What is the recommended treatment for a decreased coracoclavicular (CC) distance?

Treatment of Decreased Coracoclavicular Distance

Surgical reconstruction of the coracoclavicular ligaments is recommended for decreased CC distance associated with acute high-grade acromioclavicular joint dislocations (Rockwood types IV-VI), as this represents complete disruption of the CC ligament complex requiring anatomic restoration. 1

Understanding the Clinical Context

A decreased coracoclavicular distance typically indicates one of two scenarios:

• Acute injury: Complete AC joint dislocation with superior displacement of the clavicle (the CC distance appears decreased on the injured side relative to normal anatomy, though increased relative to the uninjured contralateral side)
• Post-surgical context: Loss of reduction after prior AC joint surgery

The American Academy of Orthopaedic Surgeons recommends surgical treatment for displaced lateral clavicle fractures with disruption of the coracoclavicular ligament complex, which directly applies to CC ligament injuries. 1

Surgical Indications and Timing

Surgery should be performed within 3-6 weeks of acute injury for optimal outcomes. 2, 3 Delayed reconstruction beyond 6 weeks is associated with inferior results and higher complication rates. 4

Key surgical indications include:

• Complete AC joint dislocation (types IV-VI) with CC ligament disruption 1
• Displacement exceeding 100% of the normal CC distance 1
• Failed conservative management with persistent instability 2

Recommended Surgical Technique

Anatomic double-bundle CC ligament reconstruction using two fixation points is superior to single-tunnel techniques, as it replicates the native trapezoid and conoid ligament anatomy and reduces complications. 3, 5

Technical Considerations for Optimal Outcomes:

Clavicular tunnel placement: The clavicular tunnel anteroposterior (CTAP) angle must be minimized to prevent loss of reduction. 3 Studies demonstrate that excessive CTAP angles (>30 degrees) correlate with significantly worse outcomes and higher rates of reduction loss. 3

Coracoid tunnel orientation: Center-center orientation at the base of the coracoid process is critical. 3 Tunnels should be placed at the anatomic footprints of the trapezoid (anterolateral) and conoid (posteromedial) ligaments. 2

Fixation Options:

• Two suture anchor technique with coracoacromial ligament transfer: Provides 85% anatomic reduction maintenance at long-term follow-up with mean Constant scores of 97 points. 2
• Double TightRope system: Allows minimally invasive anatomic reconstruction without arthroscopic assistance, reducing surgical invasiveness while maintaining stability. 5
• Single-tunnel techniques should be avoided: Associated with 47% loss of reduction rate and 20% complication rate, including clavicular fractures through the tunnel. 4

Critical Technical Pitfalls to Avoid

Posterior AC joint displacement: Occurs in 67% of cases with inadequate reduction and correlates with CTAP angles that are too steep. 3 Ensure proper anteroposterior alignment during tunnel creation.

Clavicular fracture through tunnel: Occurs in 10-15% of single-tunnel techniques due to stress concentration. 4 This complication is mitigated by using double-tunnel or double-button techniques that distribute forces across two fixation points. 5

Inadequate coracoacromial ligament augmentation: When using suture anchor techniques, the coracoacromial ligament should be transferred to the undersurface of the distal clavicle to provide additional static restraint. 2, 6

Expected Outcomes and Follow-up

Patients achieving anatomic reduction (CC distance ratio <25% compared to contralateral side) demonstrate significantly superior Constant scores (98.2 vs 90.7) at long-term follow-up. 3

• Return to normal activities: Mean 3 months postoperatively 2
• Anatomic reduction maintenance: 85% at 10+ years with proper technique 3
• Loss of reduction risk: 15% with double-bundle techniques vs 47% with single-tunnel approaches 4

Radiographic monitoring: Serial radiographs should assess CC distance immediately postoperatively, at 3 weeks, 6 weeks, 3 months, and final follow-up to detect early loss of reduction. 4 Loss of reduction >25% requires revision surgery for optimal functional outcomes. 3

Postoperative Management

Following the American Academy of Orthopaedic Surgeons recommendations for clavicular injuries:

• Sling immobilization for 4 weeks 1
• Avoid lifting, pushing, or pulling until 4 weeks 1
• Progressive rehabilitation with muscle strengthening exercises 1
• Full weight-bearing activities permitted at 8-12 weeks based on radiographic healing 1