Changes in Surgical Procedures for Acromioclavicular Joint ... - Healio

n Feature Article 

Changes in Surgical Procedures for 

Acromioclavicular Joint Dislocation 

Over the Past 30 Years 

Katsumi Takase, MD, PhD; Kengo Yamamoto, MD, PhD 

abstract 

Full article available online at Healio.com/Orthopedics. Search: 20130920-20 

Generally, surgical treatment is recommended for Rockwood type 5 traumatic acromioclavicular 

joint dislocations. Since 1980, the authors have performed the modified 

Dewar procedure, the modified Cadenat procedure, and anatomical reconstruction of 

the coracoclavicular ligaments for this injury. The goal of this study was to determine 

the ideal surgical procedure for acromioclavicular joint dislocations by comparing 

these 3 procedures. 

A 

The modified Dewar procedure was performed on 55 patients (Dewar group), the 

modified Cadenat procedure was performed on 73 patients (Cadenat group), and 

anatomical reconstruction of the coracoclavicular ligaments was performed on 11 

patients (reconstruction group). According to the UCLA scoring system, therapeutic 

results averaged 27.3 points in the Dewar group, 28.2 in the Cadenat group, and 28.4 

in the reconstruction group. The incidence of residual subluxation or dislocation in 

the acromioclavicular joint was evaluated at final radiographic follow-up. Subluxation 

occurred in 21 patients in the Dewar group, 18 in the Cadenat group, and 3 in the 

reconstruction group. Dislocation occurred in 3 patients in the Dewar group. Osteoarthritic 

changes in the acromioclavicular joint occurred in 20 patients in the Dewar 

group, 9 in the Cadenat group, and 1 in the reconstruction group. 

Figure: Anteroposterior radiographs of a 41-yearold 

man showing an acromioclavicular joint dislocation 

preoperatively (A) and its treatment using 

the modified Dewar procedure (B). 

B 

The modified Cadenat procedure can provide satisfactory therapeutic results and 

avoid postoperative failure or loss of reduction compared with the modified Dewar 

procedure. However, the modified Cadenat procedure does not anatomically restore 

the coracoclavicular ligaments. Anatomic restoration of both coracoclavicular ligaments 

can best restore acromioclavicular joint function. 

The authors are from the Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan. 

The authors have no relevant financial relationships to disclose. 

Correspondence should be addressed to: Katsumi Takase, PhD, Department of Orthopedic Surgery, 

Tokyo Medical University, 671 Nishisinjuku Shinjuku-ku, Tokyo, Japan 160-0023 (k-takase@ 

muf.biglobe.ne.jp). 

doi: 10.3928/01477447-20130920-20 

OCTOBER 2013 | Volume 36 • Number 10 

e1277


Various treatment methods, both 

conservative and surgical, have 

been used for traumatic acromioclavicular 

joint dislocations. Generally, 

surgical treatment is recommended for 

Rockwood type 4, 5, and 6 dislocations. 1 

However, surgical and conservative treatments 

for type 3 dislocations are controversial 

and have not been standardized. 

Many surgical procedures have been considered 

and reported in the literature, with 

no consensus at present. 2,3 

Since 1980, the current authors have 

performed the modified Dewar procedure 

for the reduction of the dislocated acromioclavicular 

joint using the dynamic muscle 

strength of the conjoined tendon. 4 However, 

this procedure has various problems, 

including damage by surgical invasion and 

long-term immobilization. In consideration 

of these problems, since 1995 the authors 

have performed the modified Cadenat 

procedure, which reconstructs the coracoclavicular 

ligaments using the coracoacromial 

ligaments. 5 However, anatomic restoration 

of the coracoclavicular ligaments 

can best restore acromioclavicular joint 

function. Based on the anatomical data for 

the structures of the trapezoid and conoid 

ligaments, 6 these procedures do not aim to 

anatomically reconstruct the coracoclavicular 

ligaments. Therefore, the authors 

have attempted to correctly reconstruct the 

anatomy of the coracoclavicular ligaments 

(trapezoid and conoid ligaments) using the 

ipsilateral palmaris longus tendon and an 

EndoButton (Smith & Nephew Endoscopy, 

Andover, Massachusetts) as the reconstructing 

ligament and fixation material, 

respectively. 7 

The goal of this study was to discover 

the ideal surgical procedure for acromioclavicular 

joint dislocations by comparing the 

modified Dewar procedure, the modified 

Cadenat procedure, and anatomical reconstruction 

of the coracoclavicular ligaments. 

Materials and Methods 

According to Rockwood’s classification, 

on plain radiographs all patients 

were evaluated as having type 5 traumatic 

acromioclavicular joint dislocations. 

Modified Dewar Procedure 

The modified Dewar procedure was 

performed in 55 patients (Dewar group) 

between 1980 and 1994. The group comprised 

51 (92.7%) men and 4 (7.3%) 

women with a mean age of 34.5 years 

(range, 16-66 years) at surgery. The right 

side was affected in 29 (52.7%) patients 

and the left side in 26 (47.3%) patients. 

The mechanism of injury was a traffic 

accident in 25 (45.5%) patients, a sports 

accident in 19 (34.5%), and other causes 

in 11 (20%) patients. Mean follow-up was 

50 months (range, 33-106 months). 

During the procedure, the coracoid 

process was directly confirmed through 

the deltopectoral approach. Then, approximately 

1.5 cm of the tip of the 

coracoid process was osteomized and 

detached, along with the coracobrachialis 

muscle and short head of the biceps 

brachialis muscle. The dislocated 

acromioclavicular joint was fixed using 

2 K-wires, preserving the intraarticular 

disk as much as possible, and the 

torn capsule and acromioclavicular ligaments 

were sequentially repaired. Finally, 

the detached coracoid process was fixed 

with these muscles to the anterior side of 

the clavicle approximately 3 cm from the 

distal edge of the clavicle using a screw 

with a spike washer (Figure 1) . 

Postoperative treatment consisted of 

immobilization with a Velpeau bandage 

for 5 weeks. Beginning at postoperative 

week 6, forward elevation by passive 

movement in the supine position and pendulum 

exercises were prescribed. The K- 

wires were removed 6 weeks postoperatively 

(Figure 2). 

Modified Cadenat Procedure 

Between 1995 and 2009, the modified 

Cadenat procedure was performed in 

73 patients with acromioclavicular joint 

dislocations (Cadenat group). The group 

comprised 66 (90.4%) men and 7 (9.6%) 

Figure 1: Schema of the modified Dewar procedure 

illustrating the tip of the coracoid process 

fixed by a screw (A) and the conjoined tendon including 

the coracobrachialis and short head of the 

biceps brachii (B). 

women with a mean age of 35.4 years at 

surgery (range, 16-63 years). The right 

side was affected in 41 (56.2%) patients 

and the left side in 32 (43.8%) patients. 

The mechanism of injury was traffic accident 

in 30 (41.1%) patients, sports accident 

in 18 (24.7%), work accident in 8 

(11%), and other causes in 17 (23.3%). 

Time from injury to surgery was less than 

2 weeks in 65 (89%) patients (acute cases), 

1 

2A 

2B 

Figure 2: Anteroposterior radiographs of a 41-yearold 

man showing an acromioclavicular joint dislocation 

preoperatively (A) and its treatment using 

the modified Dewar procedure (B). 

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ORTHOPEDICS | Healio.com/Orthopedics

Acromioclavicular Joint Dislocation | Takase & Yamamoto 

between 2 weeks and 1 month in 5 (6.8%) 

patients (subacute cases), and more than 1 

month in 3 (4.1%) patients (chronic cases). 

Fifty-three (72.6%) of these patients 

had participated in sports activities before 

injury, and 48 (65.8%) patients, including 

32 contact sports players, engaged in 

high-level sports activities. Mean followup 

was 30 months (range, 14-75 months). 

During the procedure, the coracoid 

process was directly confirmed through 

the deltopectoral approach. Initially, the 

coracoacromial ligaments at the acromial 

insertion site and a small bone tip were 

detached (Figure 3). The dislocated acromioclavicular 

joint was fixed using a hook 

plate, preserving the intra-articular disk 

as much as possible, and the torn capsule 

and acromioclavicular ligaments were sequentially 

repaired. Finally, the detached 

coracoacromial ligament with the bone tip 

was fixed to the anterior side of the clavicle 

using a screw with a spike washer in a 

position that allowed sufficient tension to 

be obtained (Figure 4). 


immobilization with a Désault bandage 

for 2 weeks. Beginning at postoperative 

week 4, forward elevation by passive 

movement in the supine position and pendulum 

exercises were prescribed (Figure 

5). The Wolter clavicular plate was removed 

4 months postoperatively. 

Figure 3: Schema of the modified Cadenat procedure 

showing the acromial insertion area of the 

coracoacromial ligament (diagonal line), the coracoacromial 

ligament (A), and the lateral (B) and 

medial (C) edges of the coracoacromial ligament. 

5A 

3 

Figure 4: Schema of the modified Cadenat procedure 

showing the detached coracoacromial ligament 

with the bone tip fixed to the anterior side of 

the clavicle using a screw with a spike washer in a 

position that allowed sufficient tension to be obtained. 

Abbreviations: A, coracoacromial ligament; 

B, lateral edge of the coracoacromial ligament; C, 

medial edge of the coracoacromial ligament. 

Figure 5: Anteroposterior radiographs of a 29-year-old man showing an acromioclavicular joint dislocation 

preoperatively (A) and treatment with the modified Cadenat procedure (B). 

4 

5B 

Anatomical Reconstruction of the 

Coracoclavicular Ligaments 

Since 2008, the authors have reconstructed 

the anatomical structure of the 

coracoclavicular ligaments (trapezoid and 

conoid ligaments) with an artificial ligament 

and the ipsilateral palmaris longus 

tendon used as substitute ligaments, respectively 

(reconstruction group). Eleven 

patients with acromioclavicular joint dislocations 

underwent this procedure. The 

group comprised 11 men with a mean 

age of 38.6 years at surgery (range, 19- 

67 years). The right side was affected in 

7 (63.6%) patients and the left side in 4 

(36.4%) patients. The mechanism of injury 

was traffic accident in 2 (18.2%) patients, 

sports accident in 4 (36.4%), and 

a fall in 5 (45.5%). Mean time from injury 

to surgery was 16.3 days (range, 9-30 

days). Mean follow-up was 17 months 

(range, 12-43 months). 

The double-bundle procedure reconstructing 

both the trapezoid and conoid 

ligaments was performed. Initially, a 16- 

cm or longer length of the palmaris longus 

tendon was excised from the ipsilateral 

side as the substitute for the conoid ligament 

(Figure 6A). An artificial ligament 

(Dacron; Smith & Nephew Endoscopy) 

was used for reconstructing the trapezoid 

ligament (Figure 6B). An EndoButton 

was used for fixation of the tendon or artificial 

ligament on the coracoid process 

side, and a screw with a spike washer was 

used on the clavicle side. The excised palmaris 

longus tendon was fashioned into a 

quadruple-stranded graft with a minimal 

length of 4 cm for reconstructing the conoid 

ligament. During these preparations, 

the EndoButton was placed at the loop 

end of the conoid graft and the artificial 

ligament at the other end of the conoid 

graft. The conoid ligament reconstruction 

was performed under arthroscopy. To 

acquire firm fixation and prevent sinking 


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and pendulum exercises were prescribed. 

All immobilization was discontinued at 2 

weeks postoperatively (Figure 8). 

6A 

6B 

Figure 6: Graft preparation for the conoid (A) and 

trapezoid (B) ligaments showing the EndoButton 

(Smith & Nephew Endoscopy, Andover, Massachusetts) 

continuous loop (C), quadruple-stranded 

palmaris longus tendon (D), artificial ligament (E), 

and EndoButton (F). 

Figure 7: Schema of anatomical reconstruction of 

the coracoclavicular ligaments showing the trapezoid 

ligament (1) fixed to the medial edge of the 

coracoid process (A1) and the conoid ligament (2) 

fixed to the undersurface of the basement of the 

coracoid process (A2). 

7 

Therapeutic Results and Statistical Analysis 

Therapeutic results were evaluated 

based on the UCLA scoring system (30 

points), 8 which consists of pain, function, 

range of motion, and strength, excluding 

the patient’s satisfaction. Also, radiographic 

findings were evaluated, including 

the occurrence of osteoarthritic changes 

and the complete reduction or lack thereof 

in the acromioclavicular joint. 

Statistical analysis evaluated the differences 

among the 3 groups. A P level 

less than .05 using the Mann-Whitney U 

test was considered significant. 

8A 

Figure 8: Anteroposterior radiographs of a 23-year-old man showing an acromioclavicular joint dislocation 

preoperatively (A) and treatment with anatomical reconstruction of the coracoclavicular ligaments 

showing the bone tunnels for the conoid (boxed C) and trapezoid (boxed D) ligaments (B). 

of the EndoButton, the soft tissue under 

the surface of the coracoid process was 

cleaned to expose the cortex through the 

anterior portal. 

To create a bone tunnel for reconstructing 

the conoid ligament, a 2-mm 

diameter K-wire was inserted from the 

conoid tubercle of the clavicle to the base 

of the coracoid process under arthroscopy. 

Then, a 4-mm bone tunnel was created 

for the conoid graft using a cannulated 

drill bit with a diameter matched with the 

graft diameter by overdrilling along that 

wire from the clavicle. Similarly, another 

2-mm diameter K-wire was inserted from 

the 1.5-cm medial portion from the lateral 

8B 

end of the clavicle to the medial side of 

the body of the coracoid process for reconstructing 

the trapezoid ligament. Finally, 

each graft was introduced through 

the anterior portal to the clavicle tunnel 

and fixed on the undersurface of the 

coracoid process by the EndoButton, respectively 

(Figure 7). Then, the clavicle 

side of each graft was fixed together by a 

screw with a spike washer. No temporary 

fixation of the acromioclavicular joint was 

performed. 


immobilization with a Désault bandage for 

approximately 1 week. Beginning at postoperative 

week 2, only a sling was used, 

Results 

According to the UCLA scoring system, 

mean therapeutic result was 27.3 

points (range, 18-30 points) in the Dewar 

group, 28.2 points (range, 24-30 points) in 

the Cadenat group, and 28.4 points (range, 

24-30 points) in the reconstruction group. 

When the results were examined, no significant 

difference among these groups 

was observed. However, regarding postoperative 

range of motion, 59 (80.8%) of 

73 patients in the Cadenat group recovered 

more than 160° forward elevation 

and 160° abduction at 3 months postoperatively, 

but 21 (38.1%) of 55 patients in 

the Dewar group required approximately 

1 year to gain their preinjury range of motion. 

The remaining patients did not regain 

their preinjury range of motion. 

The incidence of residual subluxation 

or dislocation in the acromioclavicular 

joint was evaluated at final radiographic 

follow-up. In the Dewar group, subluxation 

that represented less than 5 mm of 

superior translation of the clavicle occurred 

in 14 (25.5%) patients, subluxation 

that represented 5 to 10 mm of superior 

translation of the clavicle occurred in 7 

(12.7%) patients, and complete dislocation 

occurred in 3 (5.5%) patients. In the 

Cadenat group, subluxation that repre- 

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Acromioclavicular Joint Dislocation | Takase & Yamamoto 

sented less than 5 mm of superior translation 

of the clavicle occurred in 18 (24.7%) 

patients, and subluxation that represented 

more than 5 mm of superior translation of 

the clavicle or redislocation occurred in 0 

patients. In the reconstruction group, subluxation 

that represented less than 5 mm 

of superior translation of the clavicle occurred 

in 3 (27.3%) patients, and subluxation 

that represented more than 5 mm of 

superior translation of the clavicle or redislocation 

occurred in 0 patients. 

Osteoarthritic changes occurred in the 

acromioclavicular joint in 20 (36.4%) patients 

in the Dewar group, 9 (12.3%) patients 

in the Cadenat group, and 1 (9.1%) 

patient in the reconstruction group. 

Discussion 

Acromioclavicular joint separations 

are frequently treated in clinical practice. 

The degree or direction of translation of 

the clavicle against the acromion depends 

on the injury states of the acromioclavicular 

and coracoclavicular ligaments 

and detachment of deltoid or trapezius 

muscle from the clavicle. Rockwood et 

al 1 and Tossy et al 9 classified the degree 

or direction of displacement in acromioclavicular 

joint separations into 6 and 

3 types, respectively. Generally, Rockwood 

type 5 dislocations are considered 

a good indication for surgical treatment. 

Many surgical treatments exist for acromioclavicular 

joint dislocation, including 

repair of the acromioclavicular ligament 

(Phemister procedure 10 or Neviaser procedure 

11 ), fixation between the clavicle 

and the coracoid process (Bosworth procedure 

12 ), reconstruction of the coracoclavicular 

ligament using the coracoacromial 

ligament (Weaver-Dunn procedure 13 and 

Cadenat procedure 5 ), and dynamic stabilization 

of the coracoclavicular joint by 

the transferred conjoined tendon (Dewar 

procedure 4 ). 

Between 1980 and 2008, the current 

authors performed 2 different surgical 

procedures (modified Dewar procedure 

and modified Cadenat procedure), which 

were not anatomical reconstruction of 

the coracoclavicular ligament, in patients 

with Rockwood type 5 acromioclavicular 

joint dislocations. The modified Dewar 

procedure has some disadvantages, including 

a long period required for range 

of motion recovery, a high frequency of 

residual subluxation or dislocation, and 

postoperative osteoarthritic changes on 

the acromioclavicular joint. In particular, 

the latter 2 disadvantages were considered 

to result from the dynamic stabilization 

of the acromioclavicular joint by the conjoined 

tendons. Skjeldal et al 14 reported 

that nonoperative treatment gave equal or 

better long-term functional results compared 

with the modified Dewar procedure 

in acute acromioclavicular dislocations, 

and they did not recommend the procedure 

in acute cases. 

Considering these disadvantages, the 

current authors began performing the 

modified Cadenat procedure on patients 

with acromioclavicular joint dislocations 

in 1995. Patients undergoing the modified 

Cadenat procedure needed a mean 

of 3.4 months to return to their occupation 

and a mean of 3.1 months to return 

to preinjury-level sports activities. However, 

the modified Cadenat procedure also 

has some disadvantages. The mechanism 

of stabilization for the acromioclavicular 

joint is established by the coracoacromial 

ligament transferred from the acromion 

to the clavicle. This transferred coracoacromial 

ligament does not anatomically 

reconstruct the trapezoid and conoid ligaments 

that compose the coracoclavicular 

ligament. The conoid ligament attaches 

anatomically to the conoid tubercle, 

which is located at the posterior edge of 

the clavicle, and the clavicle can make an 

axial rotation during forward elevation of 

the shoulder joint. However, in the modified 

Cadenat procedure, it is possible that 

this axial rotation of the clavicle is restricted 

because the transferred coracoacromial 

ligament is fixed to the anterior 

edge of the clavicle. For this reason, even 

if the dislocated acromioclavicular joint is 

reduced in a normal position, it is possible 

that osteoarthritic changes can occur to 

the acromioclavicular joint. The Weaver- 

Dunn procedure, in which the transferred 

coracoacromial ligament is inserted into 

the distal edge of the resected clavicle, is 

close to anatomical reconstruction of the 

trapezoid ligament. However, this procedure 

does not aim to reconstruct the anatomical 

acromioclavicular joint due to the 

distal clavicle resection. 

To reconstruct the coracoclavicular 

ligaments, Yoo et al 15 used the semitendinosus 

tendon, Sloan et al 16 used the lateral 

half slip of the conjoined tendon, Lädermann 

et al 17 and Marchie et al 18 used suture 

threads, and Wei et al 19 and Salzmann 

et al 20 used an artificial ligament. However, 

of these procedures, only the method 

using an artificial ligament achieved reconstruction 

of the anatomical coracoclavicular 

ligaments. In addition, using an 

artificial ligament for the procedure may 

make it impossible to acquire the same 

function as the congenital ligaments. 

The current authors performed a double-bundle 

procedure with an artificial ligament 

and the palmaris longus tendon for 

anatomical reconstruction of the trapezoid 

and conoid ligaments, respectively. On 

considering its location, features, and operative 

demerits, the authors believe that 

the palmaris longus tendon is a suitable 

substitute for the ligament. However, this 

tendon is thin and short for reconstructing 

the trapezoid and conoid ligaments. 

Therefore, the authors used the palmaris 

longus tendon to reconstruct the conoid 

ligament, which is mainly responsible for 

stabilization of the superior translation of 

the clavicle. 

This procedure aimed to anatomically 

reproduce the distribution and attachment 

sites of the trapezoid and conoid 

ligaments. Although the excision of the 

palmaris longus tendon is a disadvantage, 

anatomical reduction of the acromioclavicular 

joint was accomplished in 8 

(72.7%) of 11 patients. Also, it is possible 

to perform this surgical technique under 


e1281


arthroscopy. During the follow-up period, 

no osseous erosion on the clavicle and 

no displacement of the EndoButton were 

noted. However, fracture of the coracoid 

process or the clavicle is possible intraoperatively. 

Therefore, the tunnel creation in 

the coracoid process or the clavicle should 

be carefully performed. 

Conclusion 

The modified Cadenat procedure can 

provide satisfactory therapeutic results 

and avoid postoperative failure or loss of 

reduction of acromioclavicular joint separations 

compared with the modified Dewar 

procedure. However, the modified Cadenat 

procedure does not anatomically 

restore the coracoclavicular ligaments. 

Anatomic reconstruction of both coracoclavicular 

ligaments can best restore acromioclavicular 

joint function. 

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