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Treatment of Symptomatic Acromioclavicular JointInstability by a Docking Technique: Clinical

Indications, Surgical Technique, and Outcomes

W. Ben Kibler, M.D., Aaron D. Sciascia, M.S., A.T.C., P.E.S., Brent J. Morris, M.D., and

David C. Dome, M.D., A.T.C.

Purpose: To report functional and objective outcomes resulting from surgical treatment of patients with symptomatictype III through V acromioclavicular (AC) joint injury by use of a modification of the anatomic AC joint reconstructiondeveloped by Carofino and Mazzocca. Methods: The study included all patients treated in 2009-2014 who presentedwith a history of direct trauma to the shoulder; deformity of the AC joint on clinical examination; radiographic findingsthat would classify the injury as a Rockwood type III, IV, or V injury; AC joint instability on clinical examination; and self-reported deficits of arm function on initial presentation, in whom a comprehensive and directed nonoperative programfailed. The surgical procedure used an allograft with reinforcing internal sutures passed around the coracoid and throughanatomically positioned clavicular holes for the coracoclavicular (CC) ligaments, used a docking technique for recon-struction of the superior AC ligaments, and included repair of the native AC ligaments. Outcomes were reported forpatients with a minimum follow-up period of 1.5 years. Outcome measurements included dynamic-static stability eval-uation and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 15 patients with 15affected shoulders. The postsurgical follow-up period averaged 3 years (range, 1.5-5 years). Postoperatively, one patientshowed loss of reduction after a fall. All others showed 2-dimensional radiographic stability and 3-dimensional dynamicclinical stability. Static radiographic measurement of the CC distance at discharge averaged 0.93 cm compared with 2.7 cmon initial examination (P < .0001). Patient-reported outcomes at an average of 3 years’ follow-up showed a DASH score of13 compared with a preoperative DASH score of 51 (P < .0001). Conclusions: This study confirms that anatomic CCligament reconstruction and repair or reconstruction of the AC ligaments help restore arm function as shown by thepatient-specific and clinical outcome metrics. These results were achieved by correction of the deformity, which in turnallowed for the obtainment of static and dynamic stability. Level of Evidence: Level IV.

he most optimal surgical treatment protocols for

Tsymptomatic high-grade acromioclavicular (AC)joint injuries are not well established, despite a rela-tively common incidence and the advocacy of manytreatment techniques.1-12 These techniques can begrouped into those that use metal or other nonbiolog-ical material to stabilize the joint and allow some type ofhealing of the damaged AC and coracoclavicular (CC)

Shoulder Center of Kentucky, Lexington, Kentucky, U.S.A.rs report that they have no conflicts of interest in the authorshipion of this article.anuary 15, 2016; accepted August 23, 2016.rrespondence to Aaron D. Sciascia, M.S., A.T.C., P.E.S., Shoulderntucky, 1221 S Broadway, Lexington, KY 40504, U.S.A. E-mail:a@eku.eduy the Arthroscopy Association of North America/1644/$36.00oi.org/10.1016/j.arthro.2016.08.023

Arthroscopy: The Journal of Arthroscopic and Related

ligaments1,2,4-6,11,12; those that use biological materialto reconstruct the CC ligaments and approximate thejoint8-10; and those that use biological material toaddress repair and reconstruction of both the AC andCC ligaments, that is, “the anatomic AC joint recon-struction.”7 The anatomic reconstruction has beenshown to result in the most biomechanically stableconstruct and to be associated with consistently favor-able clinical outcomes.7,13

Each of the types of surgical procedures has recog-nized limitations and adverse outcomes that cancreate hesitation for using any of them. Metal-basedjoint stabilization requires a second surgical proced-ure for hardware removal, frequently does not includeanatomic ligament repair, and has been found to haveoutcomes comparable to nonoperative treatment.14

CC ligament reconstruction may not stabilize all as-pects of the AC joint complex, can be complicated byclavicle or coracoid fracture, and has been shown to

Surgery, Vol 33, No 4 (April), 2017: pp 696-708

BIOMECHANICAL AC JOINT RECONSTRUCTION 697

have loss-of-reduction rates from 11% to 31%.6,10-12

The combined AC-CC ligament reconstruction showslower loss-of-reduction rates and high levels of out-comes but creates large clavicular drill holes and usessoft-tissue suture fixation to the acromion.7 Therefore,modification of the anatomic reconstruction, includingminimizing the size of the holes for graft passage and“docking” the allograft to the acromion for increasedattachment and stability (as opposed to suturing to theacromion soft tissue), may address some of the pro-posed limitations of this technique while still adheringto the underlying biomechanical principles.7

Because of these controversies and concernsregarding the optimal surgical technique, there shouldbe careful consideration regarding the exact indicationsfor surgery. At this time, clearly delineated surgicalindications are not well established. The commonmethod of establishing the diagnosis is a standardizedset of plain radiographs and use of the Rockwoodclassification system. Surgery is generally advocated forRockwood type IV and V injuries and some type IIIinjuries, although there is wide variability in determi-nation of specific Rockwood types.15 Other relative in-dications include acuity of injury, level of anticipatedpatient demand or activity, and level of limitation ofshoulder range of motion and strength.The purpose of this study was to report functional and

objective outcomes resulting from surgical treatment ofpatients with symptomatic type III through V AC jointinjury by use of a modification of the anatomic AC jointreconstruction developed by Carofino and Mazzocca.7

We hypothesized that the surgical procedure wouldprovide anatomic AC joint stability and improvedfunction at final follow-up.

MethodsThe clinical evaluation method and surgical technique

were developed and a data collection patient registry forthe described injury was established in 2009. All pa-tients who met the inclusion criteria and requestedsurgery in the years 2009-2014 were included. Onlypatients with complete data at a minimum of 1.5 yearsafter surgery were included in this report. This studywas approved by the Lexington Clinic InstitutionalReview Board (study LCO.2010.04).The inclusion criteria included patients who had a

history of direct trauma to the shoulder; deformity ofthe AC joint on clinical examination; radiographicfindings that would classify the injury as a Rockwoodtype III, IV, or V injury; and AC joint instability onclinical examination and who showed deficits (pain,weakness, loss of flexion and/or abduction, limitationswith throwing and/or lifting) of arm function on initialpresentation. The exclusion criteria included concomi-tant neurologic injury or inability to start or completethe rehabilitation program (usually because of other

associated trauma). After a short period of immobili-zation, if necessary, for an acute injury (usually7-10 days), all patients underwent a follow-up clinicalexamination and started a program of individualizedrehabilitation designed to restore any deficits shown inscapular retraction, glenohumeral range of motion, androtator cuff strength.7,16 Patients were also counseledregarding operative and nonoperative options. Patientswere re-evaluated at 3-week intervals, at which timesymptoms and change in functional status, as well aspatients’ report of their status, were assessed. Patientscontinued their rehabilitation program until theydecided to undergo surgery or returned to their desiredactivity status. At each visit, the surgical and nonsur-gical indications and procedures were reviewed.Indications for surgery included the following: the

patient’s failure to perceive functional progress intreatment on a 7-point global ratingeofechange scale(from �3, status greatly worsened, to þ3, status greatlyimproved),17 persistent painful bony deformity, andminimal change in clinical examination findings(continued weakness, decreased range of motion, andloss of scapular retraction control). Surgical treatmentwas decided on by mutual agreement between surgeonand patient. Specific outcome measures were chosen toevaluate all aspects of the clinical issues of the AC jointinjury. The measures included plain radiograph mea-surement of the CC distance as an indicator of staticstability; observational assessment of scapular motion asan indicator of dynamic stability; and Disabilities of theArm, Shoulder and Hand (DASH) scores as a patient-reported measure of physical function. The static anddynamic outcome measures were used to documentevidence of achievement of reduction of the anatomicinjury and stability of the biomechanics, and the DASHscores were used to document the change in overallpatient physical function.The CC distance was measured by a vertical line from

the top of the coracoid to the undersurface of theclavicle.7 Dynamic evaluation of joint stability byanterior-posterior and inferior-superior translationtesting and scapular motion by the clinical observationmethod18 was performed to assess 3-dimensionalmaintenance of joint stability and screw axis function.Patients prospectively completed the DASH ques-

tionnaire at initial evaluation and at most recent follow-up. This form was used to best assess aspects of totalarm function, which is frequently altered in thedescribed injury. A form was mailed to each patientannually for a minimum of 1.5 years after discharge.

Clinical EvaluationClinical evaluation of the acute injury was deferred

for 7 to 14 days after injury to minimize the acute painand swelling and to allow recovery of arm motion. Oneclinician (W.B.K.) performed a dynamic clinical

Fig 1. Dynamic assessment of scapular dyskinesis showinginferior medial scapular border prominence, indicating thepresence of scapular dyskinesis.

698 W. B. KIBLER ET AL.

examination, which was based on previous recom-mendations.18,19 The examination consisted of 3 clinicalpartsdthe AC joint examination, the scapular evalua-tion, and the glenohumeral examinationdand alsoincluded imaging. The examination was comprehensiveto identify musculoskeletal deficits that could be asso-ciated with functional deficits.20-23

The AC joint was palpated for point tenderness andcrepitus on motion. Ligament instability was evaluatedby manual manipulation of the clavicle and acromionin the inferior-superior and anterior-posteriordirections. Increased translation, compared with theuninvolved side, was considered a positive finding. Thiswas followed by visual observation of bone and jointmotion with arm motion in flexion and abduction toevaluate dynamic joint stability. A positive finding wasnoted if the acromion could be observed to displacearound the clavicle with arm motion.Scapular positional asymmetry at rest and scapular

motion asymmetry with arm motion were determinedby observation of medial border prominence; it was

Fig 2. (A) Preoperative plainradiograph of a high-grade acro-mioclavicular separation in a rightshoulder. The coracoclaviculardistance measures 2 cm. (B)Postoperative plain radiograph ofthe same patient. The cor-acoclavicular distance is 0.8 cm.

graded as yes (dyskinesis present) or no (dyskinesis notpresent) when the arms moved through and returnedfrom forward elevation (Fig 1). If the AC joint could bemanually reduced, the effect of the reduction on scap-ular dyskinesis was determined.The clinical examination also evaluated other aspects

of the shoulder anatomy, especially the labrum, whichhas been shown to be involved in AC joint injuries.22

The clinical history and specific physical examinationtestsdmainly the modified dynamic labral shear test,which has been shown to be effective in identifyinglabral injurydwere used.24

Plain radiographic imaging was used to assess relativebone position, place the patient’s injury into a Rock-wood category, allow measurement of CC distances(Fig 2), and rule out distal clavicle fractures or epiphy-seal injuries. Specialized plain radiographic methodssuch as weighted views or dynamic cross-body adduc-tion (Basamania) views were not used in this study.Magnetic resonance imaging (MRI) was not routinelyused to make the diagnosis, but some patients hadalready undergone MRI during the diagnostic processand magnetic resonance arthrogram was used in pa-tients with a clinical suggestion of labral injury.Advanced imaging can be helpful to show the pathoa-natomy and position of the AC and CC ligaments andcan frequently show the integrity of the AC ligamentattachment to the acromion while being detached fromthe clavicle (Fig 3).

Surgical TechniqueThe AC reconstruction in this study followed the

principles established by Carofino and Mazzocca,7 aswell as Mazzocca and colleagues,13 for open anatomicreconstruction with modifications regarding graft pas-sage and graft and ligament attachment by 2 of theauthors (D.C.D.,W.B.K.), leading to the procedure beingnamed the MADOK AC joint reconstruction procedure.The same procedure was used for all of the cases, andboth surgeons participated in all of the cases.The patient is placed in a slightly modified beach-

chair position with the arm and scapula placed to gainanterior, posterior, and lateral access to the area. To

Fig 3. T2 coronal magnetic resonance image of a rightshoulder with an acromioclavicular joint injury. The acro-mioclavicular ligaments are attached to the acromion but areavulsed from the clavicle, as indicated by the arrow.

BIOMECHANICAL AC JOINT RECONSTRUCTION 699

access the disrupted AC and CC ligaments (Fig 4A), thesurgical incision is placed along the anterior-superiorborder of the clavicle from the midclavicle to the jointand across to the lateral edge of the acromion (Fig 4B).The dissection is started medially, with reflection of thetrapezius fascia by electrocautery. The dissection iscarried out longitudinally over the distal clavicle to theacromion, with care taken to stay right on the claviclein the dissection so that the native anterior and

Fig 4. (A) High-grade acromio-clavicular and coracoclavicularligament injury with avulsion ofthe acromioclavicular ligamentsfrom the clavicle and mid-substance injury of the cor-acoclavicular ligaments. (B) Anincision (dotted line) is made fromthe lateral acromion to the mid-shaft of the clavicle. (C) Drill holesare made through the clavicle inline with the native attachment ofthe conoid and trapezoidligaments.

posterior AC ligaments, which are frequently stillattached to the acromion, can be identified and mobi-lized to be used in the repair. These ligaments arefrequently found scarred to the inferior half of theclavicle, and their mobilization from the clavicle facili-tates joint reduction. Debridement of the scar in thejoint, as well as thick bands at the inferior edge of theacromion, is sometimes necessary in chronic cases toallow joint reduction. After these steps, provisionalreduction of the joint is usually successful by bringingthe acromion up to the clavicle. If not, further soft-tissue mobilization is preferable to distal clavicle resec-tion to maintain adequate clavicle strut length. Distalclavicle reshaping to facilitate joint reduction can beperformed in markedly deformed distal clavicles, suchas longstanding chronic cases or those associated withprevious epiphyseal injury.The CC interval can be visualized through a deltoid-

splitting incision. Careful dissection around the cora-coid frees up the scar and creates a tunnel for graftpassage. Anatomically positioned 4.5-mm claviculardrill holes are placed into the distal clavicle, in line withthe native bony attachments of the conoid and trape-zoid ligaments (Fig 4C). The conoid drill hole is placedfrom the posterior-superior edge of the clavicle andaimed at the conoid tubercle, a readily palpable land-mark on the undersurface, which is present directlysuperior to the medial edge of the coracoid. The trap-ezoid drill hole is placed about 1 cm anterior and 1.5 to2.0 cm lateral to the conoid hole, depending on patientsize, and is aimed at the trapezoid ridge on the

Fig 5. (A) The reconstruction includes an allograft semitendinosus tendon (green) and 5 strands of No. 2 PDS (blue). (B) Thesutures and the graft are passed through the anatomically placed clavicle drill holes. (C) The PDS sutures are tied to add stabilityto the healing graft (excess suture is removed as shown by the red dotted line). (D) The graft tails are secured together using thestitch configuration shown.

700 W. B. KIBLER ET AL.

undersurface at about a 30� angle to the vertical fromthe lateral coracoid edge. Multiple instruments can beused to pass the graft. Passage of instruments from themedial to lateral side and shuttling of the graft from thelateral to medial side minimize the risk to the under-lying neurovascular structures.The CC reconstruction construct consists of a semite-

ndinosus allograft (6.0 mm � at least 260 mm) and 5No. 2 PDS sutures (Ethicon) to be used as an internalsplint (Fig 5A). The allograft was used because of itswell-documented efficacy in extra-articular re-constructions, the reproducibility of size and length, andfacilitation of decreased operative time and morbidity. Itwas sterilized by non-irradiated means. The PDS sutureswere used because of their acceptable initial tensilecapability, their biocompatibility, and their gradualreabsorption as the graft matures. Each of the graft endsis prepared with a baseball-type stitch running about25 mm on each end. This construct is passed around theundersurface of the coracoid and is passed through the4.5-mm drill holes (Fig 5B). These smaller sized holes

can be used because no screw fixation will be used butsuch holes are large enough to accommodate the graftand sutures. There were no instances of graft shreddingthrough the well-prepared holes. Both limbs of the graftconstruct are then passed without crisscrossing toreproduce the normal anatomy and mechanics (Fig 5B),and the joint is manually reduced by bringing theacromion to the clavicle. The sutures are tied down overthe clavicle to provide initial stability for the CC recon-struction (Fig 5C). The graft limbs are tensioned andthen sutured together over the clavicle with multiplenonabsorbable sutures (Fig 5D). This technique providessecure fixation with minimal graft tension and removesthe need for screws. Stability of the CC reconstructioncan be checked by showing elimination of inferior-superior laxity.The AC ligament reconstruction includes superior,

anterior, and posterior components to reproduce theentire ligamentous attachments. The graft tails can beused to reconstruct the superior AC ligaments. Onemodification of the technique of Carofino and

Fig 6. (A) Drill holes are placed through the lateral acromion to dock the graft tails into the bone. Sutures are placed into eachgraft tail (B) to assist in properly docking the graft into the previously prepared acromial edge (C). (D) The excess graft tail tissueis removed.

BIOMECHANICAL AC JOINT RECONSTRUCTION 701

Mazzocca7 involving superior AC ligament repair ad-dresses a potential problem with secure fixation of theallograft tails to the acromion. This involves directattachment of the allograft tails by docking them intothe prepared acromion. Two 2.4-mm drill holes aremade from the lateral acromial edge to the superioracromial surface at the joint edge (Fig 6A). The first isplaced into the anterior one-third of the acromion, andthe second is placed about 1.5 cm posterior, into theposterior one-third. After light debridement of themedial acromial edge (performed to enhance healing atthe attachment site), passing sutures are placedthrough each drill hole to assist in properly docking thegraft into the acromion. The allograft tails are broughtto the acromial edge, the joint is reduced, the correctlength to ensure graft tension and attachment to theacromion is determined, and a passing suturecomprising No. 1 nonabsorbable suture is placed in thegraft tail (Fig 6B). These sutures are then passedthrough the previously placed acromial drill holes andtied over the lateral acromion, docking the graft tails tothe acromion to reconstruct the superior AC ligament(Fig 6C). Excessive graft tail tissue can be removed

once the tails have been adequately docked into theacromion (Fig 6D).Next, the native tissues can be used to repair the

anterior and posterior ligaments. Two biocompatibleanchors (PushLock; Arthrex, Naples, FL) double loadedwith No. 1 nonabsorbable suture are placed into theanterosuperior and posterosuperior corners of the distalclavicle (Fig 7 A and B), and the sutures are passedthrough the mobilized native AC ligament tissues butnot tied (Fig 7C). The anterior and posterior nativetissues are then tied down, completing the repair(Fig 8). The stability of the entire construct is assessed toshow elimination of both inferior-superior andanterior-posterior laxity. An illustration of thecompleted reconstruction shown from both superiorand frontal views is provided in Figure 9. The deltoidsplit is closed, the wound is closed in layers, and a slingand swathe are applied.Postoperatively, all patients were placed in a sling and

swathe for 4 weeks. Internal rotation and abductionwere not allowed for 3 weeks, and active forwardflexion was not allowed for 6 weeks. During the first3 weeks, the patient was allowed to perform active

Fig 7. (A) Drill holes are placedinto the anterosuperior and post-erosuperior aspects of the clavicle.(B) Suture anchors, which will beused to repair the native acro-mioclavicular ligaments, areplaced into the holes. (C) Suturesare passed but not tied.

702 W. B. KIBLER ET AL.

scapular retraction and depression. All patients werereferred to formal physical therapy after the thirdpostoperative week and were provided with astandardized closedekinetic chain protocol designedto minimize shear forces at the glenohumeral joint

Fig 8. The native anterior andposterior ligaments are repaired(A) and tied down to the clavicle(B).

and to increase proprioceptive feedback throughthe shoulder and scapula (Appendix 1, available atwww.arthroscopyjournal.org). Active forward flexionand abduction were allowed with up to 90� of elevationat 6 weeks, emphasizing a closed-chain protocol. The

Fig 9. Superior (A) and frontal(B) views of the completed repairshow graft positioning.

BIOMECHANICAL AC JOINT RECONSTRUCTION 703

closed-chain protocol was continued until post-operative week 12. At 12 to 16 weeks, open-chainshoulder exercises and activities were instituted,depending on demonstrated strength. Patients werefollowed up at regular intervals that varied dependingon their capability of returning to our clinic. Radio-graphs were taken at 6 weeks, to confirm reduction,and at discharge, to confirm achievement and mainte-nance of reduction. Patients were discharged fromactive care when they reported a stable pain level,showed the capability of activating the lower trapeziusand rhomboids to retract the scapula, were able toelevate the arm to 90� of abduction, and reported theywere independent in their rehabilitation program.Descriptive statistics were performed for demographic

and historical data including age, sex, time to follow-up,type of AC joint instability (anterior-posterior, superior-inferior, or both), chronicity of injury, and previoussurgery. Distributions were assessed for normality usingthe Shapiro-Wilk test. Paired t tests were used tocompare initial DASH scores with most recent follow-up DASH scores. The level of significance was set atP < .05. All statistical analyses were performedwith STATA/IC (version 13.1; StataCorp, CollegeStation, TX).

ResultsIn total, 15 patients (aged 42 � 18 years, 10 male and

5 female patients) with 15 affected shoulders met theAC joint injury inclusion criteria and required and

requested surgery. Of these patients, 11 did not un-dergo previous surgery whereas 4 underwent previousAC joint reconstruction surgery including CC ligamentreconstruction only (2), hook plate insertion (1), andCC ligament reconstruction with distal clavicle excision(1). All patients showed continued scapular dyskinesisand pain on flexion above 90�. All 15 shoulders showedanterior-posterior laxity on clinical examination. Of the11 shoulders with no previous surgery, 10 showeddynamic superior-inferior laxity to ligament testingwhereas the remaining patient showed fixed posi-tioning of the acromion under the clavicle, with nodynamic motion. The 4 patients who underwent pre-vious surgery showed altered AC joint mechanics dueto incorrect metal fixation (fixed superior-posterioracromial position) of the hook plate and excessiveshear around the unstable AC joint due to lack of repairof the AC ligaments. All showed the anatomic defor-mity of the prominent clavicle. Ten patients showedimproved strength and decreased pain on manualscapular assistance and scapular retraction testing butcontinued to have self-reported functional limitationswhen manual stabilization was not applied. Two pa-tients in the group without previous surgery wereidentified as having labral injury, and one patient in thegroup with previous surgery had been treated for alabral injury but continued to have labral symptoms.The global ratingeofechange scores within this groupwere between �2 (status moderately worse) and �1(status slightly worse) on follow-up examination.

Table 1. Demographic Characteristics of Patients

Patient No. Sex Age, yrTime From Initial

Injury to Surgery, mo Surgery YearRockwood

Classification Instability Previous Surgery

1 Male 61 8 2009 V AP-SI None2 Female 51 10 2009 III AP-SI None3 Male 47 2 2009 V AP None4 Male 18 15 2012 III AP-SI None5 Male 39 12 2009 III AP-SI None6 Male 15 11 2013 III AP-SI None7 Male 21 36 2009 III AP None8 Female 29 118 2013 III AP-SI CC reconstruction9 Female 60 60 2012 III AP-SI None10 Female 54 3 2013 III AP-SI None11 Male 59 34 2010 III AP-SI None12 Male 63 36 2009 III AP CC reconstruction13 Male 42 182 2012 III AP CC reconstruction with DCE14 Female 50 13 2014 Preexisting

hook plateAP Hook plate

15 Male 16 11 2013 III AP-SI None

AP, anterior-posterior acromioclavicular joint instability; CC, coracoclavicular; DCE, distal clavicle excision; SI, superior-inferior acromiocla-vicular joint instability.

Table 2. Preoperative Versus Postoperative CC Distances andDASH Scores

PatientNo.

Static CC Distance, cm DASH Score

Preoperative Postoperative* Preoperative Postoperative*

1 2.1 1.1 66 82 4.1 1.2 56 23 3.2 1.1 67 294 2.2 0.72 98 15 1.6 0.63 11 246 2.7 0.59 18 07 3.4 1.3 11 48 3.2 0.92 77 129 2.8 1.0 56 3710 2.6 0.96 56 011 NA 0.81 32 012 3.6 0.94 53 3013 2.5 1.2 78 4314 2.4 NAy 65 515 NA 1.0 26 0

CC, coracoclavicular; DASH, Disabilities of the Arm, Shoulder andHand; NA, imaging not available.*Postoperative measures were significantly improved compared

with preoperative measures (P < .0001).yThe patient did not return to the office for imaging.

704 W. B. KIBLER ET AL.

These patients underwent 15 surgical treatments withthe MADOK procedure. The postsurgical follow-upperiod was 3 � 1.5 years (range, 1.5-5 years). Thepatients with identified labral injury were treated bystandard arthroscopic means25 from a lateral decubitusapproach at the time of the AC surgical procedure. Thearthroscopy was performed first; then the patient wasrepositioned for the AC surgical procedure. Eight pa-tients underwent reconstruction within the first12 months after injury, whereas 7 were treated from 1to 6 years after injury (Table 1). Postoperatively, therewas one patient with loss of anatomic reduction,shown by loss of anterior-posterior stability, that wassecondary to distal clavicle osteolysis and loss of ACligament attachment after a fall. All other patientsexhibited dynamically stable anterior-posterior andinferior-superior stability on clinical examination andsymmetric scapular motion at most recent follow-up.Radiographic determination of static stabilityshowed CC distances that averaged 0.93 cm (range,0.59-1.31 cm) at the time of discharge, whichcompared with an initial CC distance of 2.7 cm (range,1.6-4.1 cm; P < .0001; 95% confidence interval,2.3-3.2 preoperatively vs 0.83-1.1 postoperatively)(Table 2). The 1.31-cm distance was in the patient withloss of AC reduction after a fall 6 months after surgery,before which 2 radiographs showed a 1.0-cm CC dis-tance. The patients showed significant improvementfrom the preoperative DASH score (51 � 28; range,11-98) to the final DASH score (13 � 15; range, 0-43),with an average change in DASH score of 38 � 27points (P < .0001; 95% confidence interval, 33-66preoperatively vs 4-20 postoperatively) (Table 2).There were no complications relating to the surgicalprocedure, with no infections and no reoperations forloss of reduction or removal of sutures or implants. No

patients reported clinical symptoms or had positiveclinical examination findings relating to labral injury.Post hoc power analysis, in which a ¼ .05 and b ¼ .80,showed the study was adequately powered with aneffect size (d) equal to 1.3.

DiscussionThe study results confirm the research hypothesis.

The MADOK procedure can provide a CC and AC lig-ament reconstruction that confers static and dynamicstability and good patient-reported outcomes.

BIOMECHANICAL AC JOINT RECONSTRUCTION 705

The anatomic reconstruction has been developed andimplemented in large measure through the research ofMazzocca and colleagues,7,13,26,27 which has shownthe need to specifically address both CC ligaments andall parts of the AC ligaments. The surgical constructresulting from these principles has shown the bestrestoration of the anatomy and mechanics of the jointin laboratory studies.13,28 The correctness and clinicalefficacy of this approach have been shown by theimproved clinical outcomes, low complication rate,low loss-of-reduction rate, and significant improve-ment in patient-reported outcomes. The results of thisstudy add more confirmation to this approach totreatment.The MADOK surgical technique adhered to the

original principles of the anatomic reconstruction7 butwas modified slightly to address some perceived limi-tations in the technique. In the clavicle, smaller-diameter drill holes were made to minimize the riskof clavicle fracture. No screws were used to stabilizethe graft in the clavicle tunnels. The internal splint ofthe multiple sutures stabilized the CC ligamentconstruct as the graft, which was tied under correcttension, matured. This technique did not result in anyloss of fixation or change in CC distance over theperiod studied and was not associated with any frac-tures. The postoperative CC distance was significantlyimproved over the preoperative distance and wasmaintained within the ranges normally determined tobe anatomic.29

The major modifications were the techniques forthe AC ligaments. The first involved using nativetissue for repair. It was discovered, both through MRIevaluation and by careful surgical dissection, that thelarge majority of patients retained significant portionsof the anterior and posterior AC ligaments stillattached to the acromion, even in the chronic cases.This would be compatible with the mechanism ofinjury being a sleeve avulsion from the clavicle. Theseremnants have good length and strength, arefrequently adherent to the middle or undersurface ofthe clavicle, and can be mobilized and repaired withsutures from the anterior and posterior anchors. Thismodification using native tissue substitutes for the useof anterior and posterior “wrapping” of the graftaround the AC joint described by Carofino and Maz-zocca but serves the same purpose of restoring theanterior and posterior AC ligaments. The secondmodification involved a method to directly attachboth the graft tails by docking to a prepared positionon the medial edge of the acromion at the joint edgerather than suturing the graft tails to the acromialperiosteum. This re-created the capability of the su-perior AC ligaments to not only restore anterior-posterior laxity but also, by acting as a tension band,restrain lateral tilt of the scapula in relation to the

acromion. The small transacromial drill holes havenot been associated with bony problems, and theyallow secure placement of the graft to the acromion atthe joint under the correct tension to reconstruct theimportant superior AC ligament. This techniqueresulted in restoration of complete AC ligamentcompetency, as shown by negative anterior-posteriordrawer and no lateral acromial tilt at the time ofsurgery, as well as at long-term follow-up. Thistechnique using transacromial drill holes differs fromthat described by Li et al.30 in that only 2 medial-to-lateral drill holes were made in the MADOK tech-nique compared with 6; moreover, the MADOKtechnique used the sutures to attach the graft to thebone, rather than relying on the sutures alone toprovide stability.The described technique can be used in acute,

chronic, and revision reconstructions, with modifica-tions depending on the pathoanatomy. In acute repairs,no attempt was made to suture the native CC ligamenttissue, but the frequently interposed AC ligaments andcapsule were removed from between the bones andused in the repairs. In chronic and revision repairs,occasional heterotopic calcium, as well as previouslyplaced hardware or suture, was removed.Patient-reported outcomes were significantly

improved from preoperative to postoperative mea-surements, with DASH scores returning to normalvalues. This is consistent with outcomes from otherstudies that used a similar surgical approach7 and/oroutcome measure.3 The DASH scores were used asoutcome measures because it was believed that themajor clinical problem was not anatomic but functionaland the DASH assessment is considered a good esti-mation of functional status.However, anatomic and dynamic measurements were

likewise improved. Static CC distance was significantlyreduced and was maintained within accepted limitscomparable to other studies using this surgicalapproach.7 All patients showed resolution of theirscapular dyskinesis, at rest and with motion, by clinicalobservation. One patient showed loss of AC jointreduction, indicated by a 1.31-cm CC distance andincreased anterior-posterior laxity, due to distal clavicleosteolysis after a fall. However, the patient did not showscapular dyskinesis on clinical examination, showedsymmetric strength, and did not request further surgicaltreatment. For the other patients, there was no loss offixation or position on static radiographic or dynamicclinical examination and there was no demonstration ofscapular dyskinesis at final follow-up. These durableobjective and functional outcomes compare favorablyto other reports1-3,7 and were also shown to be durableat an average of 3 years’ follow-up.The literature regarding surgical treatment of symp-

tomatic AC injuries is extensive, with multiple studies

706 W. B. KIBLER ET AL.

reporting widely varying techniques, using widelyvarying materials, and reporting varying outcomes.1-7

There could be a debate about whether anotherarticle on the treatment of AC joint injuries is needed,given the large amount of information already avail-able. However, the research has better clarified theform (anatomy and clinical biomechanics) that allowsthe function (optimal arm position and motion) of theAC joint26,28,31-33 and has created a more uniformunderstanding of the principles that should guideevaluation and treatment. This work has highlightedthe clavicle’s key role as a mobile strut for scapular andarm motion, the AC joint’s role as the unifying link inthe screw axis mechanism that governs normal scap-ulohumeral rhythm,23,28,31,33 and the 3-dimensionalnature of the normal kinematics of the clavicle andscapula that occur to facilitate arm function. Thesestudies show that as the arm rotates and elevates, theclavicle, acting as a mobile strut based on the sterno-clavicular joint, elevates and rotates; the AC joint acts asa stable but slightly mobile connecting link; and thescapula, acting as a mobile but stable base for the hu-merus and arm, upwardly rotates, posteriorly tilts, andexternally rotates.28,31-33

Rockwood type III to type V AC injuries involve bothAC and CC ligament disruption and, because of thisextensive disruption, have the capability of disruptingthe normal screw axis of clavicle- or scapula-coupledmotion, which can result in altered 3-dimensionaljoint mechanics and scapular kinematics that mayaffect abduction strength, increase rotator cuffimpingement, and affect scapular function.18,33,34 Thephysical examination of the entire shoulder complexmay be beneficial in detecting some of these possibledeleterious mechanical alterations and may providemore comprehensive information to help guide thetreatment process. For example, scapular dyskinesis,defined as alteration of normal scapular position andmotion,35 can be seen as a result of this disruption andpotentially could be used as a marker of altered AC jointbiomechanics.23,27 In addition, restoration of scapularmotion could be seen as a restoration of the screw axismotion and could be helpful in determining the surgicaloutcomes. Dyskinesis, resulting from loss of ligamentintegrity and alteration of the screw axis motion, can bedetermined by using the clinical observation methodsdescribed by Uhl et al.,19 McClure et al.,36 and Tateet al.37 Scapular dyskinesis was shown in 100% of thepatients, and because this biomechanical alteration isassociated with the disruption of the clavicle andacromial strut complex,23 it could possibly be used as anadditional clinical marker of the altered biomechanicsthat may assist in developing appropriate indications forsurgery. Further studies to establish the reliability ofthis finding as an effective tool in the diagnosis need tobe carried out.

The physical examination was helpful in discoveringthe 3 cases of labral injury in our patient group,showing the importance of evaluating for this injury,which has been shown to be associated with AC jointinjury.22 The 3 positive findings from the clinical ex-amination for labral injury show the need to includethis specific testing in the evaluation of patients withAC joint injuries.Perhaps as important as surgical technique for opti-

mum outcomes is the establishment of consistent sur-gical indications. Traditional surgical indications havebeen based on establishment of the AC injury as type III,IV, or V. However, the actual clinical distinctions be-tween types III, IV, and V are neither easy nor reliable,given that arm position has been shown to affect therelative clavicle and acromial positions.15 We continueto try to better define the exact biomechanical in-dications for this surgical procedure by looking atdynamic 3-dimensional alterations rather than static2-dimensional alterations resulting from static radio-graphs. One attempt to help clarify the indications fortype III injuries is a modification to subclassify theseinjuries into type IIIA (stable joint, no overriding oncross-body radiographs, and no dyskinesis) and type IIIB(unstable joint, overriding clavicle, no improvement byphysical therapy, and dyskinesis)27; however, this clas-sification has not been clinically tested and verified.

LimitationsThere are several limitations to the study. First, we did

not measure specific strength or range-of-motion vari-ables to more precisely determine the effect of theinjury or the surgical procedure. This would be aworthwhile follow-up study. Second, although a posthoc power analysis justified the reported sample size,we did not have a large enough population to stratifyoutcomes based on duration of injury or previous sur-gery. Third, although the average follow-up period islonger than that of most published studies, the 1.5-yearminimum follow-up may not be long enough tocompletely establish the durability of the procedure.Fourth, we did not measure outcomes in nonoperativepatients or have a comparative group that underwentother surgical procedures, so this study must beconsidered a therapeutic case series. Finally, we did notperform laboratory studies to compare the biome-chanical stability of the MADOK procedure with theanatomic AC joint reconstruction. However, the pur-pose of this article was to report on a specific surgicalprocedure using techniques designed to achieve stabil-ity of both the AC and CC ligaments and restore func-tion, outcomes that could be shown by the chosenoutcome measures. The DASH scores in this study arecomparable with other published reports,38-42 and theclinical stability outcomes are equivalent or superior tothose reported for other surgical techniques.

BIOMECHANICAL AC JOINT RECONSTRUCTION 707

ConclusionsThis study confirms that anatomic CC ligament

reconstruction and repair or reconstruction of the ACligaments help restore arm function as shown by thepatient-specific and clinical outcome metrics. Theseresults were achieved by correction of the deformity,which in turn allowed for the obtainment of static anddynamic stability.

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Appendix Table 1. Rehabilitation Guidelines

Week 1-4Sling: 3 to 6 wk postoperativelySleep in sling for 3 wkMotion restrictions

No humeral internal rotation for 3 wkNo humeral abduction for 3 wkNo active openekinetic chain forward flexion for 6 wkAAROM of forward flexion may begin at week 5 but should be kept between 60� and 75�

Exercises emphasizing standing scapular retraction, depression, and scapular proprioceptive neuromuscular facilitation with arm in slingPermissible exercises: low row, sternal lift, step-out (as described in Appendix Table 2, available at www.arthroscopyjournal.org.)

Use of complementary trunk movement to facilitate scapular motion (flex and rotate away from involved side for protraction, extend androtate toward involved side for retraction)

No rotator cuff exercisesTowel slides on table as tolerated in frontal plane after 3 wkPROM and AAROM of external rotation and extension with arm as close to body as possible

After 3 wkPROM, AAROM, progression to active ROMClosedekinetic chain rotator cuff stabilization and scapular exercises, increasing arm elevation as tolerated, i.e., table slides (includes both

flexion and abduction up to 90�)Addition of tolerable arm motion to standing scapular motion exercisesFacilitation of active arm elevation through axial loading of glenohumeral joint (patient pushes on table or wall as he or she elevates in

desired plane with scapular control and stability, i.e., no overt winging or upper trapezius substitution)At 4 wk, initiation of gentle mobilizations and capsular stretching, if indicated (these can become more aggressive at 6-8 wk)

Week 4-8Exercises should progress toward functional openekinetic chain activities as ROM and strength improve.Closedekinetic chain rotator cuff strengthening with good scapular control, such as wall wash exercises and humeral head depression exercises

(inferior glide or closed-chain Codman), is allowed.We prefer rotator cuff loading that is consistent with function, including scapular and trunk motion, rather than isolated exercise.

These exercises include closed-chain punches at various (tolerable) heights and planes, as well as adding arm elevation, rotation, andextension of the lever arm to the complementary scapular exercises.

Impingement and rotator cuff referred pain should be avoided throughout.Long lever movements such as classic open-chain rotator cuff exercises should be avoided.

These include scapular plane elevation, prone and standing horizontal abduction, and prone external rotation.Exercises that place moderate levels of tension on the lower trapezius should be avoided.

These include prone flexion or abduction raises (T’s, I’s, and Y’s) unilaterally or bilaterally.

AAROM, active-assisted range of motion; PROM, passive range of motion; ROM, range of motion.

Appendix 1. Postoperative AC JointReconstruction Guidelines

Guidelines for AC Joint ReconstructionRehabilitationEach case can be very different depending on

the goals of the patient, age of the patient, sizeof the repair, type of repair, and so on. We followthe basic guidelines listed in Appendix Table 1

(available at www.arthroscopyjournal.org). Anyphysician-indicated precautions override theseguidelines.

Example Exercises for Functional ShoulderRehabilitationExample exercises for functional shoulder rehabilita-

tion are presented in Appendix Table 2 (available atwww.arthroscopyjournal.org.)

BIOMECHANICAL AC JOINT RECONSTRUCTION 708.e1

Appendix Table 2. Example Exercises

Scapular controlWhen: Beginning of therapeutic exercise through the end of rehabilitation, may begin without glenohumeral motion or arm elevation,introduction of glenohumeral motion and arm elevation once indicated and scapular control increases

Goals: Facilitate scapular motion and scapular re-education, strengthen scapular musculature in functional movement patternsSample exercises: trunk diagonals, sternal lifts, shoulder dumps (incorporates glenohumeral elevation and external rotation), tubing fencing,dumbbell or tubing punch-pull, modified dumbbell “cleans”

Closed kinetic chainWhen: Begin at the onset of therapeutic exercise and continue throughout the programGoals: Stimulate pain-free co-contractions of rotator cuff, scapular musculature independently and in coordination; promote glenohumeralcompression and dynamic stabilization

Sample exercises: weight shifting on fixed hand, ball stabilization in appropriate plane and degree of elevation, various levels of push-ups,scapular PNF with UE fixed at 12- or 6-o’clock position and 3- or 9-o’clock position

Axially loaded exercisesWhen: Glenohumeral translation or scapulohumeral coordination is determined to be limiting factor in increasing AROMGoals: Increase active arm elevation with appropriate rotator cuff and scapular stabilizer co-contractions; facilitation of weakest components ofAROM to achieve appropriate, pain-free ROM; transition to active, openekinetic chain arm elevation

Sample exercises: table slides, ball rolling, wall slides, Pro-Fitter (Fitter International, Calgary, Alberta, Canada)Integrated exercises

When: After scapular plane elevation control and AROM are at or approaching normalGoals: Integrated strengthening of scapular, rotator cuff, and trunk musculature

AROM, active range of motion; PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; UE, upper extremity.

708.e2 W. B. KIBLER ET AL.