An Innovative Approach to Chronic and Neglected Acromioclavicular Joint Dislocation: A Cost-Effective and Reliable Solution

Introduction

The acromioclavicular (AC) joint, a diarthrodial joint, accounts for 40–50% of shoulder injuries ^[1,2]. Dislocations of the AC joint occur more frequently in males than females (5:1 ratio) and are more often incomplete than complete (2:1 ratio) ^[3]. Patients with AC joint injuries often experience changes in scapular orientation, leading to rotator cuff injuries and chronic pain ^[4]. Biomechanical studies underscore the importance of anatomically reconstructing the coracoclavicular (CC) ligaments in cases of unstable AC joint injuries ^[5].

The treatment strategy for chronic AC joint instability (ACJI) differs from that of acute cases. In the acute phase, the AC and CC ligaments have the potential to heal, thus the treatment focuses on aligning the torn ligament ends during tissue healing. However, this healing potential is lost after 3 weeks ^[6]. Various techniques have been documented for treating AC joint dislocation, including primary joint fixation, CC ligament reconstruction, clavicle excision, dynamic muscle transfers, coracoacromial ligament transfer, and various fixation methods. Combinations of these techniques are now prevalent ^[7].

This case series presents a technique for AC joint reconstruction in chronic cases of Rockwood types 3, 4, and 5, utilizing a synthetic tape alongside lateral clavicle excision. This method is demonstrated to be rapid, economical, effective, and associated with low morbidity and favorable clinical outcomes (Fig.1–9).

Materials and Methods

In this retrospective study, we evaluated 11 patients with delayed presentation (6 weeks or more post-injury) who underwent surgery. Patients were excluded if they had associated fractures, brain injuries, cognitive impairments, or abnormal shoulder function before injury.

Results

The procedure was performed on 11 patients with neglected AC joint dislocations of Rockwood grades 3 to 5, with a mean age of 46.6 years. The right shoulder was involved in 8 of 12 cases, with a male-to-female ratio of 3:1. Injuries were caused by falls in 10 cases and road traffic accidents in 2 cases. Pre- and post-operative assessments of pain, daily activities, cosmesis, and range of motion showed satisfactory functional outcomes without paracervical or trapezius pain.

One patient experienced a 20% vertical displacement of the clavicle’s lateral end, but had no clinical complaints. The mean post-operative ACJI score improved from 63.7 pre-operatively to 81.4 post-operatively at 2 years. The visual analog scale score improved from 6.41 pre-operatively to 2.68 at 6 months and 1.25 at 12 months. The Constant Murley score improved from 51 pre-operatively to 92.08 at 12 months. At final follow-up, all patients had satisfactory outcomes in terms of pain, cosmesis, and shoulder function. The AC joint was stable both clinically and radiologically in all cases (Table 1 & 2).

Discussion

Despite various surgical techniques for treating these injuries, achieving long-term functional outcomes has been challenging ^[8]. Techniques include fixing the AC joint with K-wires or tension bands or reconstructing the CC ligaments with various materials. The clavicle hook plate is a simple and beneficial method, but complications, such as hardware prominence and fixation loss are significant ^[9]. Arirachakaran et al. found that loop suspensory fixation of the CC joint yields better functional scores than hook plates for AC joint dislocations ^[10].

Most techniques assume the CC ligaments will heal to their original length and strength, but if they do not, these methods may fail. Reconstruction can avoid this issue by using local tissue sources or tendon grafts, either autografts or allografts, to align the clavicle and coracoid. Initial reconstruction techniques by Weaver and Dunn involved ligament transfer ^[11], but this method had higher risks of dislocation compared to anatomical ligaments. Dewar and Barrington ^[12] described coracoid bone transposition, which carries high risks of bone fracture and nerve injury.

Autologous graft use for CC ligament reconstruction loses up to 30–40% of its original strength ^[13], and early graft weakness during necrosis and revascularization can lead to failure ^[14]. In addition, the graft remains weak post-fixation, increasing the risk of stress fractures ^[15].

Studies have shown that CC ligaments provide superior stability, while AC ligaments provide anterior-posterior stability ^[8,16,17]. Beitzel et al. concluded that both ligaments should be anatomically repaired for optimal function, but our case did not include AC ligament repair and resulted in no functional outcome changes.

Anatomical AC joint reduction and CC ligament reconstruction are essential for achieving good clinical and imaging results, regardless of the material used. Mersilene tape avoids implant-related complications and does not require removal, offering favorable functional outcomes and pain-free shoulder movement. This method is cost-effective compared to imported alternatives, making it more accessible and providing good objective and subjective outcomes with minimal complications.

Conclusion

This technique offers a cost-effective, rapid, robust, and reproducible solution with durable and predictable outcomes for treating chronic AC joint dislocations.

Clinical Message

Chronic and neglected AC joint dislocations (Rockwood grades 3–5) can be reliably managed using a simple, low-cost Mersilene tape reconstruction of the CC ligaments combined with lateral clavicle excision, avoiding the need for grafts or fixation hardware. This technique offers durable joint stability, significant pain relief, and improved shoulder function, making it a reproducible and accessible option, particularly in resource-limited settings.

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About the Authors

• 

  Vishal Rathod

• 

  Parag Munshi