ANATOMY AND BIOMECHANICS OF THE ACROMIOCLAVICULAR JOINT

ROBB SELLARDS, MD

Knowledge of the anatomy and biomechanics of the acromioclavicular (AC) joint is important for the orthopaedic surgeon. An understanding of the complex soft tissue and bony relationships in the AC joint is critical to achieving operative success. Failure to protect supporting structures during surgery or neglect of preoperatively damaged ligaments can lead to postoperative failure in procedures addressing the AC joint. KEY WORDS: acromioclavicular joint, biomechanics, anatomy, acromioclavicular ligament, coracoacromial ligament, distal clavicle resection 2004 Elsevier Inc. All rights reserved.

The acromioclavicular (AC) joint is the articulation than anchors the clavicle to the scapula. The anatomy and design of the joint allow it to sustain a signicant amount of force before disruption. There are many procedures and protocols that have been devised to treat the AC joint. Choosing the appropriate treatment is confusing due to the magnitude of research with conicting outcomes. It is important to understand the biomechanics and anatomy of the joint to critically evaluate the existing studies. An understanding of these basic principles can then allow the orthopaedic surgeon to choose the appropriate treatment. This review denes and explains the anatomy and biomechanics of the AC joint.

ANATOMY
The acromioclavicular joint is a diarthrodial joint that has four degrees of freedom, allowing movement in the anterior/posterior and the superior/inferior planes. It is surrounded by a joint capsule with a synovial lining. Hyaline cartilage coats the articular surfaces and there is an intervening intraarticular meniscus type structure which has tremendous variation in size and shape. DePalma et al1 Petersson,2 and Salter3 have demonstrated that with age this meniscal homologue undergoes rapid degeneration until it is no longer functional beyond the fourth decade. Its actual function in the joint is negligible. The acromioclavicular joint is stabilized by both static and dynamic stabilizers. The static stabilizers include the acromioclavicular ligaments (superior, inferior, anterior, and posterior), the coracoclavicular ligaments (trapezoid and conoid), and the coracoacromial ligament (Fig 1). The

From the Section of Sports Medicine, Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA. Address reprint requests to Robb Sellards, MD, Assistant Professor, Section of Sports Medicine, Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 2025 Gravier Street, Suite 400, New Orleans, LA 70112. 2004 Elsevier Inc. All rights reserved. 1060-1872/04/1201-0002$30.00/0 doi:10.1053/j.otsm.2004.04.006

dynamic stabilizers include the deltoid and trapezius muscles. All of the soft tissues at the acromioclavicular joint function in a synergistic, complex manner to provide AC joint stability.4,5 The acromioclavicular joint capsule and the capsular ligaments are the primary restraints of the distal clavicle to anterior to posterior translation.6 The superior AC ligament is more substantial and thicker than the inferior AC ligament. The superior AC ligament attaches to the clavicle and its bers interdigitate with the musculotendinous aponeurosis of the deltotrapezial fascia (Fig 2).3 These muscles add stability to the joint when they contract or stretch. There have been few descriptions of the capsular anatomy of the AC joint. In a recent study by Renfree and coworkers, histologic sections revealed that the superior aspect of the AC capsule inserted onto the distal clavicle an average of 5.5 mm from the joint line.7 In an anatomical dissection study by Nicholson and coworkers, the AC capsule was dissected circumferentially from the inside out. The capsule was incised in line with the joint and was sharply dissected off the bone of the clavicle and acromion working from the underneath side of the capsule. Qualitatively the most identiable and robust aspects were the superior and posterior portions of the capsule. The average insertional footprint increased from anterior to posterior on the distal clavicle. The capsule began an average of 0.3 mm from the joint line on the distal clavicle, and the superior posterior aspect of the capsule inserted an average of 13.5 mm from the joint line.8 The dimensions in this study were greater than those reported by Renfree. The authors speculated that this may be due to specimen preparation and methodology. It may also represent a thicker, deeper, shorter aspect to the superior AC capsule, with a thinner, broader, more extensive supercial capsular aspect to this structure. The coracoclavicular ligaments main contribution is with vertical stability preventing superior and inferior translation of the clavicle. This complex is made up of two structures: the trapezoid and the conoid ligaments. As the name implies, the ligaments originate on the coracoid

Operative Techniques in Sports Medicine, Vol 12, No 1 (January), 2004: pp 2-5

The motion of the acromioclavicular joint is important clinically. Procedures that either fuse the acromioclavicular joint or stabilize the clavicle to the scapula with a coracoclavicular screw still allow full forward elevation in abduction. This motion has allowed these screws and hardware to migrate as well as break over time.

ACROMIOCLAVICULAR CAPSULAR LIGAMENTS

Several biomechanical studies have illustrated the importance of ligaments in regard to AC joint stability. (Table 1) Klimkiewicz and coworkers performed cadaveric dissections to dene the relative roles of the individual acromioclavicular capsular ligaments in preventing posterior translation of the distal clavicle in normal acromioclavicular joints.14 Each ligament was sectioned and the resultant clavicular translation was measured. Their results indicated that if the anterior and inferior ligaments are sectioned, there is no signicant effect on posterior translation. However, if the posterior and superior ligaments are sectioned, there is a signicant effect on clavicular translation. The superior and posterior capsular ligaments contribute 56 and 25%, respectively, of the force required to produce a given posterior displacement.14 Posterior horizontal instability of the distal clavicle can cause abutment of the posterolateral portion of the clavicle into the spine of the scapula (Fig 3). Clinically, resistance to posterior translation is critical to avoid painful horizontal instability of the acromioclavicular joint with an abutment of the posterolateral end of the clavicle on the spine of the scapula. The authors recommended procedures that spare the posterior and superior ligaments when removing the distal clavicle.

Fig 1. Anatomy of the acromioclavicular joint. (Reprinted with permission from McMahon et al.22)

process of the scapula and insert on the undersurface of the distal clavicle. These two stout ligaments are responsible for suspending the scapula and the upper extremity from the under surface of the clavicle.9 The trapezoid is anterior and lateral to the conoid, and both the trapezoid and conoid ligaments are posterior to the pectoralis minor attachment on the coracoid. The trapezoid ligament insertion ends approximately 16 mm from the AC joint line. The conoid ligament insertion ends approximately 30 mm from the joint line. The trapezoid ligament was found to be thicker in all dimensions than the conoid ligament. The mean lengths of the ligaments from coracoid to clavicle were 19.3 and 19.4 mm for the trapezoid and conoid, respectively.10 Bearden et al reported a range of values for the coracoclavicular space of 1.1 to 1.3 cm.11 This distance becomes clinically important when differentiating incomplete versus complete acromioclavicular joint separations. The larger the distance between the coracoid and the clavicle the more likely that a complete dislocation has occurred. The coracoclavicular ligaments perform two major functions: (1) they mediate synchronous scapulohumeral motion by attaching the clavicle to the scapula and (2) they strengthen the acromioclavicular articulation.

CORACOCLAVICULAR LIGAMENTS
Fakuda et al initially described the role of the coracoclavicular (CC) ligaments in AC joint stability.6 They reported that with small displacements the acromioclavicular ligaments are the primary restraints to posterior (89%) and superior (68%) translation of the clavicle. With larger displacement, the conoid ligament was found to be the primary restraint (62%) to superior translation. The trap-

BIOMECHANICS
ACROMIOCLAVICULAR JOINT MOTION
Rockwood et al have reported that there is approximately 5 to 8 of motion detected at the acromioclavicular joint with forward elevation and abduction to 180.12 The clavicle rotates between 40 and 50 during full overhead elevation. This motion is combined with scapular rotation rather than through the acromioclavicular joint. This synchronous motion of the clavicle, rotating upward, and the scapula, rotating downward, during abduction and forward elevation was described by Codman as synchronous scapula clavicular rotation.13 This is coordinated by the coracoclavicular ligaments.
AC JOINT ANATOMY AND BIOMECHANICS

Fig 2. Histologic section of the AC joint. (Reprinted with permission from Renfree et al.7)

TABLE 1. Summary of Biomechanical Studies Investigating the Structures Primarily Responsible for Resisting
Displacement of the Distal Clavicle
Direction of Displacement Author Fukuda et al Lee et al5 Debski et al15
6

Anterior Conoid (large displacements) Inferior AC ligament Superior AC ligament (conoid with capsule transected)

Posterior AC ligaments Trapezoid Trapezoid (capsule transected) Superior AC ligament

Superior AC ligaments (conoid for large displacements) Conoid (capsule intact and transected) Trapezoid

Klimkiewicz et al14 Salter et al3

ezoid ligament was found to be the primary restraint to compression of the acromioclavicular joint at both small and large displacements. Lee and coworkers further determined that the trapezoid ligament was the primary restraint to posterior displacement of the distal clavicle with an intact AC joint.5 Debski and coworkers provided further insight regarding the biomechanical properties of the CC ligaments.4 Under a 70-N load in the anterior, posterior, and superior directions, the clavicle translates 5.1, 5.6, and 4.2 mm, respectively (Fig 4). The in situ force in the superior AC ligament was greatest in response to an anterior load, whereas the in situ force was greatest in the conoid ligament in response to a superior load. With complete transaction of the AC ligaments, the in situ forces of the CC ligaments increased signicantly when compared with an intact joint. Under a 70-N load, the conoid served as the primary restrain against anterior and superior loading, whereas the trapezoid functioned as the primary restraint against posterior loading.15 The difference in the contributions by the two ligaments is most likely due to their relative orientations.4 The authors attributed the difference between their results and those reported by others to the number of constraints placed on the resulting joint motion and the magnitude of load applied to the joint. In situ forces in each ligament are affected by coupled motions that occur during loading. This soft tissue force is redis-

tributed during loading when a greater number of degrees of freedom of motion are allowed.15 The coracoclavicular ligaments should be considered for reconstruction to restore AC joint stability, especially for posterior distal clavicle instability.5 Under normal circumstances, distal clavicle resection would be unlikely to lead to failure of the coracoclavicular ligaments based on their structural properties.10,16 However, DCR performed in the face of a previous AC joint separation could compromise the previously stressed AC and CC ligaments, resulting in increased risk of distal clavicle instability postoperatively.17 The relative vertical orientation of the coracoclavicular ligaments prevents effective resistance against anteriorposterior translation.

CORACOACROMIAL LIGAMENT
The coracoacromial ligament is important as a secondary glenohumeral stabilizer preventing anterosuperior displacement of the humeral head in longstanding massive rotator cuff disease (cuff tear arthropathy). Disruption of this ligament commonly occurs with subacromial decompression, a procedure often performed in conjunction with distal clavicle resection. Biomechanical testing indicates that arthroscopic subacromial decompression alone does not signicantly alter the mechanics of the AC joint during the application of an anterior, posterior, or superior load of 70 N to the distal clavicle.18

Fig 3. Instability of the distal clavicle in the horizontal plane can result in abutment of the posterior clavicle into the anterior aspect of the scapular spine. (Reprinted with permission from Mazzocca et al.23)

Fig 4. The anterior view of a left shoulder demonstrates the coordinate system associated with forces applied to the distal clavicle during biomechanical testing. The X axis is an anterior force, the Y axis is a superior force, and the Z axis is a medial force. (Reprinted with permission from Debski et al.18)
ROBB SELLARDS

DISTAL CLAVICLE RESECTION

Distal clavicle resection eliminates painful bony contact in the AC joint. As a result, unusually high loads (compression and translation) are transferred to the intact soft tissue structures.19 Branch and coworkers determined that only 5 mm of bone needs to be resected to ensure that no bone to bone contact occurs in postoperative range of motion. Furthermore, this study revealed that there was no difference in the three orthogonal axes of AC joint rotation (anteriorposterior, abductionadduction, protraction retraction) whether the superior or inferior acromioclavicular ligaments were cut before the removal of 5 mm of distal clavicle.20 A biomechanical study evaluating the effects of arthroscopic and open procedures for distal clavicle resection indicated that both procedures eliminate bony contact postoperatively. In this study, 0.5 to 1.0 cm of bone was removed arthroscopically and 1.5 to 2.0 cm of bone was removed by an open procedure. The average displacement was signicantly greater for the surgically altered AC joints than the intact AC joints, although there was no signicant difference in displacement between the surgically altered joints. Both procedures removed sufcient bone, and bony contact was prevented by the intact trapezoid and conoid ligaments.21

REFERENCES
1. DePalma A, Callery G, Bennett G: Variational anatomy and degenerative lesions of the shoulder joint. Instr Course Lect 6:255-281, 1949 2. Petersson C: Degeneration of the acromioclavicular joint: A morphological study. Acta Orthop Scand 54:434-438, 1983 3. Salter EJ, Nasca R, Shelley B: Anatomical observations on the acromioclavicular joint and supporting ligaments. Am J Sports Med 15:199-206, 1987 4. Debski RE, Parsons IM, Fenwick J, et al: Ligament mechanics during three degree of freedom motion at he acromioclavicular joint. Ann Biomed Eng 28:612-618, 2000 5. Lee KW, Debski RE, Chen CH, et al: Functional evaluation of the ligaments at the acromioclavicular joint during anteroposterior and superoinferior translation. Am J Sports Med 25:858-862, 1997 6. Fukuda K, Craig EV, An KN, et al: Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Joint Surg Am 68:434-440, 1986

7. Renfree KJ, Riley MK, Wheeler D, et al: Ligamentous anatomy of the distal clavicle. J Shoulder Elbow Surg 12:355-359, 2003 8. Nicholson GP, Mazzocca AD, Romeo AA: Acromioclavicular capsular anatomy. Presented at the 19th Annual American Shoulder and Elbow Surgeons Meeting, Pebble Beach, CA, November 1, 2002 9. Bosworth B: Complete acromioclavicular dislocation. N Engl J Med 241:221-225, 1949 10. Harris RI, Wallace AL, Harper GD, et al: Structural properties of the intact and the reconstructed corococlavicular ligament complex. Am J Sports Med 28:103-108, 2000 11. Bearden J, Hughston J, Whatley G: Acromioclavicular dislocation: Method of treatment. Am J Sports Med 1:5-17, 1973 12. Rockwood CJ, Williams G, Young D: Disorders of the acromioclavicular joint, in Rockwood CJ, Matsen F (eds): The Shoulder (vol. 1). Philadelphia, PA, Saunders, 1998, pp 483-553 13. Codman E: The Shoulder. Huntington, NY, Krieger, 1934, pp 52-54 14. Klimkiewicz JJ, Williams GR, Sher JS, et al: The acromioclavicular capsule as a restraint to posterior translation of the clavicle: A biomechanical analysis. J Shoulder Elbow Surg 8:119-124, 1999 15. Debski RE, Parsons IM, Woo SL, et al: Effect of capsular injury on acromioclavicular joint mechanics. J Bone Joint Surg Am 83:13441351, 2003 16. Vangura A, Fenwick JA, Rodosky MW, et al: Morphological, viscoelastic and structural properties of the coracoclavicular ligaments. Trans Orthop Res Soc 25:394, 2000 17. Flatow EL, Duralde XA, Nicholson GP, et al: Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 4:41-40, 1995 18. Debski RE, Fenwick JA, Vangura A, et al: Effect of arthroscopic procedures on the acromioclavicular joint. Clin Orthop 406:89-96, 2003 19. Costic RS, Jari R, Rodosky MW, et al: Joint compression alters the kinematics and loading patterns of the intact and capsule-transected AC joint. J Orthop Res 21:379-385, 2003 20. Branch TP, Burdette HL, Shahriari AS, et al: The role of the acromioclavicular ligaments and the effect of distal clavicle resection. Am J Sports Med 24:293-297, 1996 21. Matthews LS, Parks BG, Pavlovich LJ, et al: Arthroscopic versus open distal clavicle resection: A biomechanical analysis on a cadaveric model. Arthroscopy 15:237-240, 1999 22. McMahon PJ, Tibone FE, Pink MM: Functional anatomy and biomechanics of the shoulder, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine (ed 2). Philadelphia, PA, Saunders, 2003, pp 841856 23. Mazzocca AD, Sellards R, Garretson R, et al: Injuries to the acromioclavicular joint in adults and children, in Delee JC, Drez D (eds): Orthopaedic Sports Medicine (ed 2). Philadelphia, PA, Saunders, 2003, pp 912-934

AC JOINT ANATOMY AND BIOMECHANICS