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Address correspondence to Juha O. Ranne, M.D., Neo Hospital, Joukahaisenkatu 6, 20520 Turku, Finland.
Affiliations
Sports Trauma Research Unit, Neo Hospital, Turku, FinlandPaavo Nurmi Centre, Department of Physical Activity and Health, the University of Turku, Turku, Finland
Sports Trauma Research Unit, Neo Hospital, Turku, FinlandPaavo Nurmi Centre, Department of Physical Activity and Health, the University of Turku, Turku, Finland
Several techniques have been introduced to treat acromioclavicular separation with coracoclavicular ligament reconstruction using graft augmentation. A modified arthroscopic technique for coracoclavicular ligament reconstruction was used based on a previous technique where the supportive device and tendon graft share the clavicular and coracoid drill holes. A notable problem with the previous technique was large protruding suture knots on the washer and clavicle, which could predispose to wound infection. In this modified technique, titanium implants were introduced. The implants hid the suture knot on the clavicle, and less foreign material was needed between the clavicular and coracoid implants.
Technique Video
See video under supplementary data.
Few skeletal traumas are associated with as many operative techniques as acromioclavicular (AC) joint separation. Controversy exists regarding the indications for surgery, but a common consensus is that grade I-II AC separations should be treated conservatively, whereas grade III-V dislocations may need surgery. Many recent techniques include coracoclavicular (CC) tendon reconstruction using tendon grafts and are either arthroscopic or arthroscopy-assisted.
Arthroscopic technique for stabilization of chronic acromioclavicular joint instability with coracoclavicular and acromioclavicular ligament reconstruction using gracilis tendon graft.
Surgical technique for arthroscopy-assisted anatomical reconstruction of acromioclavicular and coracoclavicular ligaments using autologous hamstring graft in chronic acromioclavicular joint dislocations.
was used in this study where the anterior tendon graft limb was fixed to the middle of the clavicle, recreating the trapezoid ligament. The posterior graft limb was wrapped around the posterior edge of the clavicle, recreating the conoid ligament (Fig 1A). Furthermore, the posterior limb prevented posterior instability of the distal clavicle. Reconstruction of both ligaments stabilized the distal clavicle and was anatomically accurate. The technique specifies one 6-mm and one 4.5-mm drill hole in the clavicle and coracoid, respectively. Essentially, in this technique, the graft and the interconnecting sutures share the same drill holes to minimize clavicular fracture risk.
Fig 1(A) In this technique, the anterior tendon graft limb is fixed to the middle of the clavicle, recreating the trapezoid ligament. The posterior graft limb is wrapped around the posterior edge of the clavicle, recreating the conoid ligament (arrows). Left shoulder, anteromedial view. (B) The Clavicular Clip (a) and Subcoracoid Clip (b). The length of the Clavicular Clip is 14 mm, 16 mm, or 20 mm.
Although practical, the washer on the clavicle in the previous technique had significant problems: the fixation sutures left large protruding knots on the washer and clavicle. In several cases, irritation or infection of the clavicular wound was noted. Large palpable knots also remained underneath the healed skin wound occasionally, making the patients uncomfortable. An interference screw was used to fix the graft limbs in the clavicular drill holes, which increased the amount of foreign material underneath the clavicular skin wound. The washer also spread the interconnecting sutures into a funnel shape, gradually up to 8 mm × 10 mm, inside the clavicular drill hole. These led to increased tunnel widening of the clavicular drill hole.
The Technical Note aims to introduce the modified CC reconstruction technique using knot hiding clavicular and subcoracoid titanium implants. The implants hide the protruding knots on the clavicle and allow less foreign material in the reconstruction, especially focusing on early-phase wound healing.
The Technique
The Implants
The Clavicular Clip (CC-Clip, Turku, Finland), made of medical titanium, is designed to sit flush on the clavicular surface without leaving a protruding knot. The loop of the clip hides the connecting suture knot in the clavicular drill hole. The 5-mm Clavicular Clip loop and the knot located in the 6-mm drill hole, at the same time, squeeze the tendon graft limbs against the clavicular drill-hole wall. Hence an interference screw is unnecessary decreasing the amount of foreign material required. The Subcoracoid Clip (CC-Clip) is designed to be a simple ring with a smooth crossbar (Fig 1B). The interconnecting suture is attached to the Subcoracoid Clip with a loop knot, which reduces friction on the suture. The clips allow the use of a single double-folded No. 5 braided nonresorbable suture. The line between the Clavicular Clip loop and the Subcoracoid Clip is straight through the drill holes; therefore, a No. 5 braided nonresorbable interconnecting suture is sufficiently strong. In cyclical load stress tests, forces up to 400 N per >100 cycles can be applied to suture knots without their snapping depending on the suture material (Mectalent, Oulu, Finland; Design Verification Report 2017; No. MEC-157). The implants are to be left in place and subsequent implant removal is unneeded.
The Operative Technique
The patient is placed in the beach chair position. A semitendinosus autograft or allograft, as well as artificial tendon grafts, may be used as the tendon graft, which is prepared by fixing a No. 2 passing suture at one end of the graft. A No. 2 passing suture is also attached to a double-folded No. 5 braided nonresorbable interconnecting suture. Four portals (posterior, lateral, anterolateral, and clavicular) are made. A standard 30° arthroscope is used. A longitudinal clavicular incision (2.5 cm in length) is made over the clavicle, 2.5 cm medially from the AC joint.
Using the conventional drill guide technique, a 4.5-mm drill hole is made through the clavicle and coracoid (Fig 2A). The clavicular drill hole is centrally located on the clavicle, approximately 2.5 cm proximal to the AC joint. The coracoid drill hole is located centrally and as proximally as possible. The clavicular drill hole is then widened to 6 mm (Fig 2B). The passing sutures are passed through the drill holes using the Blunt Lasso Guide (CC-Clip) (Fig 3A). The tendon graft is pulled first through the clavicular and coracoid drill holes (Fig 3B). The distal limb end is then pulled to the clavicular portal behind the clavicle. Thereafter, the interconnecting sutures are passed through the drill holes and pulled out through the anterolateral portal. The Subcoracoid Clip is attached to the No. 5 suture loop and then pulled back into its position underneath the coracoid (Fig 4). The end of the dorsal graft limb is taken over the dorsal edge of the clavicle, slipped through the Clavicular Clip, and then pulled through the clavicular drill hole beside the anterior graft limb using the Blunt Lasso Guide (Fig 5A). With the entire reconstruction in place, the clavicle is repositioned (Fig 5B). The repositioning is checked arthroscopically under visual control. The interconnecting suture and tendon graft are tensioned, and the sutures are tied using a knot pusher (Fig 6A). Once the sutures are tied, the Clavicular Clip loop is allowed to sink into the clavicular drill hole hiding the suture knot (Fig 6B). Finally, the anterior graft limb end is fixed onto the dorsal limb behind the clavicle with No. 2 nonresorbable sutures (Fig 7, Video 1).
Fig 2(A) Using the conventional drill guide technique, a 4.5-mm drill hole is made through the clavicle and coracoid. Left shoulder, anterolateral view. (B) The clavicular drill hole is widened to 6 mm (arrow). Left shoulder, anterolateral view.
Fig 3(A) The passing sutures are pulled through the drill holes using the Blunt Lasso Guide. In this technique, it is important that the welded end of the lasso loop always come first (arrow). Otherwise the welding easily splits leaving the passing suture loose. Left shoulder, anterior view. (B) The No. 2 passing suture (a) for the interconnecting No. 5 suture (arrow). It is important that the tendon graft (b) is always pulled first through the drill holes to avoid entanglement. Left shoulder, anterior view.
Fig 5(A) The anterior graft limb (a). The Blunt Lasso Guide is used once again to pull the passing suture for the dorsal graft limb (b) through the clavicular drill hole. Again, it is important that the welded end of the lasso loop comes first (arrow). Left shoulder, posterosuperior view. (B) The anterior graft limb (a) runs through the clavicular and coracoid drill holes. The end of the dorsal graft limb (b) is wrapped around the dorsal edge of the clavicle and dorsal rim of the Clavicular Clip. Then it is pulled through the clavicular drill hole adjacent to the anterior graft limb (a). Left shoulder, posterosuperior view.
Fig 6(A) The Clavicular Clip on the edge of the clavicular drill hole. Note the No. 5 suture knot (arrow). Left shoulder, anterior view. (B) The Clavicular Clip loop is slipped into the clavicular drill hole hiding the knot (arrow). The 5-mm Clavicular Clip loop and the knot compress the graft limbs against the 6-mm drill-hole walls. Therefore, there is no need for an interference screw. Left shoulder, anterior view.
In chronic cases, once the CC ligament reconstruction is completed, the clavicular wound may be extended laterally to expose the AC joint. If the AC joint capsule is addressed, it is done openly making the operation arthroscopy-assisted. The AC joint may be debrided and the clavicular end may be resected if necessary. Thereafter, the AC joint capsule can be sutured and plicated with interrupted sutures to enhance the anterior-posterior stability of the distal clavicle (Figs 8 and 9).
Fig 8The complete coracoclavicular reconstruction (a). Note the optional plication of the acromioclavicular joint capsule (b). Left shoulder, anterior view.
Fig 9(A) The postoperative radiograph of a reduced clavicle. The superior part of the Clavicular Clip (16 mm) lies flush on the clavicular surface (a). The Subcoracoid Clip is in its position underneath the coracoid process (b). Left shoulder. (B) The skin wounds after 2 weeks from surgery. The lateral portal (a), anterolateral portal (b), and clavicular skin wound (c). Note that the clavicular opening is extended laterally to address also the acromioclavicular joint capsule (arrow). The initial dorsal portal is not visible in this projection. Left shoulder, anterolateral view.
A padded dressing is applied with a sling. The patients are discharged from the hospital on the same day and each wears a sling for 4 weeks. They are allowed light rotatory movements and passive lifting of the arm within the limits of pain. The sling is removed after 4 weeks, and active rehabilitation is initiated 8 weeks after surgery. The patients are allowed to resume heavy labor and sports at postoperative 3 and 4-6 months, respectively.
Discussion
The strong interconnecting suture applied between the CC Clip and Subcoracoid Clip is considered semitemporary; the authors believe that it will eventually snap. Therefore, a tendon graft is necessary for the reconstruction, especially in chronic cases.
The Clavicular Clip was particularly designed for the 2-tunnel solution and to address the problems related to earlier techniques. The Clavicular Clip has a simple design; it worked as expected and was easy to handle. The Subcoracoid Clip was equally practical and the amount of wire or suture needed was minimal due to the straight direction of the suture material between the implants. The loop attachment of the Subcoracoid Clip is strong with minimal movement in the loop knot, thus, reducing friction. The first 2 months postoperatively are critical. The tendon graft must heal properly before physiotherapy is initiated. Subsequently, it is very unlikely for the reconstruction to fail excluding new external trauma. The technique is simple enough for any experienced shoulder surgeon to perform. However, the technique does include its pitfalls (Table 1).
Table 1Tips and Tricks
Pearls
Pitfalls
Risks
Portals
It is essential to have the portals in the right places—always use needles
A displaced portal—a notable problem
Mishandling the arthroscopic procedure
Posterior portal P
The surgery is initiated through the standard posterior portal
We present a modified arthroscopic coracoclavicular ligament reconstruction technique. This modification is based on our previous technique where the supportive device and semitendinosus graft share the same drill holes. In the previous technique, a significant problem was the large suture knots on the washer and the clavicle increasing the risk of wound infections. In this modified technique, new titanium implants, the Clavicular Clip and Subcoracoid Clip, are introduced. The Clavicular Clip effectively hides the suture knot in the clavicular drill hole leaving no protruding objects on the clavicle. The patient is placed in the beach chair position. In this video, the surgery is conducted on the right shoulder. The operation is initiated through the posterior portal. The arthroscope is then moved to the subacromial space. The lateral portal is used throughout the operation with a view on the proximal coracoid. A semitendinosus graft is harvested from the ipsilateral thigh. No. 2 passing sutures are fixed on one end of the graft and on the No. 5 supportive suture. The drill holes to the clavicle and coracoid are made using conventional drill guides. The passing sutures for both the graft and the fixation device are pulled through the bone tunnels using the Blunt Lasso Guide and a nitinol lasso. First the graft is pulled through the clavicular and coracoid drill holes to the lateral portal and from there to the skin opening behind the clavicle. The interconnective No. 5 suture is then pulled to the lateral portal and the passing suture is removed. The Subcoracoid Clip is attached to the interconnecting suture with a loop fixation. The loop fixation is used to minimize friction in the suture material. The Subcoracoid Clip is then pulled into its position underneath the coracoid. The other limb of the interconnecting suture and the anterior graft limb are slipped through the Clavicular Clip. The dorsal graft limb is then pulled over the dorsal rim of the Clavicular Clip, and taken through the clavicular drill hole using the lasso technique. Therefore, the tendon graft goes through the clavicular drill hole twice, completing the double-bundle reconstruction. Once the clavicle has been repositioned, the graft is tensioned and the sutures are tied.
Arthroscopic technique for stabilization of chronic acromioclavicular joint instability with coracoclavicular and acromioclavicular ligament reconstruction using gracilis tendon graft.
Surgical technique for arthroscopy-assisted anatomical reconstruction of acromioclavicular and coracoclavicular ligaments using autologous hamstring graft in chronic acromioclavicular joint dislocations.
The authors report the following potential conflicts of interest or sources of funding: J.O.R. is a shareholder of the CC-Clip company, which has the rights to the CE mark and the US patent. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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