Biomechanical impact of sagittal plane clavicle hook plate positioning on subacromial stress

Jung-Min Lee; Jae-Hoo Lee

doi:10.1016/j.asmart.2026.08.004

. 2026 Oct 27;46:91–95. doi: 10.1016/j.asmart.2026.08.004

Biomechanical impact of sagittal plane clavicle hook plate positioning on subacromial stress

Jung-Min Lee ^a, Jae-Hoo Lee ^b,^⁎

PMCID: PMC13733321 PMID: 42985262

Abstract

Introduction

In open reduction and hook plate fixation for high-grade acromioclavicular (AC) joint dislocation, proper placement of the hook plate is crucial in preventing subacromial osteolysis and improving clinical outcomes. This study aimed to identify the optimal sagittal plane positioning of the hook plate to minimize subacromial stress and erosion.

Materials and methods

Six pairs of artificial bone models, designed to mimic human clavicle and scapula anatomy, were used to assess the biomechanical effects of three hook plate positions: anterior (group A), neutral (group N), and posterior (group P). Each model was equipped with a 5-hole clavicle hook plate secured with 3.5-mm locking screws. A pressure sensor measured contact pressures and areas under sagittal rotations. The clavicle and scapula were fixed in customized jigs, and physiological loading conditions were simulated with a preload of 20 N and a 70 N upward force on the clavicle. Clavicular rotations of 15° internal and external were applied to evaluate their effect on contact pressures.

Results

Group P showed a significantly lower mean pressure (1.27 MPa) than group A (1.92 MPa, p < 0.01) and group N (1.83 MPa, p < 0.01). Maximum pressure in group P (1.37 MPa) was also significantly lower than in group A (2.75 MPa, p < 0.01) and group N (2.34 MPa, p < 0.01). The contact area was smallest in group P (11.00 mm²) compared to group A (19.00 mm², p < 0.01) and group N (17.00 mm², p < 0.01). Clavicular rotations significantly increased subacromial pressure and contact area at all plate positions compared to the neutral position (p < 0.01).

Conclusion

Posterior position of the hook plate in the sagittal plane significantly reduced subacromial pressure and contact area compared to neutral or anterior positions. Additionally, internal and external rotations of the clavicle further increased subacromial stress, indicating the importance of considering clavicular movement in clinical settings. Within the biomechanical test, these findings suggest that posterior positioning of the hook plate may help attenuate subacromial stress and could thereby have the potential to reduce the likelihood of subacromial bone erosion; however, further clinical or finite-element validation is warranted before this can be translated into a clinical recommendation for the surgical treatment of high-grade AC joint dislocations.

Keywords: Acromioclavicular dislocation, Hook plate, Range of motion, Subacromial erosion

Highlights

•
Posterior hook plate positioning significantly reduced subacromial pressure in AC joint dislocation treatment.
•
Posteriorly tilted position of the hook plate demonstrated lower mean pressure (1.27 MPa) than anterior (1.92 MPa) and neutral (1.83 MPa) positions.
•
Clavicular rotations increased subacromial pressure and contact area, emphasizing the need for careful positioning.
•
Within this in biomechanical test, posterior positioning reduced subacromial stress and may have the potential to attenuate subacromial bone erosion, warranting further clinical or finite-element validation.

1. Introduction

Acromioclavicular (AC) joint dislocations are a common shoulder injury, accounting for approximately 9% of all shoulder girdle injuries and predominantly affecting young, active individuals.¹ Managing high-grade AC joint dislocations, classified as Rockwood IV to VI, poses significant challenges due to the disruption of both the AC and coracoclavicular ligaments.²^,³ The traditional management of high-grade AC joint dislocations varies widely, ranging from conservative treatment to surgical intervention, and often depends on the severity of the dislocation, the patient's activity level, and functional demands.⁴ Among surgical options, open reduction and internal fixation with a hook plate is a commonly used technique.² It stabilizes the AC joint by hooking under the acromion and securing the clavicle; thereby, providing mechanical support while the ligamentous structures heal.⁵

Despite the effectiveness of the hook plate in managing high-grade AC joint dislocations, several disadvantages and potential complications have been identified that merit careful consideration.³^,⁶ One such complication is subacromial erosion or osteolysis, which represents a notable risk following the surgical use of hook plates and may compromise shoulder function over time.²^,³ Several clinical studies have demonstrated that the degree of subacromial erosion is dependent on the depth and location of the hook plate and the anatomical morphology of the acromion ¹^,7, 8, 9, 10.

In the normal shoulder, the clavicle undergoes repeated rotation and movement relative to the scapula over 30°, with the degree of rotation varying depending on the range of motion of the shoulder.¹¹^,¹² A series of computed tomography (CT)-based simulation studies have demonstrated that hook plate fixation directly interferes with shoulder joint movement, particularly affecting the clavicle's rotation in a normal shoulder joint.¹²^,¹³ Despite various surgical methods and clinical factors aimed at reducing subacromial stress and erosion, biomechanical analysis of the movement of the clavicle and the position of the hook plate in the sagittal plane has been limited. This study aimed to perform a biomechanical analysis of the sagittal plane positioning of the hook plate to identify the optimal placement that minimizes subacromial stress and erosion during the treatment of AC joint dislocation. Our hypothesis suggested that positioning the tip of the hook plate parallel to the sagittal curvature of the acromial undersurface would result in the least subacromial stress.

2. Materials and Methods

Six pairs of artificial bone models (Sawbones Pacific Research Laboratories, Vashon, WA, USA), consisting of custom-made left scapulae and clavicles, were used to ensure minimal variance in the experimental design. These specimens closely mimicked the human bone anatomy, with polyurethane foam representing cancellous bone and an outer layer of short glass fibers in epoxy resin simulating cortical bone.¹⁴ To implement hook plate fixation for AC joint dislocation, a clavicle hook (depth: 15 mm; 5-hole), secured with 3.5-mm locking screws (Clavicle hook plate, DePuy Synthes, Switzerland), was implanted on the distal clavicle of each specimen without any additional manipulation, such as bending the hook. Three groups were created to compare the anterior, neutral, and posterior positions of the hook plate in the sagittal plane. A neutral position (group N) was defined as the parallel placement of the hook plate to the plane of the distal clavicle. Based on the sagittal position of group N along the axis of the clavicle, anterior (group A) and posterior (group P) reimplantation of the hook plate was performed by angulating it 10° anteriorly and posteriorly in each specimen, respectively (Fig. 1).

Fig. 1 — Test set-up and three different post-operative hook plate positions: (a) 10° anterior position; (b) neutral position; and (c) 10° posterior position.

For the experimental setting, customized jigs were designed to facilitate upward force and anterior-posterior rotation of the clavicle by attaching the system to a universal material testing machine (MTS Bionix, MTS Systems Corp., Minnesota). The proximal clavicle, including 8 cm from its proximal end, was potted in resin (Trayplast NF, Vertex, Netherlands) within a customized cylindrical jig. The scapula was positioned in a customized rectangular jig, titled 10° relative to the axial plane to maintain anatomical alignment of the AC joint. Before testing, the anatomical alignment of the clavicle and scapula was identified by measuring three points on each bone, using reference positions along the three-dimensional directional axis with a Microscribe system (Microscribe® M, Revware Inc., Raleigh, NC, USA). Reference points were obtained from paired artificial bone models (Fig. 2).

Fig. 2 — Results of pressure changes in various hook plate procedure offsets.

To simulate physiological loading conditions consistent with early postoperative rehabilitation and to improve test reproducibility, an initial preload and a subsequent physiological load were applied. 20 N preload was applied via a pulley system to establish a consistent initial tension condition, maintain AC joint contact, and reduce creep-related and setup-dependent variability.¹⁵^,¹⁶ The load was then gradually increased from 20 to 70 N in the superior direction, and a 70 N upward force was applied to the proximal clavicle to reproduce superior clavicular translation relative to the scapula.¹⁶^,¹⁷ This 70 N level has been described as representative of approximately 10% of the stress associated with a mild postoperative physical therapy protocol, supporting its use as a clinically relevant rehabilitation-level physiological load 15, 16, 17. During testing, a high-resolution and ultra-thin pressure sensor (Model 4000, Tekscan Inc., USA), capable of accurate measurements on irregular geometries, was placed between the hook plate and the acromial undersurface to measure contact pressures and areas. Following the positioning and upward loading of the three groups, sagittal rotation of the clavicle was performed to compare the pressure and contact area relative to the neutral position in each group. Clavicular rotations of 15° internal and external were conducted along the clavicle's axis by rotating the cylindrical jig while maintaining the 70 N upward load (Fig. 3). Subacromial pressures and contact areas were investigated for nine conditions, including the neutral position and internal and external clavicular rotations in each group.

Fig. 3 — Change of contact pressure and area on the subacromial surface in different hook plate positions.

All continuous variables were expressed as median (interquartile range [IQR]) due to the non-parametric nature of the data. The Wilcoxon signed-rank test assessed differences in contact pressures and areas among the three sagittal positions (groups A, N, and P) and under different rotational conditions (internal 15°, neutral, and external 15°). For each comparison, p-values were calculated to determine statistical significance, with the threshold set at p < 0.05. Given the multiple comparisons conducted across the nine experimental conditions, a Bonferroni correction was applied to adjust the significance level; thereby, controlling for the increased risk of Type I errors. All analyses were conducted using R version 4.4.1 (R Foundation for Statistical Computing, Vienna, Austria).

3. Results

3.1. Position of the plate

The median (IQR) values between the acromial undersurface and the hook of the hook plate based on fixation position were significantly lower in group P (1.27 [1.12, 1.95] MPa) than in groups A (1.92 [1.88, 2.06] MPa, P < 0.01) and N (1.83 [1.46, 2.21] MPa, P < 0.01), and equivalent in groups A and N (P > 0.05). The maximum pressure showed no difference between groups A (2.75 [2.40, 2.79] MPa) and N (2.34 [1.74, 2.72] MPa, P = 0.17); however, group P (1.37 [1.17, 2.62] MPa, P < 0.01) had significantly lower values compared to the others. The contact area measurements (mm²) varied with plate position, with group A demonstrating a larger contact area (19.00 [16.50, 21.00] mm²) than groups N (17.00 [15.00, 19.00] mm²) and P (11.00 [8.50, 18.75] mm²) (Table 1).

Table 1.

Results of pressure and contact area in different hook plate procedure offsets.

Clavicle rotation	Hook plate Offset position	Mean pressure (MPa ± SD)	Peak pressure (MPa ± SD)	Contact area (mm² ± SD)
Anterior rotation (15°)	Anterior (10°)	2.00 ± 0.09	2.85 ± 0.09	23.0 ± 1.73
	Neutral (0°)	1.84 ± 0.06	2.47 ± 0.34	16.7 ± 2.08
	Posterior (10°)	1.26 ± 0.08	1.43 ± 0.22	10.7 ± 0.58
Non-rotation (0°)	Anterior (10°)	1.79 ± 0.12	2.43 ± 0.32	18.3 ± 3.06
	Neutral (0°)	1.36 ± 0.13	1.56 ± 0.14	15.0 ± 00
	Posterior (10°)	1.09 ± 0.03	1.15 ± 0.05	9.3 ± 1.15
Posterior rotation (15°)	Anterior (10°)	2.09 ± 0.27	2.93 ± 0.20	19.0 ± 00
	Neutral (0°)	2.27 ± 0.02	3.83 ± 0.11	20.5 ± 3.54
	Posterior (10°)	1.99 ± 0.07	2.93 ± 0.19	19.0 ± 00

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Note. MPa, megapascal; mm², square millimeter; SD, standard deviation.

3.2. Rotation of clavicle

Overall, positioning the hook plate in the 10° posterior orientation resulted in relatively lower mean and peak contact pressures compared with the anterior and neutral plate positions. The mean pressure between the acromial undersurface and the hook of the hook plate based on clavicle rotation was lowest in the neutral position (1.09 ± 0.03 MPa), increasing significantly with anterior rotation (1.26 ± 0.08 MPa) and posterior rotation (1.99 ± 0.07 MPa, p < 0.01). The peak pressure followed the same trend, with the lowest values in the neutral position (1.15 ± 0.05 MPa) and significant increases with anterior rotation (1.43 ± 0.22 MPa) and external rotation (2.93 ± 0.19 MPa, p < 0.01). The contact area was significantly narrower in the neutral position (9.30 ± 1.15 mm²) than in anterior rotation (10.70 ± 0.58 mm²) and external rotation (19.00 ± 0 mm², p < 0.01). Mean and maximum pressures, along with contact areas based on clavicle rotation, showed similar patterns across plate locations (Table 1).

4. Discussion

The results of this biomechanical study demonstrated the impact of sagittal plane positioning of the hook plate on contact pressure and the area between the acromial undersurface and the hook plate during the surgical management of AC joint dislocations. Posterior position (group P) significantly reduced subacromial contact pressures compared with neutral and anterior tilt, whereas clavicular rotation (internal/external) increased mean and maximum pressures compared with neutral rotation, indicating higher subacromial stress with rotational positioning. Posterior position of the hook plate led to the lowest mean and maximum pressures, as well as the smallest contact area, compared to neutral and anterior placements. Both internal and external rotation of the clavicle in the sagittal plane significantly increased subacromial stress relative to the neutral position. These results suggest that posterior position of the hook plate may be advantageous in minimizing subacromial stress; thereby, potentially reducing the risk of complications such as subacromial erosion and osteolysis, which are recognized concerns associated with hook plate fixation.

In the surgical treatment of AC joint dislocations and distal clavicle fractures using a clavicle hook plate, subacromial erosion is a clinically significant factor closely associated with postoperative complications.¹^,¹⁰ A retrospective clinical study reported that postoperative CT scans revealed subacromial erosion in all patients who underwent hook plate fixation for acute AC joint dislocations, with a mean erosion depth of approximately 5.0 mm, representing 50% of the total acromial thickness.¹ Subacromial erosion is considered to affect clinical outcomes and functional recovery following surgery. Additionally, subacromial erosion has been identified as a risk factor for postoperative acromial fractures.³^,¹⁰^,¹⁸ The results of our biomechanical experiments demonstrated that the contact area and pressure between the hook plate and the subacromial surface varied significantly based on plate positioning and clavicle movement. These biomechanical changes are crucial for determining the degree and depth of acromial erosion.

Several studies have explored the optimal hook plate location to minimize subacromial erosion¹^,⁸^,¹⁰^,19, 20, 21. Numerous clinical studies have indicated that the position of the hook, along with the slope of the AC joint and the morphology of the acromion, influences the development of subacromial erosion.¹^,⁷^,²⁰^,²² Moreover, acromion erosion can be minimized by appropriately bending the hook of the clavicular hook plate to match the variation in the slope of the AC joint in the coronal plane22, 23, 24, 25. In our experimental setup, the hook did not bend; however, we used a sawbone model that exhibited the same degree of anatomical consistency. Nevertheless, even when the clavicle hook plate was fixed in the same position, the contact pressure and area underwent alteration because of the movement of the sagittal plane of the clavicle. These findings indicate that the frequency and extent of subacromial erosion may be influenced by the duration and degree of plate maintenance after surgery, even when the hook plate is fixed according to the characteristics of the coronal plane of the AC joint and acromion.²²^,²⁶^,²⁷

In the sagittal plane, the anatomical characteristics of the acromion, which is flat anteriorly but curved downward posteriorly, are associated with subacromial erosion due to the hook plate.¹⁰ Clinical studies indicate a positive correlation between the positioning of the hook posteriorly and the incidence of postoperative complications, including intensive pain and scapular winging.¹⁰ The authors hypothesized that posterior hook placement would exert more force on the inferior aspect of the acromion due to the downward slope of the posterior acromion, which would result in more erosion when the hook is positioned posteriorly.¹⁰ However, the anatomical curvature of the posterior aspect of the acromion has not been clinically considered. In our study, applying a clavicular hook plate at a 10° posterior angle relative to the sagittal plane, as opposed to a neutral position, resulted in a notable reduction in subacromial pressure despite the plate being fixed without bending the hook. This finding suggests that the anatomical characteristics of the acromion process shape have a biomechanical influence.

Regarding AC joint motion, the hook plate has been reported to cause biomechanical deterioration compared to the rotation and anatomical position of the normal clavicle.¹¹^,¹³^,²⁸^,²⁹ A study analyzing patients with distal clavicle fractures who underwent hook plate surgery utilized three-dimensional CT scans in neutral and full abduction positions. These analyses revealed a mean difference in distal clavicle rotation of 16° and an anterior translation difference of 2.2 mm between shoulders, indicating decreased posterior position and increased external rotation of the scapula relative to the thorax in shoulders fixed with a hook plate.¹³ Another study comparing 15 patients using CT scans in neutral and full forward flexion positions reported a significant reduction in posterior position (22° ± 10° vs. 31° ± 8°) and an increase in external rotation (19° ± 9° vs. 7° ± 5°) of the scapula, accompanied by translational (4.0 ± 1.6 mm) and angular motion (15° ± 8°) of the hook plate relative to the acromion, potentially contributing to subacromial erosion, though the hook did not impinge on the humeral head, maintaining a minimum distance of 6.9 mm during arm elevation.²⁹ In the study using the two clinical datasets above, the phenomenon of a decrease in the posterior position of the scapula and an increase in external rotation, which were observed in both forward flexion and abduction, was consistently shown in our experiment. The present experimental study confirmed that the subacromial pressure significantly increased during both internal and external rotation of the distal clavicle when fixed with a hook plate. These findings indirectly indicate that surgical removal after a specific interval following fixation with a hook plate may reduce the likelihood of complications resulting from subacromial erosion.

Studies have demonstrated that bending the plate hook to align with the lateral slope of the patient's AC joint reduces the incidence of subacromial erosion.²³^,²⁴^,³⁰ This approach aims to lower peak stress by increasing the contact area between the acromion and hook; thereby, decreasing the risk of erosion. To address the hypothesis that a wider contact area would reduce the peak stress between the hook and acromial undersurface, a finite element analysis study found that the double-hook clavicular plate significantly improved joint stability, reduced stress on the clavicle and acromion by over 45% compared to a single-hook plate, and enhanced the uniformity of stress distribution.³¹ Nevertheless, our experimental study did not reveal a significant correlation between the contact area of the hook plate in accordance with the fixation position and the peak or mean pressure. The findings suggest that, within the context of our study, the location of the acromion in contact with the hook was predominantly confined to the medial border. This covered an area of approximately 10–20 mm², representing only a limited portion of the hook's total surface area.

This study had several limitations. Firstly, using a sawbone model provided better consistency and control over experimental variables but did not replicate the complexities of a clinical setting, including soft tissue interactions and the dynamic nature of living systems.¹⁴ This absence may have limited the translatability of our findings to actual surgical scenarios, where soft tissues significantly influence joint biomechanics and outcomes. Secondly, the primary healing mechanism of hook plate fixation for high-grade AC joint dislocations involves scarring of the surrounding soft tissue, a process not replicated in this experimental setting. Thirdly, despite the usefulness of the pressure sensor, technical difficulties related to its placement and the reliability of the data collected may have affected the validity of the study. Finally, restricting the analysis to the sagittal plane alone may have omitted crucial biomechanical insights that a multi-planar approach could have provided; thus, limiting the comprehensiveness of our findings in addressing subacromial stress in AC joint dislocation treatment. Overall, the present findings should be regarded as arising from a simplified, static sagittal-plane biomechanical model that does not reproduce the dynamic scapulothoracic motion or soft-tissue environment of in vivo conditions, and they therefore require confirmation through future clinical or finite-element validation studies before broader clinical recommendations can be made.

5. Conclusion

This experimental study demonstrated that the sagittal plane orientation of the hook plate significantly influenced subacromial contact pressure and area, with posterior angulation yielding the lowest values compared to neutral and anterior positions. Moreover, 15° of internal and external clavicular rotation caused significant changes in subacromial stress regardless of the fixation position. These findings suggest that the sagittal orientation of the hook plate may contribute to differential osteolysis rates, which should be interpreted in the context of individual anatomical variability, bone quality, and muscle forces. Within the limits of this simplified, static sagittal-plane biomechanical model, posterior angulation of the hook plate may be advantageous for attenuating subacromial stress and may thus have the potential to reduce the likelihood of subacromial erosion and osteolysis in the surgical treatment of high-grade AC joint dislocations; nevertheless, these exploratory findings warrant confirmation through future clinical or finite-element validation studies before broader clinical recommendations can be made.

Author contributions

Jung-Min Lee mainly contributed to construct the biomechanical test of the shoulder complex and figured out pattern of contact pressure on the between the subacromial area and the hook plate. Jae-Hoo Lee designed the study, supported clinical opinion in the results and revised the manuscript.

Funding

This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2021R1G1A1012450).

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgments

N/A.

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PERMALINK

Biomechanical impact of sagittal plane clavicle hook plate positioning on subacromial stress

Jung-Min Lee

Jae-Hoo Lee