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The coracoclavicular (CC) ligament is the major vertical stabilizing factor of the acromioclavicular joint.  It provides strong support between the lateral end of the clavicle and the scapular coracoid process.  They are placed medially on each side, below the acromioclavicular joints.  The CC ligaments are divided into two parts viz. concoid ligament and trapezoid ligament.  The concoid ligament passes superomedially from the base of the coracoid to conoid tubercle on the under surface of the clavicle.  It looks like an inverted cone.  The trapezoid ligament passes horizontally and laterally from the superior surface of the coracoid to the trapezoid line on the under surface of the clavicle.  This ligament is stronger compared to coracoids ligament.

The two ligaments are generally continuous posteriorly, but anteriorly tend to be perpendicular.  The coracoclavicular ligaments discharge a pivotal role in the movement of the pectoral girdle.  The concoid ligament restricts anterior motion of the scapula with respect to the collarbone, whereas the trapezoid ligament controls posterior movement between these two bones.  Coracoclavicular ligament prevents the clavicle from overriding the lateral side of the clavicle.

Acromioclavicular ligament injuries are common orthopedic injuries and account for 9% of shoulder girdle injuries and are mostly associated with direct blows to the shoulder bone or axially directed forces onto the ipsilateral extremity.  If the tear in the clavicle is not deep, it is typically managed with non-operative treatment.  However, operative intervention is warranted for high grade injuries.  It should be understood that operative intervention is needed for low-grade injuries also, if it remains chronic and symptomatic for a prolonged period of time.

Rockwood’s classification is the standard for separating acromioclavicular joint injuries.  For grade I and grade II injuries, non-operative treatment is indicated.  Operative intervention is warranted for grade IV through VI.  As for grade III, it is generally managed surgically in active patients.  In order to fix an injured coracoclavicular ligament multiple reconstruction techniques have been demonstrated over the past several decades.

The advent of arthroscopy has revolutionized the treatment of shoulder joint.  With an arthroscope (a small camera), a surgeon can inspect, diagnose and repair problems inside a joint with minimal incision.  During an arthroscopy procedure on shoulder, the surgeon inserts a small arthroscope into your shoulder joint.  The other end of the arthroscope is connected to a monitor and the camera sends picture to that monitor.  With the help of these visuals, the surgeon makes small cuts into the joint with miniature surgical instruments.

As for coracoclavicular ligament reconstruction, the primary goal is to reestablish anatomic reduction of the acromioclavicular joint.  Though many open surgeries are currently available to repair an injured coracoclavicular ligament, there is the risk of increasing morbidity.  It is here arthroscopic coracoclavicular ligament reconstruction assumes significance.  During the operation, apart from regaining the anatomical reduction of the acromioclavicular joint, biometrical forces of the coracoclavicular ligaments are also reconstructed.  As opposed to the open surgical method where wires, hook plates and coracoclavicular screws are used, arthroscopically the coracoclavicular ligaments are reconstructed using semitendinosus allograft and tendon screws.  Moreover, the deltoid attachment onto the distal clavicle is not disrupted.

On biomechanical testing, coracoclavicular ligament reconstruction with soft-tissue grafts has shows superiority.  In the case of a conventional surgery, bone tunnels through the clavicle are commonly used to reconstruct the injured coracoclavicular ligament.  However, this way, the down side is it may lead to decreased clavicle strength, thereby increasing the risk of fractures post operation.  As for arthroscopy-assisted coracoclavicular ligament reconstruction, there is a soft-tissue allograft that eliminates the need for large bone tunnels in the clavicle.

Rehabilitation protocol:

Post the surgical procedure, the patient ought to use shoulder immobilization for six weeks.  Immediate active range of motion after the procedure is encouraged; this may also involve active motion of the elbow.  Shoulder is also passively rotated externally to assess the range of motion.  From week four, passive glenohumeral elevation up to 90° is allowed.  After weeks six, the patient can have unrestricted active range of motion.  Strengthening of the shoulder is allowed only after week eight.

Merits of arthroscopic, coracoclavicular ligament reconstruction:

It would allow intra-articular diagnosis and can visualize the coracoclavicular ligament

Proper visualization of the coracoclavicular ligament facilitates debridement of the adhesions even at the base of the ligament

Guidewire can be properly positioned with the correct knowledge of the base of the coracoid.  This way the guidewire can be placed at the center.

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