A right hand dominant 61 year‐old male faculty member was playing doubles tennis. During play, he was moving to his right in an attempt to extend for a forehand when his shoes caught an edge causing him to fall to the court surface. His right shoulder impacted the surface as he attempted to roll but sustained significant impact prior to completing the roll. Although he played two additional points, he was unable to elevate the shoulder in order to perform a serving motion. The subject had sustained a second‐degree acromioclavicular injury four decades prior. Subsequent to the reinjury sustained during tennis, he was able to palpate the freely positioned clavicle, which exhibited easy ballottement, consistent with a Grade III injury, and not a IV, V or VI. As the shoulder was exquisitely painful, ice was applied throughout the night and the subject attempted to sleep in a recliner with the arm supported via pillow propping. The next morning he went to an orthopaedic walk‐in clinic in order to have a radiographic assessment to rule out possible fracture. Initially, he was using a typical sling which was readily available, in order to minimize discomfort that was present in the standing position (). His presentation was classic for an AC joint injury, with obvious loss of normal contour and significant descent of the glenohumeral complex making the clavicle appear significantly elevated ().
Presentation of patient in basic sling.
Unsupported right shoulder while standing. Note the apparent superior positioning of the distal clavicle.
New residents and fellows staffed the orthopaedic clinic that the subject utilized for radiographic studies. The immediate discussion offered by the resident there was to utilize magnetic resonance imaging (MRI) to better delineate the soft tissue involvement. The subject (a physical therapist with 30+ years of experience) questioned how this delineation might impact the actual management. The resident physician stated that it would determine if surgery would be performed. The subject then asked why surgery would be performed for this diagnosis if the plain radiographs did not show a fracture and that the free ballottement of the clavicle obviously indicated a Rockwood Grade III injury. After consultation with the attending physician, a standard radiographic series was obtained. The radiographs are presented as , , .
Antero‐posterior view radiograph of the subject's right shoulder. Disruption of the acromioclavicular joint is the obvious finding.
Axillary view radiograph of the subject's right shoulder, used to examine the positional relationship of the humeral head and glenoid fossa, which was intact in this case.
This modified lateral view radiograph was completed because of the subject's intolerance (due to pain) of alternate positioning requested by the radiological technician.
At this point, the attending physician agreed that there was no need to do a weighted view to enable comparison to the left as he was relatively certain that the injury was well described as a Rockwood Grade III. A relatively short discussion ensued regarding management options. This discussion included the newest surgical options being designed to truly reconstruct the coracoclavicular ligaments in as anatomically correct fashion as possible. The following is a synopsis of the literature related to surgical approaches to the Type III acromioclavicular separation.
Early approaches were designed to hold the clavicle in proper alignment with the acromion using screws, wires, or pins to provide fixation. Because of problems with wires breaking and migrating, surgeons moved to Steinmann pins which may still break and migrate, thus, being problematic.7
Because of these complications seen with wires and pins, surgeons changed to utilization of screws of many varieties to stabilize the clavicle in a temporary fashion. The use of screw fixation was later advanced to clavicular–coracoid placement using a large headed lag screw designed by Bosworth ().8
Other surgeons used a distal hooked‐plate to stabilize the joint proper ().9
Typically, the screw or plate was inserted to provide temporary fixation and removed at a later date.
Example of a Bosworth screw stabilizing the clavicle‐coracoid distance (not in the subject of this case report).
Example of Hook‐plate stabilization (not in the subject of this case report).
Surgeons later progressed to loops of material (including wire and Dacron®) around the clavicle and coracoid in order to create a restraint to displacement.10,11
Unfortunately, using looped materials led to erosion into the bony structures where they resided, resulting from the normal rotational clavicular movements that still occurred. Difficulties encountered with looped materials pushed surgeons to minimize the use of looped materials and design a technique that did not create the aforementioned complications. In 1972, Weaver and Dunn published their procedure which included distal clavicle resection and transferring the acromial insertion of the coracoacromial ligament to the distal clavicle.12
In the more recent past, focus has shifted to surgery designed to restore anatomic normalcy to the greatest extent possible. The anatomy related to reconstruction was defined well by Rios et al13
and Salzmann et al.14
Likewise, the surgical considerations related to anatomy were defined by Coale et al,15
while Beitzel et al16
examined the biomechanics of the newest repair techniques. This has led to the use of an endobutton placed in the clavicle in order to better duplicate the desired insertions of the conoid and/or trapezoid ligaments.17
Today, if surgical repair or reconstruction is performed, surgeons attempt to duplicate anatomy and enable normal relationships to be recreated.
Interestingly, during the past 20 years numerous studies have been completed which examined the outcomes after these surgeries when compared to conservative care. An early report by Taft et al6
in 1987 showed that in 127 subjects (52 surgical and 75 conservative) with an approximate 10‐year follow‐up period, that the “clinical (subjective and objective) ratings were equal in the two groups.” In 1989, Bannister et al3
published a randomized control trial of the management of acute acromioclavicular dislocation. Sixty patients were randomly assigned to receive screw
fixation or sling immobilization (27 and 33, respectively). Results were equal between groups four years post‐operatively. Further, the surgeons reported that non‐operative treatment was superior in the early timeframes. Consistent with these early reports, Schlegel et al5
provided the natural history of untreated patients with third degree acromioclavicular injury. The average return to work was nine days, objective findings were “surprisingly good considering that no formal treatment was given for this injury” with only a decrease in the strength of the bench press demonstrable, and concluded “that a majority of patients will do well without any formal treatment.”5, p. 702
Smith et al concluded in their recent meta‐analysis: “based on the current evidence base, operative management of grade III acromioclavicular dislocations results in better cosmetic outcome (p<0.0001) but a greater duration of sick leave (p<0.001) compared to non‐operative management. There was no difference between the two interventions in terms of strength, pain and throwing ability (p>0.05).”18, p. 26
Kim et al3
outlined the recommended imaging studies to be performed during assessment of these injuries and reiterate that plain film imaging is the expected and most appropriate starting point.