Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 27, Issue 12, pp 3813–3820 | Cite as

Superior clavicle drilling points and fluoroscopic inclination for anatomic coracoclavicular ligament reconstruction: a cadaveric study

  • Tetsuya Takenaga
  • Masahito Yoshida
  • Richard E. Debski
  • Freddie H. Fu
  • Volker Musahl
  • Albert LinEmail author



This study aims to investigate the superior clavicle cortex drilling points and fluoroscopic inclination angles for anatomic tunnel drilling in coracoclavicular ligament reconstruction.


Twelve cadaveric shoulders with a mean age of 55.9 ± 6.2 years were investigated. Two 2.0 mm Kirschner wires were inserted penetrating the footprint centers of conoid and trapezoid both on the clavicle and coracoid. The location of the Kirschner wires on the superior clavicle cortex was measured. Fluoroscopy was used to obtain three views of shoulder: an anteroposterior, lateral, and cortical ring sign view. Reproducible angles were then recorded.


The Kirschner wire penetrating the conoid was located 40.0 ± 3.9 mm from the distal end and 18.1 ± 3.0 mm from the anterior edge of the clavicle. For the trapezoid, the Kirschner wire was located 19.1 ± 3.6 mm from the distal end and 9.9 ± 3.9 mm from the anterior edge. On the anteroposterior view, the conoid was 11.1° ± 10.1° medially and trapezoid was 26.8° ± 11.8° laterally tilted to the glenohumeral joint line. On the lateral view, the conoid was 42.8° ± 15.1° and trapezoid was 15.5° ± 12.0° superiorly tilted to the scapular spine. On the cortical ring sign view, the conoid was 50.8° ± 12.9° and trapezoid was 14.2 °± 11.0° superiorly tilted to the scapular spine.


The superior clavicle cortex drilling points and fluoroscopic inclination angles for anatomic tunnel drilling in coracoclavicular ligament reconstruction were demonstrated. Arthroscopy-assisted anatomic coracoclavicular ligament reconstruction has increased in popularity, and these findings may facilitate a more anatomic approach to coracoclavicular ligament reconstruction.


Acromioclavicular joint separation Coracoclavicular ligament reconstruction Anatomy Inclination Fluoroscopy Trans-clavicular drilling Clavicle drilling point 



No external funding was used.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


  1. 1.
    Cerciello S, Edwards TB, Morris BJ, Cerciello G, Walch G (2014) The treatment of type III acromioclavicular dislocations with a modified Cadenat procedure: surgical technique and mid-term results. Arch Orthop Trauma Surg 134(11):1501–1506CrossRefGoogle Scholar
  2. 2.
    Cisneros LN, Sarasquete Reiriz J, Besalduch M, Petrica A, Escola A, Rodriguez J, Fallone JC (2015) Horizontal and vertical stabilization of acute unstable acromioclavicular joint injuries arthroscopy-assisted. Arthrosc Tech 4(6):e721–729CrossRefGoogle Scholar
  3. 3.
    Darabos N, Vlahovic I, Gusic N, Darabos A, Bakota B, Miklic D (2015) Is AC TightRope fixation better than Bosworth screw fixation for minimally invasive operative treatment of Rockwood III AC joint injury? Injury 46(Suppl 6):S113–118CrossRefGoogle Scholar
  4. 4.
    Debski RE, Parsons IM 3rd, Fenwick J, Vangura A (2000) Ligament mechanics during three degree-of-freedom motion at the acromioclavicular joint. Ann Biomed Eng 28(6):612–618CrossRefGoogle Scholar
  5. 5.
    Esenyel CZ, Ozturk K, Bulbul M, Ayanoglu S, Ceylan HH (2010) Coracoclavicular ligament repair and screw fixation in acromioclavicular dislocations. Acta Orthop Traumatol Turc 44(3):194–198CrossRefGoogle Scholar
  6. 6.
    Fleiss JL, Cohen J (1973) The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educ Psychol Meas 33(3):613–619CrossRefGoogle Scholar
  7. 7.
    Flik K, Lyman S, Marx RG (2005) American collegiate men’s ice hockey: an analysis of injuries. Am J Sports Med 33(2):183–187CrossRefGoogle Scholar
  8. 8.
    Fukuda K, Craig EV, An KN, Cofield RH, Chao EY (1986) Biomechanical study of the ligamentous system of the acromioclavicular joint. J Bone Jt Surg Am 68(3):434–440CrossRefGoogle Scholar
  9. 9.
    Garrigues GE, Marchant MH Jr, Lewis GC, Gupta AK, Richard MJ, Basamania CJ (2010) The cortical ring sign: a reliable radiographic landmark for percutaneous coracoclavicular fixation. J Shoulder Elbow Surg 19(1):121–129CrossRefGoogle Scholar
  10. 10.
    Grutter PW, Petersen SA (2005) Anatomical acromioclavicular ligament reconstruction: a biomechanical comparison of reconstructive techniques of the acromioclavicular joint. Am J Sports Med 33(11):1723–1728CrossRefGoogle Scholar
  11. 11.
    Harris RI, Vu DH, Sonnabend DH, Goldberg JA, Walsh WR (2001) Anatomic variance of the coracoclavicular ligaments. J Shoulder Elbow Surg 10(6):585–588CrossRefGoogle Scholar
  12. 12.
    Jari R, Costic RS, Rodosky MW, Debski RE (2004) Biomechanical function of surgical procedures for acromioclavicular joint dislocations. Arthroscopy 20(3):237–245CrossRefGoogle Scholar
  13. 13.
    Kibler WB, Sciascia AD, Morris BJ, Dome DC (2017) Treatment of symptomatic acromioclavicular joint instability by a docking technique: clinical indications, surgical technique, and outcomes. Arthroscopy 33(4):696–708.e692CrossRefGoogle Scholar
  14. 14.
    Kienast B, Thietje R, Queitsch C, Gille J, Schulz AP, Meiners J (2011) Mid-term results after operative treatment of rockwood grade III–V acromioclavicular joint dislocations with an AC-hook-plate. Eur J Med Res 16(2):52–56CrossRefGoogle Scholar
  15. 15.
    Koh KH, Shon MS, Choi NH, Lim TK (2018) Anatomic tunnel placement is not feasible by transclavicular–transcoracoid drilling technique for coracoclavicular reconstruction: a cadaveric study. Arthroscopy 34(7):2012–2017CrossRefGoogle Scholar
  16. 16.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33(1):159–174CrossRefGoogle Scholar
  17. 17.
    Mazzocca AD, Arciero RA, Bicos J (2007) Evaluation and treatment of acromioclavicular joint injuries. Am J Sports Med 35(2):316–329CrossRefGoogle Scholar
  18. 18.
    Pallis M, Cameron KL, Svoboda SJ, Owens BD (2012) Epidemiology of acromioclavicular joint injury in young athletes. Am J Sports Med 40(9):2072–2077CrossRefGoogle Scholar
  19. 19.
    Phemister DB (1942) The treatment of dislocation of the acromioclavicular joint by open reduction and threaded-wire fixation. JBJS 24(1):166–168Google Scholar
  20. 20.
    Rios CG, Arciero RA, Mazzocca AD (2007) Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments. Am J Sports Med 35(5):811–817CrossRefGoogle Scholar
  21. 21.
    Salzmann GM, Paul J, Sandmann GH, Imhoff AB, Schottle PB (2008) The coracoidal insertion of the coracoclavicular ligaments: an anatomic study. Am J Sports Med 36(12):2392–2397CrossRefGoogle Scholar
  22. 22.
    Salzmann GM, Walz L, Buchmann S, Glabgly P, Venjakob A, Imhoff AB (2010) Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med 38(6):1179–1187CrossRefGoogle Scholar
  23. 23.
    Shibata T, Izaki T, Miyake S, Doi N, Shibata Y, Irie Y, Tachibana K, Yamamoto T (2019) Anatomical study of the position and orientation of the coracoclavicular ligaments: differences in bone tunnel position by gender. Orthop Traumatol Surg Res 105(2):275–280CrossRefGoogle Scholar
  24. 24.
    Stehle J, Moore SM, Alaseirlis DA, Debski RE, McMahon PJ (2007) Acromial morphology: effects of suboptimal radiographs. J Shoulder Elbow Surg 16(2):135–142CrossRefGoogle Scholar
  25. 25.
    Takase K (2010) The coracoclavicular ligaments: an anatomic study. Surg Radiol Anat 32(7):683–688CrossRefGoogle Scholar
  26. 26.
    Takase K, Yamamoto K (2016) Arthroscopic procedures and therapeutic results of anatomical reconstruction of the coracoclavicular ligaments for acromioclavicular joint dislocation. Orthop Traumatol Surg Res 102(5):583–587CrossRefGoogle Scholar
  27. 27.
    Weaver JK, Dunn HK (1972) Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Jt Surg Am 54(6):1187–1194CrossRefGoogle Scholar
  28. 28.
    Zhu NF, Rui BY, Zhang YL, Chen YF (2016) Anatomic study of coracoclavicular ligaments for reconstruction of acromioclavicular joint dislocations. J Orthop Sci 21(6):749–752CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Tetsuya Takenaga
    • 1
    • 2
  • Masahito Yoshida
    • 1
    • 2
  • Richard E. Debski
    • 1
    • 3
    • 2
  • Freddie H. Fu
    • 1
    • 2
    • 3
  • Volker Musahl
    • 1
    • 2
    • 3
  • Albert Lin
    • 1
    • 2
    Email author
  1. 1.Orthopaedic Robotics LaboratoryUniversity of PittsburghPittsburghUSA
  2. 2.Department of Orthopaedic SurgeryUniversity of Pittsburgh, UPMC Freddie Fu Sports Medicine CenterPittsburghUSA
  3. 3.Department of BioengineeringUniversity of PittsburghPittsburghUSA

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