Primary Stability of an Acromioclavicular Joint Repair Is Affected by the Type of Additional Reconstruction of the Acromioclavicular Capsule
Authors: Dyrna Felix , Imhoff Florian B. , Haller B. , Braun Sepp , Obopilwe Elifho , Apostolakos John M. , Morikawa Daichi , Imhoff Andreas B. , Mazzocca Augustus D. , Beitzel Knut 
Published: November 2018

Background: The synergistic effect of the acromioclavicular (AC) capsule and coracoclavicular (CC) ligaments on AC joint stability has gained recent recognition for its importance. Biomechanical and clinical studies have shown the benefit of combined reconstruction with multiple variations of surgical techniques for AC capsule augmentation. The ideal configuration remains unknown for such capsular repair aimed at achieving optimal stability with anatomic reconstruction. Hypothesis: Primary AC joint stability can be restored by AC capsule augmentation, while position of the additional suture construct is critical. It was hypothesized that techniques that reconstruct the anterior capsular structures would restore native stability against rotations and translations. Study Design: Controlled laboratory study. Methods: Thirty fresh-frozen human cadaveric shoulders were used. Each sample was tested in the native state and served as its own control. After complete capsulotomy, 1 of 5 AC capsular repair configurations was performed: anterior, superior, posterior, O-frame, and X-frame. After testing of the AC capsular repair configurations, the tests were repeated after dissection of the CC ligaments and after CC ligament reconstruction with a suture button system. AC joint stability was immediately tested after each step under rotation and horizontal translation. To accomplish this, the AC joints were anatomically positioned on a custom fixture linked to a servohydraulic testing system. A 3-dimensional optical measuring system was used to evaluate the 3-dimensional joint motion. Clavicle posterior translation in relation to the acromion, rotation around the long axis of the clavicle, and displacement of the lateral clavicle in relation to the center of rotation were measured. The torques and forces required to rotate and translate the clavicle were recorded. Results: In terms of translational testing, after the complete capsulotomy, a significant reduction of resistance force was found across all groups, with a mean 13% to 20% remaining ( P < .05). All AC suture augmentations were able to significantly increase the average resistance force as compared with the native ( P = .01) against posterior translation. Subsequent cutting of the CC ligaments did not result in a significant change in any of the groups ( P = .23). The synergistic effect of AC capsule augmentation and CC ligament reconstruction could be demonstrated without exception. In terms of rotational testing, the complete capsulotomy resulted in a significant reduction of resistance torque in all groups ( P < .05), with a remaining torque ranging between 2% and 11% across the groups. However, all AC suture constructs significantly increased the resistance torque as compared with the capsulotomy ( P = .01). The subsequent cutting of the CC ligaments resulted in a significant change in 2 of the 5 groups (O-frame, P = .01; X-frame, P = .02) and an overall remaining torque reduction ranging from 3% and 42%. The combined reconstruction of the AC capsule and CC ligaments achieved the highest percentage of regained resistance torque but remained significantly weaker than the native specimen ( P = .01). Conclusion: Native translational stability could be restored by the addition of AC capsule augmentation, while partial rotational instability remained. The tested constructs revealed no significant individual differences. Clinical Relevance: Combined stabilization of the AC capsule and CC ligaments demonstrated the greatest capacity to restore the native stability against translational and rotational loads, with the specific configuration of the AC capsule repair to be chosen according to the personal preferences of the surgeon.