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Arthroscopic Coracoclavicular Ligament Reconstruction Using Graft Augmentation and Titanium Implants

Open AccessPublished:April 09, 2018DOI:https://doi.org/10.1016/j.eats.2017.11.005

      Abstract

      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.
      • Pühringer N.
      • Agneskirchner J.
      Arthroscopic technique for stabilization of chronic acromioclavicular joint instability with coracoclavicular and acromioclavicular ligament reconstruction using gracilis tendon graft.
      • Bancha C.
      • Prashant P.
      Surgical technique for arthroscopy-assisted anatomical reconstruction of acromioclavicular and coracoclavicular ligaments using autologous hamstring graft in chronic acromioclavicular joint dislocations.
      • Natera L.
      • Reiriz J.
      • Abat F.
      Anatomic reconstruction of chronic coracoclavicular ligament tears: Arthroscopic-assisted approach with nonrigid mechanical fixation and graft augmentation.
      • Millett P.J.
      • Warth R.J.
      • Greenspoon J.A.
      • Horan M.P.
      Arthroscopically assisted anatomic coracoclavicular ligament reconstruction technique using coracoclavicular fixation and soft-tissue grafts.
      • Martetshläger F.
      • Tauber M.
      • Habermeyer P.
      • Hawi N.
      Arthroscopically assisted acromioclavicular and coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability.
      • Pan Z.
      • Zhang H.
      • Sun C.
      • Qu L.
      • Cui Y.
      Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation.
      A modified version of the arthroscopic CC reconstruction technique described by Ranne et al.
      • Ranne J.
      • Sarimo J.
      • Rawlins M.
      • Heinonen O.
      • Orava S.
      All-arthroscopic double-bundle coracoclavicular ligament reconstruction using autogenous semitendinosus graft: A new technique.
      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.
      Figure thumbnail gr1
      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.
      • Woodmass J.
      • Esposito J.
      • Ono Y.
      • et al.
      Complications following arthroscopic fixation of acromioclavicular separations: A systematic review of the literature.
      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).
      Figure thumbnail gr2
      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.
      Figure thumbnail gr3
      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.
      Figure thumbnail gr4
      Fig 4The Subcoracoid Clip in its place underneath the coracoid. Note the loop fixation (arrow). Left shoulder, medial view.
      Figure thumbnail gr5
      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.
      Figure thumbnail gr6
      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.
      Figure thumbnail gr7
      Fig 7The arthroscopic photograph showing the complete double-bundle reconstruction. The anterior graft limb (a), dorsal graft limb (b), and interconnecting suture (arrow).
      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).
      Figure thumbnail gr8
      Fig 8The complete coracoclavicular reconstruction (a). Note the optional plication of the acromioclavicular joint capsule (b). Left shoulder, anterior view.
      Figure thumbnail gr9
      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.

      Postoperative Treatment

      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
      PearlsPitfallsRisks
      PortalsIt is essential to have the portals in the right places—always use needlesA displaced portal—a notable problemMishandling the arthroscopic procedure
      Posterior portal PThe surgery is initiated through the standard posterior portalCheck additional trauma: labrum, supraspinatus tendonMissing the whole picture
      Lateral portal LPlace a needle in front of the biceps tendon and place the L portal thereMake sure the needle reaches the proximal coracoidMissing the whole picture
      Anterolateral portal ALL+AL portals: good access to the proximal coracoidMissing the whole picture
      Clavicular portal CClavicular portal behind the clavicle. Direct the needle to the coracoid neckMake sure the needle reaches the proximal coracoidMissing the whole picture
      Clavicular portal CCreate a soft-tissue channel underneath the clavicle to the coracoid neck bluntly, with scissorsOtherwise it is difficult to get the suture passer into the right position
      Operative techniqueMeticulous hemostasis using electrocautery throughout the surgeryBleeding may hamper visionMishandling the arthroscopic procedure
      Passing the graftAlways pull the graft before the supportive sutureThe sutures and graft may tangleThe graft gets stuck
      Passing the graftPull the passing suture of the graft first to the clavicular portal and then pull the graftThe graft does not usually slide well in the suture passer eyeletThe graft gets stuck
      Passing the graftWhen pulling the graft through the drill holes assist with a suture passer placed underneath the coracoidTo avoid the dead man angleThe graft gets stuck
      Passing the graftAll of the graft must be in its place before snapping the coracoid clip into the clavicular drill holeThe clip fits tightly, and it is difficult to pass anything through it once it is in placeProblems, repeating it is time consuming
      Tensioning the graft and the supportive deviceBefore the sutures are tied the assistant presses the clavicular head downIt helps to tension the interconnecting suture sufficientlyThe interconnecting suture remains too loose
      Knot tyingUse the knot pusher. It fits into the clip loopIt is easier to make the knots sufficiently tight enoughThe interconnecting suture knots remain too loose

      Supplementary Data

      References

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