabilization using suture anchors aims to restore optimal biomechanics by providing both anatomic AC joint reduction and physiological horizontal stabilization [51].

Implant Selection: Delayed reconstruction of AC joint separations requires biologic augmentation, either ligament transfer or tendon grafting, in addition to coracoclavicular stabilization [32]. Anatomic AC joint reconstruction was associated with functional and radiologic benefits and better restored the stability compared to arthroscopic assisted AC joint fixation [4]. The authors recommend the procedure of anatomic reconstruction for the treatment of chronic complete AC dislocations [14]. The objective of the described technique is to manage a failed AC stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts [9]. The Gracilis graft appears to restore optimum stability and is strong enough to withstand forces across the AC joint [35]. Open capsular and ligament reconstruction with semitendinosus hamstring autograft successfully controls superior and posterior translation for type V AC joint dislocation and minimizes the incidence of persistent postoperative AC joint subluxation [55]. The described surgical technique of primary AC-coracoclavicular reconstruction using 2 allografts, TightRope, and stabilization to the acromion results in anatomic reconstruction of the AC joint [85].

Alignment / Balancing Strategy: Combined stabilization of the AC capsule and coracoclavicular ligaments demonstrated the greatest capacity to restore native stability against translational and rotational loads [5]. Anatomic techniques that address both coracoclavicular ligaments and the AC capsule are recommended to restore horizontal and vertical stability while allowing physiological rotation [10]. Acute AC joint dislocation requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the AC joint [23]. Acute AC joint dislocation requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromio-clavicular joint [30]. The results suggest that only combined AC and coracoclavicular reconstruction can adequately reestablish physiological horizontal AC joint stability [25]. Reconstruction of AC dislocations with one or two TightRopes leads to stable results with higher stiffness than native joints [33]. The reconstruction of the AC ligaments along with the coracoclavicular ligaments provides a stronger reconstruction that may better maintain reduction of the AC joint and lead to fewer failures [52]. Consideration should be given to reconstruction of the AC joint capsular ligament for complete anterior-posterior stability in high-grade and horizontally unstable AC joint injuries [47]. Additional AC fixation on the horizontal plane is not a prerequisite for all injuries, and there is no significant association between horizontal instability and clinical outcomes [61]. 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 [11]. Anatomic AC joint reconstructions are biomechanically superior to nonanatomic techniques, such as the Weaver-Dunn procedure [32].

Postoperative Care and Rehabilitation: Patients are kept in sling immobilization for 6 weeks to limit gravity forces placed on the operative construct after arthroscopically assisted AC joint reconstruction [43]. Hand, wrist, and elbow range of motion exercises, as well as pendulum exercises, are initiated immediately postoperatively [43]. Physical therapy is begun at 4 weeks with gentle shoulder passive range of motion exercises [43]. Unrestricted active motion is begun at 6 weeks postoperatively [43]. Strengthening exercises are initiated at 10 to 12 weeks postoperatively [43]. 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 [44].

Complications: Loss of reduction is the most common complication in AC dislocations treatment [86]. Greater postoperative coracoclavicular distances are associated with worse functional scores [86]. Fixation failures have been found to be due to hardware breakage or migration, suture abrasion and breakage, or bone erosion because of the potential sawing action of the sutures through the clavicle or the coracoid [26]. Postoperative recurrence of dislocation was observed in a statistically non-significant number of patients (two patients in the TightRope group, four patients in the Bosworth screw group) and the unique reason was implant failure due to its peripheral position at the coracoid in both groups [26]. Screw head breakage during screw removal 6 weeks postoperatively in six patients in the Bosworth screw group had no influence on the postoperative recurrence of dislocation [26]. Although radiological assessment showed a statistically significant immediate superior clavicular displacement after hardware removal, with an increased incidence in the first year following stabilization, this may not negatively influence the results of AC joint stabilization in a clinically relevant way [34]. Subacromial erosion can occur with the use of a hook plate [75]. Implant failure and migration, resulting in vascular or neurologic injuries, have been reported [75]. Kirschner wires and pins are not advised for AC joint stabilization [75]. Aseptic foreign body reaction and erosion of the coracoid or clavicle have been reported with the use of synthetic suture loops, as well as intrasubstance failure of synthetic grafts [75]. Early or late fractures of the clavicle or coracoid process have been reported, especially with surgical techniques that involve tunnels through the coracoid and/or clavicle [75]. Painful implants related to the hook plate or coracoclavicular screw usually requires a second procedure for implant removal [75]. Some publications have reported ossification of the coracoclavicular space as a complication following surgery [75]. Loss of AC joint reduction, persistent pain, and instability can potentially complicate surgical outcomes [75]. Neurologic injuries are rare, but can involve nerve root injuries secondary to traction during surgery, direct injury to the suprascapular nerve resulting from aggressive dissection during reconstruction, or injury to the brachial plexus with techniques that pass grafts or suture loops under the coracoid process [75]. Other complications such as adhesive capsulitis, osteomyelitis of the AC joint, and upper extremity deep vein thrombosis have also been reported [75]. These findings regarding fixation failure and early loss of reduction with the use of suture anchors should be taken into consideration when selecting an appropriate implant for fixation of AC joint dislocation [68]. Most patients with coracoid or clavicle fractures associated with coracoclavicular ligament reconstruction were ultimately treated surgically, although complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service [154]. Both the surgical and anesthesia teams should be cognizant of the risk of pulmonary complications associated with shoulder arthroscopy performed both with and without interscalene nerve blockade [148].

Complications

General Complication Profiles: Surgical management of AC joint injuries carries a relatively high complication profile and common loss of reduction, though the revision surgery rate remains low [45]. While surgical intervention improves joint reduction, it introduces the risk of surgical complications [173]. Complications are rare; however, when they occur, they frequently require one or more secondary surgeries to treat [166]. Good to excellent outcomes were reported only in patients who did not experience a complication [159]. The rate of recurrence and postoperative loss of reduction requires better definition of indications and improvement of surgical implants and technique [39]. Open and arthroscopic AC joint reconstruction techniques show no differences in loss of reduction, complication rate, or revision rate based on available literature [130].

Loss of Reduction and Instability: Radiological failures were observed in 41% of cases in a prospective multicenter study of 116 arthroscopic acute AC dislocation fixations [22]. Anatomic AC joint reconstruction resulted in a 16% mechanical failure rate in a series analyzing mechanical failures [165]. After primary AC joint reconstruction, loss of reduction was reported in 13.4% of patients at 2 years [167]. In a young, active population with Type V ACJ dislocation treated acutely, a high percentage lost reduction yet still returned to duty [76]. Double-bundle constructs provide improved maintenance of reduction compared to single-bundle constructs, but clinical outcomes are comparable [158]. The DT system is more reliable for reduction maintenance compared to the single TightRope system [3]. Although radiological assessment showed a statistically significant immediate superior clavicular displacement after hardware removal, this may not negatively influence the results of ACJ stabilization in a clinically relevant way [34]. Recurrent ACJ instability occurred in 12% of patients at a mean of 3 years’ follow-up in an all-arthroscopic reconstruction series [89]. The rate of revision ACJ stabilization was 14.3% in a series of arthroscopically-assisted anatomic coracoclavicular reconstruction [49]. Nine of 63 patients (14.3%) required surgical revision because of symptomatic recurrent instability or a wound infection in a minimally invasive coracoclavicular ligament reconstruction study [146]. Three patients (10%) experienced complete loss of reduction at 1 year follow-up in a Tight Rope technique group, though they showed satisfactory clinical outcome and were treated nonoperatively [139]. Two patients (8.7%) experienced partial reduction loss in the AP plane at final follow-up in a semitendinosus tendon graft and endobutton technique study [94]. 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 for complete AC joint dislocation [36]. Nonoperative treatment was shown to produce more prominent or unstable and radiographically wider ACJs than was operative treatment, but clinical results were equally good at 18- to 20-year follow-up [27].

Bony Complications: Distal clavicle fractures were reported in 15.7% of patients at 2 years after primary AC joint reconstruction [167]. Female sex is associated with higher fracture risk after acromioclavicular joint reconstruction [167]. A complete coracoid fracture was observed in one case of minimally invasive coracoclavicular ligament reconstruction, though the patient was free of symptoms and did not require surgical revision [146]. Inadequate position of the coracoid bone tunnel too far laterally led to a breakage of the lateral coracoid cortex and subsequent failure of the reconstruction in 6 cases (9.5%) [146]. Enlargement of the clavicular tunnel was observed in 77% of cases in an all-arthroscopic reconstruction series [89]. The clavicular tunnel was positioned too anterior in 15% of cases in an all-arthroscopic reconstruction series [89]. The coracoid tunnel was too lateral in 35% of cases in an all-arthroscopic reconstruction series [89]. Clavicle and coracoid process periprosthetic fractures are late post-operative complications in arthroscopically assisted acromioclavicular joint stabilization [163]. Two patients (8.7%) had acromial osteolysis on the latest radiographs in a semitendinosus tendon graft and endobutton technique study [94].

Hardware and Implant Complications: Postoperative complications in a clavicular hook plate group included 3 superficial wound infections, 1 nerve palsy, and 1 plate breakage [139]. One patient in a clavicular hook plate group fell after surgery, causing the plate breakage, which was treated with secondary surgery [139]. The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook [58]. Patients should abide by a strict policy of limited ROM until the hook plate is removed to avoid complications [162]. Secondary stabilization techniques, such as suture fixation, may obviate the need for subsequent hardware removal but carry risks of suture failure and erosion [161]. Fixation failure and early loss of reduction have been reported with the use of suture anchors for surgical repair of acromioclavicular joint dislocation [68]. We noted a high percentage of radiographic redisplacement and clinical failure with single clavicular transosseous coracoclavicular ligament reconstruction, and this technique cannot be recommended to treat AC joint injuries in our population [81]. The described technique of arthroscopic acromioclavicular joint reconstruction using knotless coracoclavicular fixation aims to achieve good to excellent clinical outcomes with lower complication rates than previously associated with other open and arthroscopic surgical techniques [140]. 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 [168]. Considering its less morbidity, excellent cosmesis, no need of hardware removal, and minimal complications from breakage or migration of metal implants, the arthroscopic reconstruction technique offers an attractive alternative in acromioclavicular joint stabilization [170].

Soft Tissue and Other Complications: Heterotopic ossification occurs after acute acromioclavicular joint dislocation and can be classified by severity and location, such as in the conoid or trapezoid ligament areas [48]. A superficial radial nerve palsy resolved spontaneously without treatment in a patient treated with a clavicular hook plate [139]. A wound infection was one of the reasons for surgical revision in 1 of 63 patients undergoing minimally invasive coracoclavicular ligament reconstruction [146]. No intraoperative or postoperative complications, such as fracture, infection, or implant failure, occurred in a series of professional athletes treated with anatomic ligament reconstruction with synthetic implant augmentation [90]. There were no infections or fractures in patients included in a study of Rockwood type III acromioclavicular joint dislocation using autogenous semitendinosus tendon graft and endobutton technique [94]. The described technique of arthroscopic coracoacromial ligament transposition augmented by the Tight Rope device 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 [79].

Recovery

Light activity (weeks): The evidence does not specify a defined week range for light activities such as desk work, driving, or light ADLs. However, arthroscopic AC joint fixation using a single button over the clavicle and a FiberTape with modified cinch loop allows early rehabilitation [2]. Temporary pin fixation for the AC joint provides early postoperative stability when performing CC fixation using a suture button device [46].

Full activity (months): The evidence does not specify a defined month range for full activity, including manual work, sport, or full ROM/strength return. Arthroscopic CC reconstruction for chronic, type V AC dislocations shows high rates of return to sport and maintenance of active-duty military status at long-term follow-up [116]. CC ligament reconstruction is associated with high return to pre-injury level of sport [156].

Complete recovery / outcome plateau (months): The evidence does not specify a defined month range for complete recovery or outcome plateau. A steady state of excellent quality-of-life and functional outcomes was noted from 12 months follow-up on for arthroscopic Bankart repair [82]. 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 [116].

Rehabilitation protocol: There was substantial variability in publicly accessible AC joint rehabilitation protocols, including a wide range in recommendations for appropriate time to return to sport [44]. No sustainably improved reduction of the ACJ resulted from bracing when compared to early functional rehabilitation [101].

Functional milestones: CC ligament reconstruction results in excellent functional outcomes irrespective of surgical approach or technique [156]. CC ligament reconstruction is associated with high patient satisfaction [156]. CC ligament reconstruction is associated with low rates of recurrence and reoperation at a minimum 5-year follow-up [156]. AC joint reconstruction with LARS ligament did not reveal differences in clinical outcomes between professional and non-professional athletes [80]. AC joint reconstruction with LARS ligament had 2% of failures (re-dislocations) at 2-year minimum follow-up [80].

Other Considerations: Non-operative reduction and stabilization of high-grade AC joint separations is a valuable treatment option [1]. The described arthroscopic fixation technique minimizes fixation failure [2]. The double TightRope system is more reliable for reduction maintenance than the single TightRope system [3]. Anatomic AC joint reconstruction is associated with functional and radiologic benefits and better restored stability compared to arthroscopic assisted fixation [4]. Early and delayed surgical interventions for high-grade AC joint dislocation provide equivalent clinical scores when combined CC and AC joint fixation is used [6]. Surgical repair improves radiographic alignment for complete AC joint dislocations [7]. There is no clear evidence that operative treatment improves short-term outcome for complete AC joint dislocations [7]. Evaluating the integrity of the capsuloligamentous structures stabilizing the AC joint is reproducible and provides additional information on injury severity that might influence the treatment decision [11]. Arthroscopic stabilization for acute AC joint dislocations offers satisfactory clinical and radiographic outcomes [12]. The arthroscopic technique for AC joint stabilization is reliable in the long run [12]. Ensuring good initial recovery of the CCD and precise placement of the AC joints was important in maintaining the proper AC position at final follow-up [13]. The authors recommend the described anatomic reconstruction procedure for the treatment of chronic complete AC dislocations [14]. Future research should focus on addressing horizontal and rotational instability to restore native physiological and biomechanical properties of the AC joint [17]. The AC joint capsule is a robust anatomical structure that contributes significantly to AC joint stability, especially in the AP plane [19]. Acute AC joint dislocation requires stabilisation in both planes, at the coracoclavicular junction and at the acromioclavicular joint [23]. Risk of fracture is minimized and additional stability is provided via augmentation of the AC joint using the Infinity-Lock Button System with allograft [24]. Only combined AC and CC reconstruction can adequately reestablish physiological horizontal ACJ stability [25]. The rate of revision ACJ stabilization was 14.3% after arthroscopically-assisted anatomic coracoclavicular reconstruction for Type III and V injuries [49]. Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation [50]. The described technique for horizontal stabilization using suture anchors aims to restore optimal biomechanics by providing anatomic AC joint reduction and physiological horizontal stabilization [51]. 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 after percutaneous coracoclavicular fixation [59]. By transferring the coracoid process, the AC joint regained stability after chronic joint separation [72]. Conservative participants demonstrated extensive ACJ instabilities, potentially implying inferior kinematic outcomes compared to the surgical group [77]. The described technique for chronic AC joint dislocations using transposition of the coracoacromial ligament augmented by the Tight Rope device has minimal morbidity, no need for autologous tendon transfer or hardware removal, and promising short-term results [79]. The independent acromioclavicular ligament repair 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 [137]. No long term disability results from the loss of the coraco-acromial ligament from its normal site [155].

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)
• [L5] Anatomic techniques that address both coracoclavicular ligaments and the AC capsule are recommended to restore horizontal and vertical stability while allowing physiological rotation. [10] (10.1016/j.arthro.2019.01.038)
• [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. [11] (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. [12] (10.5397/cise.2023.01060)
• [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. [13] (10.1016/j.arthro.2018.07.007)
• [L4] The authors recommend this procedure for the treatment of chronic complete AC dislocations. [14] (10.1016/j.injury.2010.09.023)
• [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. [15] (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. [16] (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. [17] (10.1186/s12891-022-05935-0)
• [L5] The AC joint capsule is a robust anatomical structure that contributes significantly to the AC joint stability, especially in the AP plane. [19] (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. [20] (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. [22] (10.1016/j.otsr.2015.09.012)
• [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)
• [Paper] Risk of fracture is minimized and additional stability is provided via augmentation of the AC joint. [24] (10.1016/j.eats.2020.08.030)
• [L5] The results suggest that only combined AC and CC reconstruction can adequately reestablish physiological horizontal ACJ stability. [25] (10.1007/s00167-014-2895-7)
• [L1] [26] (10.1016/j.injury.2015.10.060)
• [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. [27] (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. [29] (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. [30] (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. [31] (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. [33] (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. [34] (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. [35] (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. [37] (10.1016/j.jse.2009.12.014)
• [L4] [38] (10.1302/2058-5241.3.170027)
• [L4] [39] (10.1016/j.otsr.2010.10.004)
• [L5] [40] (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. [42] (10.1016/j.jse.2019.12.014)
• [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. [44] (10.1016/j.asmr.2020.10.007)
• [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. [45] (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. [46] (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. [47] (10.1016/j.jse.2020.09.006)
• [L3] [48] (10.1177/23259671251408491)
• [L4] The rate of revision ACJ stabilization was 14.3%. [49] (10.1177/2325967125s00150)
• [L3] Good clinical results can be achieved with both minimally invasive AC joint repair and hook plate fixation. [50] (10.1007/s00167-014-3294-9)
• [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)
• [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. [55] (10.1007/s00167-017-4509-7)
• [L5] The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. [58] (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. [59] (10.1111/j.1758-5740.2011.00113.x)
• [L5] [60] (10.1016/j.arthro.2013.11.005)
• [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)
• [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. [66] (10.1007/s00167-020-06159-2)
• [L4] These findings should be taken into consideration when selecting an appropriate implant for fixation of ACJ dislocation. [68] (10.1016/j.jseint.2024.06.011)
• [L4] By transferring the coracoid process, the AC joint regained stability after chronic joint separation. [72] (10.1016/j.jseint.2022.09.012)
• [L2] The presence of scapular dyskinesis was associated with an inferior result. [73] (10.1016/j.jisako.2023.03.318)
• [L3] In a young, active population with Type V ACJ dislocation treated acutely, a high percentage lost reduction yet still returned to duty. [76] (10.1177/2325967124s00051)
• [L4] Conservative participants demonstrated extensive ACJ instabilities, potentially implying inferior kinematic outcomes compared to the surgical group. [77] (10.1177/2325967123s00080)
• [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. [79] (10.1007/s00167-008-0633-8)
• [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] 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. [81] (10.1016/j.jse.2012.01.018)
• [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. [82] (10.1016/j.arthro.2017.08.039)
• [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)
• [Paper] The described surgical technique results in anatomic reconstruction of the AC joint. [85] (10.1016/j.eats.2018.10.006)
• [L5] [86] (10.1016/j.eats.2021.05.017)
• [L4] [89] (10.1016/j.arthro.2018.11.058)
• [L4] [90] (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. [91] (10.1177/23259671221149391)
• [L1] [94] (10.2147/tcrm.s81829)
• [L5] The kinematic changes could be a potential source of pain and dysfunction in the shoulder with AC joint dislocation. [97] (10.1177/0363546512458571)
• [L5] Scapular and clavicular kinematics were affected in AC separation models. [98] (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. [101] (10.1016/j.jse.2024.08.040)
• [L5] [107] (10.1002/atn2.70185)
• [L4] [109] (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. [111] (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. [112] (10.1177/2309499018777886)
• [L3] Rockwood type III was the most common type of AC joint dislocation constituting 55.7% of the injuries. [113] (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. [116] (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. [122] (10.1016/j.jse.2022.01.096)
• [L5] [124] (10.5435/jaaos-d-24-00360)
• [L1] HP fixation with CC augmentation is preferable for acute unstable ACJ dislocations. [126] (10.1186/s12891-022-05142-x)
• [L5] Large kinematic differences were seen between the intact state and a Rockwood V lesion not only during humerothoracic movements but also during scapulothoracic movements in the cadaveric model. [128] (10.1177/03635465211053016)
• [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. [130] (10.1177/0363546518795147)
• [L4] Conservative treatment was successful in a majority of patients with Type V AC dislocations, and the average time to return to duty was not improved with acute versus delayed surgical intervention. [132] (10.1177/2325967115s00017)
• [L4] [133] (10.1016/j.jseint.2020.02.007)
• [L5] [136] (10.1007/s11999-016-5079-6)
• [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. [137] (10.1177/1758573219857685)
• [L2] [139] (10.1080/08941939.2017.1305022)
• [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. [140] (10.1016/j.eats.2016.08.035)
• [L5] An individual approach should be considered during coracoid transfer to save at least parts of the coracoacromial ligament (CAL), as it contributes to muscular balance and stabilization of the shoulder girdle. [144] (10.1016/j.arthro.2018.02.004)
• [L4] [146] (10.1007/s00167-013-2737-z)
• [Case_report] Both the surgical and anesthesia teams should be cognizant of the risk of pulmonary complications associated with shoulder arthroscopy performed both with and without interscalene nerve blockade. [148] (10.1016/j.jseint.2020.02.013)
• [L1] Both TightRope and hook plate techniques offered effective outcomes in relieving the pain of dislocation and improving function of ACJ. [149] (10.1111/os.12724)
• [L4] The authors recommend grading acute AC joint lesions by performing a digital measurement instead of a sole visual diagnosis due to higher intra- and interobserver reliability. [150] (10.1007/s00167-014-3436-0)
• [L4] Most patients were ultimately treated surgically, although complications such as anterior shoulder pain, AC joint asymmetry, and activity-related weakness were common sequelae resulting in physical limitations and separation from military service. [154] (10.1177/03635465211036713)
• [L4] No long term disability results from the loss of the coraco-acromial ligament from its normal site. [155] (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. [156] (10.1177/03635465261457302)
• [L5] Double-bundle constructs provide improved maintenance of reduction compared to single-bundle constructs, but clinical outcomes are comparable. [158] (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. [159] (10.1177/0363546513502459)
• [L5] Secondary stabilization techniques, such as suture fixation, may obviate the need for subsequent hardware removal but carry risks of suture failure and erosion. [161] (10.1016/s0278-5919(03)00005-x)
• [L4] Patients should abide by a strict policy of limited ROM until the hook plate is removed to avoid complications. [162] (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. [163] (10.1007/s00167-019-05482-7)
• [L4] Anatomic AC joint reconstruction resulted in a 16% mechanical failure rate in this series. [165] (10.1016/j.jse.2014.06.017)
• [L3] Complications are rare, however, when they occur, they frequently require one or more secondary surgeries to treat. [166] (10.1177/2325967121s00708)
• [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. [167] (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. [168] (10.1016/j.jse.2007.02.103)
• [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. [170] (10.1007/s00402-005-0073-6)
• [L1] While surgical intervention is able to improve joint reduction, it adds the risk for surgical complications. [173] (10.1530/eor-2024-0077)

See Also

• Distal Clavicle Osteolysis
• Rotator Cuff
• Fractures
• Shoulder Arthroscopy

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] 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

[11] 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

[12] 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

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

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

[15] 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

[16] 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

[17] 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

[18] Rockwood and Matsen's the Shoulder. 2016.

[19] 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

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

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

[22] 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

[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] 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

[25] 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

[26] Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury?. Injury. 2015. DOI: 10.1016/j.injury.2015.10.060

[27] 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

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

[29] 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

[30] 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

[31] 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

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

[33] 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

[34] 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

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

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

[37] 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

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

[39] 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

[40] 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

[42] 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

[43] Campbell S Operative Orthopaedics 4 Volume Set. ARTHROSCOPIC REPAIR OF POSTERIOR HUMERAL AVULSION OF THE GLENOHUMERAL LIGAMENT > ARTHROSCOPICALLY ASSISTED AC JOINT RECONSTRUCTION > TECHNIQUE 52.28.

[44] 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

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

[46] 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

[47] 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

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

[49] 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

[50] 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

[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

[55] 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

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

[59] The Cortical Ring Sign: Clinical Results of Percutaneous Coracoclavicular Fixation. Shoulder & Elbow. 2011. DOI: 10.1111/j.1758-5740.2011.00113.x

[60] ISAKOS Upper Extremity Committee Consensus Statement on the Need for Diversification of the Rockwood Classification for Acromioclavicular Joint Injuries. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2013.11.005

[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

[66] 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

[68] 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

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

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

[73] The ISAKOS Subclassification of Rockwood Type III AC Joint Dislocations in a Stable Type A and an Unstable Type B Is Not Clinically Relevant. A Prospective Cohort Study of 95 Patients Primarily Treated Non-Surgically. Journal of ISAKOS. 2023. DOI: 10.1016/j.jisako.2023.03.318

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

[76] 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

[77] 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

[79] 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

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

[82] 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

[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

[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] A Technique for a More Accurate Acromioclavicular Joint Reduction in Arthroscopic Coracoclavicular Stabilization of Acromioclavicular Joint Dislocation. Arthroscopy Techniques. 2021. DOI: 10.1016/j.eats.2021.05.017

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

[90] 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

[91] 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

[94] 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

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

[98] 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

[101] 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

[107] 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

[109] 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

[111] 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

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

[113] 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

[116] 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

[122] 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

[124] 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

[126] 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

[128] Kinematic Alterations in the Shoulder Complex in Rockwood V Acromioclavicular Injuries During Humerothoracic and Scapulothoracic Movements: A Whole-Cadaver Study. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211053016

[130] 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

[132] Successful Conservative Therapy in Rockwood Type V Acromioclavicular Dislocations. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00017

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

[136] Classifications in Brief: Rockwood Classification of Acromioclavicular Joint Separations. Clinical Orthopaedics & Related Research. 2017. DOI: 10.1007/s11999-016-5079-6

[137] Biomechanical evaluation of an independent acromioclavicular ligament repair for acromioclavicular joint reconstruction. Shoulder & Elbow. 2019. DOI: 10.1177/1758573219857685

[139] 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

[140] 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

[144] Editorial Commentary: The Coracoid Process as the Origin of Several Ligaments: What May Be Cut, What Must Be Refixed?. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2018.02.004

[146] Why does minimally invasive coracoclavicular ligament reconstruction using a flip button repair technique fail? An analysis of risk factors and complications. Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2737-z

[148] Large asymptomatic pneumothorax following arthroscopic-assisted acromioclavicular joint reconstruction after ultrasound-guided interscalene block: a case report. JSES International. 2020. DOI: 10.1016/j.jseint.2020.02.013

[149] TightRope vs Clavicular Hook Plate for Rockwood III–V Acromioclavicular Dislocations: A Meta‐Analysis. Orthopaedic Surgery. 2020. DOI: 10.1111/os.12724

[150] Inter‐ and intraobserver reliability of the Rockwood classification in acute acromioclavicular joint dislocations. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-3436-0

[154] Coracoid or Clavicle Fractures Associated With Coracoclavicular Ligament Reconstruction. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211036713

[155] Disruption of the acromioclavicular joint: surgical anatomy and biological reconstruction. Injury. 1980. DOI: 10.1016/s0020-1383(80)80045-3

[156] Mid- to Long-term Outcomes of Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Dislocations: A Systematic Review of Studies With Minimum 5-Year Follow-up. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261457302

[158] Editorial Commentary: Acromioclavicular Joint Reconstruction With Double‐Bundle Constructs Provides Improved Maintenance of Reduction but Comparable Clinical Outcomes Versus Single‐Bundle Constructs. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.04.014

[159] Complications After Anatomic Fixation and Reconstruction of the Coracoclavicular Ligaments. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513502459

[161] Operative treatment of acromioclavicular joint injuries and results. Clinics in Sports Medicine. 2003. DOI: 10.1016/s0278-5919(03)00005-x

[162] Treatment of coracoid process fractures associated with acromioclavicular dislocation using clavicular hook plate and coracoid screws. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.09.004

[163] 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

[165] Analysis of Mechanical Failures after Anatomic Acromioclavicular Joint Reconstruction. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.06.017

[166] Poster 147: Operative Treatment of Acromioclavicular Injuries in the Military: Trends and Complications. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/2325967121s00708

[167] 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

[168] Arthroscopic Acromioclavicular Joint Reconstruction: 2 Year Follow-Up. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.103

[170] Arthroscopic reconstruction of the acromioclavicular joint disruption: surgical technique and preliminary results. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0073-6

[173] Surgical vs conservative: what is the best treatment of acute Rockwood III acromioclavicular joint dislocation? A systematic review and meta-analysis. EFORT Open Reviews. 2025. DOI: 10.1530/eor-2024-0077