Using a 5- to 6-mm cannulated reamer, separate posteromedial and anterolateral bone tunnels were created in the distal clavicle (Fig. 6). The two ends then were passed through the bone tunnels in the clavicle (Fig. 7). The two limbs of the graft were sewn together on top of the distal clavicle with heavy nonabsorbable sutures (Fig. 8), and the remaining graft was imbricated into the AC joint capsule with nonabsorbable sutures. Biotenodesis screws may be used in the clavicle to augment fixation but were not routinely used. The periosteum, AC capsule, and pectoralis fascia were closed. Subcutaneous tissue and skin were closed similarly in a layered fashion.
Postoperatively, patients wore a sling for 6 weeks. Hand, wrist, and elbow motion was allowed immediately. Two weeks postoperatively, patients began passive forward elevation of the shoulder with gravity eliminated (ie, pendulum exercises) and isometrics involving the rhomboid and lower trapezius muscles at home after instruction by the surgeon. Lifting a glass of water was permitted 4 weeks postoperatively. Formal physical therapy often was not required but typically was not considered until 6 to 8 weeks postoperatively. Full activity was permitted 3 months postoperatively.
Patients reported for office evaluation with radiographs on a monthly basis until 12 weeks postoperatively. Subsequently, radiographs, including anteroposterior, outlet, and Zanca views, were obtained at 6 months and annually after surgery. Baseline, immediate postoperative, and the last available radiographs of the AC joint were reviewed by the senior authors (GRH, JMI) as part of routine clinical care and were reevaluated in a study-specific manner for redisplacement.
Pain was assessed preoperatively and postoperatively as a binary variable (presence or absence of pain) at each followup. Postoperative Simple Shoulder Test  (SST) and Disabilities of the Arm Shoulder and Hand  (DASH) scores were obtained by phone interview. The DASH instrument is a 30-question self-reported questionnaire that assesses patients with upper extremity dysfunction; the maximum score is 100 and lower scores correspond with higher function . The SST is a 12-question self-reported questionnaire that assesses shoulder function for various everyday tasks; the maximum score is 12 and higher scores indicate better function . In addition, any complications associated with the surgery were recorded. Demographic characteristics and mean outcome scores were calculated with SPSS® Version 15.0 (SPSS Inc, Chicago, IL).
For 13 of 21 patients successfully contacted by telephone for administration of the postoperative outcomes questionnaire, the average postoperative DASH score was 11.8 (95% confidence interval [CI]: 2.8, 20.7). The median DASH score was 4.3. The average SST score was 10.6 (95% CI: 9.3, 12.0). The median SST was 12. All patients had pain preoperatively. Only two of 21 had pain at their final followup. One patient had a Rockwood screw that was removed for a concomitant clavicle fracture as part of routine care. Another patient had symptomatic rotator cuff arthropathy, which subsequently required a reverse total shoulder arthroplasty, although the AC joint reconstruction remained stable and this patient remained asymptomatic at this joint. When these two patients were eliminated from analysis (n = 11), the mean DASH score was 5.4 (95% CI: 2.1, 8.7), and the mean SST was 11.7 (95% CI: 11.4, 12.0).
One patient (4.8%), with a Type V separation with 300% elevation, had radiographic evidence of elevation of the distal clavicle at the 8-month followup. In this one case, there was less than 100% elevation of the distal clavicle in relation to the acromion at followup. We considered this a redisplacement. This patient continued to complain of pain at the 27-month followup.
No patients had coracoid fractures. One patient had a nondisplaced fracture through the lateral clavicular drill hole. The fracture healed uneventfully without further surgery. At last followup, this patient had no residual pain and no displacement of the AC joint.
The rationale for development of the luggage tag technique of anatomic fixation of displaced AC dislocations is that the technique carries the theoretic strength of anatomic restoration of the AC joint  while decreasing the hardware-related complications of the modified Weaver-Dunn technique  and other forms of nonanatomic reconstruction . Similarly, unlike the original description of anatomic CC ligament reconstruction, the luggage tag technique eliminates a drill hole in the base of the coracoid, thereby minimizing risk of subsequent coracoid fracture.
Limitations of our study include lack of preoperative patient-centered data, direct comparison with other forms of fixation, and long-term followup. However, despite two surgeons with slight differences in operative technique, the use of the luggage tag coracoid fixation with reconstruction of both CC ligaments by these surgeons yielded a median DASH of 4.3, a median SST of 12, and only one (4.8%) AC joint redisplacement. Although two patients had only short-term followup, 19 of 21 had greater than 1 year followup and all but five had greater than 2 years followup.
The modified Weaver-Dunn procedure with isolated CA ligament transfer is associated with 90% good or excellent patient-reported results and few reported complications related to ligament fixation. However, as much as 17% of patients experience recurrence of the initial deformity with this technique . Several methods of fixation were developed to improve on this. The modified Weaver-Dunn group of techniques involves transferring the CA ligament to the intramedullary canal and then securing the construct with hardware. This method is associated with a 14% to 15% incidence of redisplacement [14, 30]. Another method of fixation involves transferring the CA ligament and then augmenting the fixation with a CC screw or loop of nonabsorbable suture. This method is associated with 16% and 29% redisplacement rates, respectively [30, 35]. To combat relatively high rates of redisplacement of these nonanatomic methods of fixation, an anatomic method of fixation using autograft or allograft was developed. Mazzocca et al.  reported a biomechanical analysis of an anatomic method of reconstruction of the trapezoid and conoid ligaments with a soft tissue graft. This procedure involves drilling a 7-mm bone tunnel into the base of the coracoid and two 6-mm transosseous tunnels in the distal clavicle. A semitendinosus graft then is doubled over and, at the halfway point, is sutured to itself. That middle portion then is placed in the coracoid base tunnel and secured with a bioabsorbable interference screw. The two ends then are placed in the clavicle tunnels and held in place with interference screws . Using this method in a cadaveric, biomechanical study, Mazzocca et al.  reported no difference in displacement under stress in the anteroposterior or superior direction over the intact state. In addition, this anatomic two-bundle approach yielded substantially less anterior and posterior displacement than the Weaver-Dunn approach. There were no differences in superior load to failure . The luggage tag graft configuration avoids violation of the coracoid base and allows secure fixation about the coracoid, while restoring the conoid and trapezoid ligament components in the reconstruction. It is a stable construct at the coracoid base, and the lack of soft tissue screw fixation in the coracoid theoretically reduces failure of fixation with cyclic loading. Because the technique is similar to other anatomic AC joint reconstructions that restore the conoid and trapezoid ligamentous structures, the luggage tag fixation should restore coronal and sagittal plane stability to the distal clavicle similar to the native AC joint. After a mean of 53 months followup, only one patient experienced a recurrence of deformity in our series, and this was a partial redisplacement. This redisplacement rate (4.8%) compares favorably with other procedures reported in the literature (Table 1).
Hardware-related complications are a major concern with many of the nonanatomic methods of fixation. Failure of fixation in the form of broken wires or screws can lead to clavicle redisplacement . When hardware has been used to augment the fixation of historical AC joint reconstructive techniques, it is associated with high rates of hardware-associated complications (Table 1). As hardware is not used routinely in this procedure, there is no risk of hardware-related complications. In addition, by avoiding creation of a bone tunnel in the coracoid, the risk of iatrogenic fracture of the coracoid at the time of surgery theoretically is reduced. A potential complication of restoring conoid and trapezoid ligaments through clavicular bone tunnels is the risk of clavicle fracture. We did identify one such fracture several months after the patient had recovered from his AC joint reconstruction; however, this fracture healed uneventfully without adverse effect on the patient's overall function, satisfaction, or outcome. Our technique is comparable and in some ways superior to other methods of fixation of AC dislocation in terms of hardware-related complications and redisplacement (Table 1).
We believe the luggage tag method of coracoid fixation is an improvement on prior methods for anatomically reconstructing the AC joint in that it provides stable coracoid fixation and allows restoration of both CC ligaments yet minimizes the risk of fracture from violation of the cortical bone of the coracoid. The average postoperative DASH score was 11.7, which is virtually indistinguishable from the average employed adult score of 13 found by Jester et al. , particularly in light of the fact that the minimum detectable change for this instrument is 12.7 . Our data suggest this procedure relieves pain, reliably prevents redisplacement of the distal clavicle, and is associated with a low hardware complication rate.
1. Adachi, K., Yagi, H., Futami, T. and Tsukamoto, M. Surgical treatment of acromioclavicular dislocation by coracoacromial ligament transfer. J Orthop Surg.
1996; 4: 7-11.
2. Adam, FF. and Farouk, O. Surgical treatment of chronic complete acromioclavicular dislocation. Int Orthop.
2004; 28: 119-122. 10.1007/s00264-003-0520-3
3. Bannister, GC., Wallace, WA., Stableforth, PG. and Hutson, MA. The management of acute acromioclavicular dislocation: a randomized prospective controlled trial. J Bone Joint Surg Br.
1989; 71: 848-850.
4. Beaton, DE., Davis, AM., Hudak, P. and McConnell, S. The DASH (Disabilities of the Arm, Shoulder and Hand) Outcome Measure: what do we know about it now? Br J Hand Ther.
2001; 6: 109-118.
5. Cadenat, F. The treatment of dislocations and fractures of the outer end of the clavicle. Int Clin.
1917; 1: 145-169.
6. Cox, JS. The fate of the acromioclavicular joint in athletic injuries. Am J Sports Med.
1981; 9: 50-53. 10.1177/036354658100900111
7. Dawe, CJ. Acromioclavicular joint injuries. J Bone Joint Surg Br.
1980; 62: 269.
8. Dias, JJ., Steingold, RF., Richardson, RA., Tesfayohannes, B. and Gregg, PJ. The conservative treatment of acromioclavicular dislocation review after five years. J Bone Joint Surg Br.
1987; 69: 719-722.
9. Dumontier, C., Sautet, A., Man, M. and Apoil, A. Acromioclavicular dislocations: treatment by coracoacromial ligamentoplasty. J Shoulder Elbow Surg.
1995; 4: 130-134. 10.1016/S1058-2746(05)80067-9
10. Godfrey, J., Hamman, R., Lowenstein, S., Briggs, K. and Kocher, M. Reliability, validity, and responsiveness of the simple shoulder test: psychometric properties by age and injury type. J Shoulder Elbow Surg.
2007; 16: 260-267. 10.1016/j.jse.2006.07.003
11. Guy, DK., Wirth, MA., Griffin, JL. and Rockwood, CA Jr. Reconstruction of chronic and complete dislocations of the acromioclavicular joint. Clin Orthop Relat Res.
1998; 347: 138-149. 10.1097/00003086-199802000-00017
12. Jari, R., Costic, RS., Rodosky, MW. and Debski, RE. Biomechanical function of surgical procedures for acromioclavicular joint dislocation. Arthroscopy.
2004; 20: 237-245.
13. Jester, A., Harth, A. and Germann, G. Measuring levels of upper-extremity disability in employed adults using the DASH Questionnaire. J Hand Surg Am.
2005; 30: 1074-1074.
14. Karisson, J., Arnarson, H. and Sigurjonsson, K. Acromioclavicular dislocations treatment by coracoacromial ligament transfer. Arch Orthop Trauma Surg.
1986; 106: 8-11. 10.1007/BF00435643
15. Kawabe, N., Watanabe, R. and Sato, M. Treatment of complete acromioclavicular separation by coracoacromial ligament transfer. Clin Orthop Relat Res.
1984; 185: 222-227.
16. Kennedy, JC. and Cameron, H. Complete dislocation of the acromioclavicular joint. J Bone Joint Surg Br.
1954; 36: 202-208.
17. Klimkiewicz, JJ., Williams, GR., Sher, JS., Karduna, A., Dex Jardins, J. and Iannotti, JP. The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis. J Shoulder Elbow Surg.
1999; 8: 119-124. 10.1016/S1058-2746(99)90003-4
18. Krackow, KA., Thomas, SC. and Jones, LC. A new stitch for ligament-tendon fixation. J Bone Joint Surg Am.
1986; 68: 764-766.
19. Kumar, S., Sethi, A. and Jain, AK. Surgical treatment of complete acromioclavicular dislocation using the coracoacromial ligament and coracoclavicular fixation: report of a technique in 14 patients. J Orthop Trauma.
1995; 9: 507-510. 10.1097/00005131-199509060-00008
20. Kutschera, HP. and Kotz, RI. Bone-ligament transfer of coracoacromial ligament for acromioclavicular dislocation: a new fixation method used in 6 cases. Acta Orthop Scand.
1997; 68: 246-248. 10.3109/17453679708996694
21. Lancaster, S., Horowitz, M. and Alonso, J. Complete acromioclavicular separations: a comparison of operative methods. Clin Orthop Relat Res.
1987; 216: 80-88.
22. Larsen, E. and Petersen, V. Operative treatment of chronic acromioclavicular dislocation. Injury.
1987; 18: 55-56. 10.1016/0020-1383(87)90388-3
23. Lupo, R. and Rapisarda, S. Variations in method in the use of the coracoacromial ligament for the surgical treatment of acromioclavicular dislocations. Chir Organi Mov.
2000; 85: 293-301.
24. Mazzocca, AD., Santangelo, SA., Johnson, ST., Rios, CG., Dumonski, ML. and Arciero, RA. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med.
2006; 34: 236-246. 10.1177/0363546505281795
25. Pavlik, A., Csepai, D. and Hidas, P. Surgical treatment of chronic acromioclavicular dislocation by modified Weaver-Dunn procedure. Knee Surg Sports Traumatol Arthrosc.
2001; 9: 307-312. 10.1007/s001670100222
26. Press, J., Zuckerman, JD., Gallagher, M. and Cuomo, F. Treatment of grade III acromioclavicular separations: operative versus nonoperative management. Bull Hosp Jt Dis.
1997; 56: 77-83.
27. Rauschning, W., Nordesjö, LO., Nordgren, B., Sahlstedt, B. and Wigren, A. Resection arthroplasty for repair of complete acromioclavicular separations. Arch Orthop Trauma Surg.
1980; 97: 161-164. 10.1007/BF00389721
28. Rockwood, CA., Green, DP. and Bucholz, RW. Rockwood and Green's Fractures in Adults
, 3th ed. Philadelphia, PA: JP Lippincott Co; 1991: 1186-1199.
29. Shoji, H., Roth, C. and Chuinard, R. Bone block transfer of coracoacromial ligament in acromioclavicular injury. Clin Orthop Relat Res.
1986; 208: 272-277.
30. Sood, A., Wallwork, N. and Bain, IG. Clinical results of coracoacromial ligament transfer in acromioclavicular dislocations: a review of published literature. Int J Shoulder Surg.
2008; 2: 13-20. 10.4103/0973-6042.39582
31. Tienen, TG., Oyen, JF. and Eggen, PJ. A modified technique of reconstruction for complete acromioclavicular dislocation: a prospective study. Am J Sports Med.
2003; 31: 655-659.
32. Virata, SR., Holekamp, NM. and Meredith, TA.“Luggage-tag” suture fixation of partially dislocated intraocular lenses. Ophthalmic Surg Lasers.
2001; 32: 346-348.
33. Warren-Smith, CD. and Ward, MW. Operation for acromioclavicular dislocation: a review of 29 cases treated by one method. J Bone Joint Surg Br.
1987; 69: 715-718.
34. Weaver, JK. and Dunn, HK. Treatment of acromioclavicular injuries especially complete acromioclavicular separation. J Bone Joint Surg Am.
1972; 54: 1187-1194.
35. Weinstein, DM. Surgical treatment of complete acromioclavicular dislocations. Am J Sports Med.
1995; 23: 324-331. 10.1177/036354659502300313