Acromioclavicular joint dislocations: 20 years of experience
Acromioclavicular joint dislocations (ACJDs) remain one of the most debated entities in shoulder trauma surgery, with persistent controversies surrounding indications, timing, and choice of fixation. This article draws on twenty years of clinical and surgical experience to provide a critical, narrative overview of the evolution of ACJD management, with emphasis on the rationale underpinning current practice and on the unresolved questions that continue to shape the field.
The discussion addresses, in turn, the refinement of surgical indications beyond the traditional Rockwood-based algorithm, integrating functional, aesthetic, and psychosocial dimensions, as well as the increasing demand generated by the “active elderly” population. The debate between early and delayed surgery is explored, including the technical consequences of chronicity, the impact of cutaneous lesions, and the role of supplementary graft procedures such as the Weaver–Dunn-type reconstruction in chronic presentations.
The evolution of surgical techniques is then reviewed, from historically popular but now largely abandoned methods — Kirschner wires, tension-band wiring, transcoracoclavicular screws, hook plates, and subcoracoid cerclage — to the advent of arthroscopic endobutton ligament reconstruction. Reported complication rates of 20 to 40% with early arthroscopic constructs are analysed, together with their principal mechanisms of failure: malposition of transosseous tunnels, progressive tunnel widening, implant migration, coracoid and clavicular fractures, and residual horizontal instability. Recent optimisations are detailed, including the use of smaller-diameter drills, anatomically guided tunnel positioning, and a dedicated posterior offset clavicular guide. The rationale for bidimensional (vertical and horizontal) stabilisation is developed, reflecting current understanding of rotatory acromioclavicular instability. The authors’ present technique — combining arthroscopic coracoclavicular adjustable-loop fixation with a mini-open horizontal acromioclavicular anchor construct — is described step by step, along with postoperative rehabilitation.
Ongoing SOFEC multicentre research and emerging avenues such as intraoperative three-dimensional imaging are outlined. This overview will be of interest to shoulder and upper-limb surgeons seeking a pragmatic, experience-based perspective on the contemporary management of ACJDs.
