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Arthroscopically Assisted Tensionable Cerclage Reconstruction of an Acromioclavicular Separation With Combined Fixation of the Coracoclavicular and Acromioclavicular Ligaments
A variety of surgical techniques are currently available to manage high-grade acromioclavicular (AC) separations, including hook plates/wires, nonanatomic ligament reconstruction, and anatomic cerclage with or without biological augmentation. Traditional reconstructions focused on the coracoclavicular ligaments alone and often were associated with high rates of recurrent deformity. Biomechanical and clinical data have suggested that additional fixation of the AC ligaments is beneficial. This Technical Note describes an arthroscopically assisted approach for combined reconstruction of the coracoclavicular and AC ligaments with a tensionable cerclage.
The video for an arthroscopically assisted cerclage fixation and biologic reconstruction of the coracoclavicular and acromioclavicular ligaments for acromioclavicular joint separation on a right shoulder in a patient in lateral decubitus position.
Technique Video
See video under supplementary data.
Acromioclavicular (AC) joint separation is a common injury, particularly among young male athletes, with a reported incidence of 2.0 per 1,000 person-years in the general population.
Classically, Rockwood type 1 and 2 AC separations are managed conservatively, types 4 to 6 warrant surgical intervention, and the treatment of type 3 injuries is controversial.
Multiple surgical treatments have been proposed to address high-grade AC separations, but no consensus exists as to which is the gold standard. While AC separations involve disruption of both the coracoclavicular (CC) and AC ligaments, traditional constructs focused on reconstruction of the CC ligaments alone. Recurrent deformity was common after such reconstructions, with rates as high as 47%.
Better radiographic reduction and lower complication rates with combined coracoclavicular and acromioclavicular ligament reconstruction than with isolated coracoclavicular reconstruction.
Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations.
Nonetheless, technical limitations remain, including obtaining a complete superior-to-inferior reduction as well as achieving fixation in the acromion for AC ligament reconstruction. The purpose of this technique is to describe an arthroscopically assisted approach to managing AC separations with tensionable cerclage and ligamentous reconstruction of both the CC and AC ligaments. This technique uses a tensionable construct to facilitate superior to inferior reduction of the CC ligaments and a unique subacromial approach to acromion preparation.
Surgical Technique (With Video Illustration)
Indications
This approach is indicated for the treatment of high-grade AC separations (Rockwood type 4-6), although it can be considered in type 3 injuries among highly active, young individuals. Bilateral Zanca views and axillary lateral views are used to assess superior to inferior and anterior to posterior instability, respectively.
However, we place more emphasis on the clinical examination than the Rockwood classification and use instability and pain at the AC joint with cross-body adduction as an indication for surgery. In the setting of a very chronic injury (>1 year from injury), it is also important to confirm that the AC joint remains reducible.
Technique Description
The patient may be placed in a lateral decubitus or beach-chair position based on surgeon preference. The procedure begins with open exposure of the AC joint. A 5-cm transverse incision is made centered over the AC joint (Fig 1). The deltotrapezial fascia is incised, and the flaps are elevated to expose the lateral 3 cm of the clavicle and 2 cm of the medial acromion.
Fig 1A 5-cm incision is made over the acromioclavicular joint to expose the joint and distal clavicle on a right shoulder in a patient in lateral decubitus position. (A, acromion; C, clavicle.)
Next, bone tunnels are created for suture-based cerclage fixation of the AC joint. A 3.0-mm cannulated drill is passed transversely through the clavicle from anterior to posterior, 1 cm medial to the lateral edge. A nitinol guidewire is passed through the drill and used to pass a shuttling suture with a closed loop on one end (#2 FiberLink; Arthrex Inc., Naples, FL) through the clavicle. The looped end of the suture is kept on the posterior aspect of the clavicle (Fig 2A).
Fig 2A step-by-step schematic of the acromioclavicular cerclage technique on a right shoulder. (A) A tunnel is drilled in the clavicle from anterior to posterior and a shutting suture is passed through this tunnel, leaving the looped end posteriorly. (B) A posterior acromion tunnel is drilled superior to inferior. (C) The straight end of the suture is inserted and shuttled through the posterior acromion tunnel. (D) An anterior tunnel is then drilled, followed by shuttling the suture from inferior to superior and to the posterior looped end creating a figure-of-8 construct. (A, acromion; Ant, anterior; C, clavicle; LE; looped end; Post, posterior; SE, straight end.)
Attention is turned to the arthroscopic portion of the procedure. A diagnostic arthroscopy is performed through a posterior viewing portal and any concomitant pathology is addressed. The arthroscope is then directed to the subacromial space. A complete bursectomy is performed via a lateral working portal in order to expose the undersurface of the AC joint and the scapular spine. An 8.25-mm cannula is then placed in the lateral portal. An adjustable drill guide (AC Drill Guide; Arthrex Inc.) is inserted through the lateral portal and used to created two bone tunnels in the acromion from superior to inferior. A posterior tunnel is drilled first (Fig 2B). This tunnel is placed in line with the posterior edge of the clavicle, 1 cm lateral to medial edge of the acromion. The inferior position is confirmed arthroscopically, and the superior position is confirmed via direct visualization. The straight end of the suture previously shuttled through the anterior clavicle is then shuttled through the posterior acromion tunnel from superior to inferior (Fig 2C). A second tunnel is then similarly prepared in the acromion in line with anterior edge of the clavicle, 1 cm lateral to the medial edge of the acromion. The straight end of the shuttling suture is then passed through this tunnel from inferior to superior (Fig 3). The shuttling suture is now positioned for a figure-of-eight cerclage of the AC joint (Fig 2D).
Fig 3Arthroscopic view of a right shoulder in a patient in lateral decubitus position from a posterior subacromial viewing portal shows the shuttling suture used for the figure-of-8 acromioclavicular cerclage passing through the acromion tunnels. (A, acromion; C, clavicle.)
Attention is then turned to the CC fixation. A tunnel-free technique is used, going underneath the coracoid and over the clavicle. One can move the arthroscope to the lateral portal and approach the coracoid extra-articularly, although we prefer an intra-articular approach from the posterior glenohumeral viewing portal. The rotator interval is opened, and the tip of the coracoid is exposed. A 70° arthroscope is then introduced, and an anterior cannula is placed. Dissection then proceeds from the tip of the coracoid to the base of the coracoid under direct visualization, staying on bone. Through the open incision, a switching stick is passed posterior to the clavicle and medial to the coracoid. The medial base of the coracoid is typically easily felt with the tip of the switching stick. Typically, this is 3 to 4 cm medial to the lateral edge of the clavicle. A reusable metal cannula inserter for an 8.25-mm cannula is passed over the switching stick to dilate the path. This helps create a path for subsequent graft shuttling. These instruments are removed, and a cannulated curved coracoid passing guide (AC Wire Passer; Arthrex) is introduced. A nitinol guidewire is threaded through the passer and retrieved out the anterior cannula. The closed looped end of a FiberLink suture is then shuttled under the coracoid so that the loop exits the open incision posterior to the clavicle. Via the open incision, a switching stick is then passed anterior to the clavicle and lateral to the coracoid. The position is confirmed arthroscopically. The cannula inserter is used again to dilate this path. The switching stick is then removed, and a nitinol wire is threaded from superior to inferior through the cannulation of the cannula inserter. This wire is retrieved out the anterior cannula and used to shuttle the closed end of the FiberLink suture back out the open incision. The FiberLink is now posterior to the clavicle, medial to the coracoid and anterior to the clavicle, lateral to the coracoid.
Reconstruction of the CC ligaments is performed with an allograft and tensionable suture tape cerclage (FiberTape Tension Compression Bridge [TCB]; Arthrex). We use an allograft in all cases, regardless of surgical timing. Before commencing surgery, a 7- to 8-mm semitendinosus allograft is prepped on the back table by whipstitching both ends of the graft with #2 suture (Fig 4). The TCB kit has two sets of 2-mm suture tape (FiberTape) that are doubled over and have a half-racking hitch on one end that can be used to tension the construct while preventing slippage. Using the FiberLink suture, the prepared allograft and one TCB suture set are shuttled posterior to the clavicle, underneath the coracoid and back anterior to the clavicle (Fig 5). Graft and suture position beneath the coracoid is confirmed arthroscopically (Fig 6). This concludes the arthroscopic portion of the technique.
Fig 4A semitendinosus graft is prepared on the back table and whipstitched on both ends. A tape-like suture (arrow) is aligned with the graft for subsequent (Arthrex).
Fig 5Illustration of the coracoclavicular reconstruction with a tunnel-free technique in a right shoulder. The graft and cerclage sutures are passed posterior to the clavicle and medial to the coracoid. Then, anterior to the clavicle and lateral to the coracoid.
Fig 6Arthroscopic view of a right shoulder in a patient in lateral decubitus position from a posterior glenohumeral viewing portal with a 70° arthroscope. The semitendinosus graft and cerclage sutures have been shuttled in place to rest beneath the coracoid. (CB, coracoid base; G, graft; SSc, subscapularis.)
The free ends of the TCB are passed through the half-racking hitch knot on the other end. The AC separation is manually reduced and then a half-hitch knot is tied at the end of the TCB to provisionally hold the reduction. Next, a spring-loaded disposable tensioning device (FiberTape Cerclage Single-Use Tensioner; Arthrex) is used to remove all remaining slack and complete the reduction (Fig 7). Typically, tensioning results in an additional 5 to 10 mm of reduction that was not obtained manually. The construct is locked with 2 additional half-hitches and the limbs are cut. The allograft is then tied over itself and the limbs are sewn together with 3 to 4 #2 sutures. Before tying the graft, the graft is positioned so that one limb is longer and can be taken out over the top of the AC joint.
Fig 7A disposable tensioner (FiberTape Cerclage Disposable Tensioner; Arthrex) is used to maximize reduction and remove slack in the acromioclavicular and coracoclavicular cerclages.
Next, the AC cerclage is completed. The other TCB suture set is shuttled through the clavicle and acromion via the previously placed FiberLink. The allograft is positioned underneath this suture set. The AC sutures are then tensioned as done previously. Finally, any excess graft is cut, and the end is incorporated into a fascial closure. The final construct is shown in Figures 8 and 9. The pearls and pitfalls of the procedure are shown in Table 1. The full technique is portrayed in Video 1.
Fig 8Open view of the final construct in a right shoulder. One graft limb taken from the coracoclavicular reconstruction is lengthened and taken over the acromioclavicular joint. Then, this limb is secured beneath a cerclage suture. (A, acromion; C, clavicle; G, graft.)
Fig 9Illustration of the final construct demonstrates combined coracoclavicular and acromioclavicular cerclage fixation and biologic reconstruction using a tunnel-free technique in a right shoulder.
Postoperatively, patients are placed in an abduction sling for 6 weeks. Passive external rotation is allowed at 3 weeks. Overhead motion follows at 6 weeks, strengthening at 12 weeks, and full activities at 6 months’ postoperatively. Figure 10 shows a postoperative Zanca view of the right shoulder at the 2-week follow-up.
Fig 10Pre- (A) and postoperative (B) Zanca views of the right shoulder on a patient undergoing AC and CC cerclage for AC separation (blue arrows). (AC, acromioclavicular; CC, coracoclavicular.)
A wide variety of techniques have been described for the surgical management of AC separations. Our technique uses a tensionable construct to facilitate reduction and a unique arthroscopic-assisted approach to preparation of the acromion for AC joint fixation. This technique provides robust biomechanical fixation at time zero with biologic reconstruction of the CC and AC ligaments. In addition, our technique may reduce the risk of iatrogenic coracoid or clavicle fracture.
Historically, the Weaver–Dunn procedure was the most widely used technique in the surgical management of a high-grade AC separation.
Subsequently, techniques were developed to obtain fixation between the coracoid and clavicle with interference screws or buttons. Such constructs improved biomechanical performance, but clinical failure rates of 8% to 35% continued to be seen.
Drawbacks of these techniques included the risk of iatrogenic fracture of the clavicle or coracoid from bone tunnel stress risers, lack of graft augmentation in many cases, and the lack of AC joint stabilization. Milewski et al.
reported iatrogenic clavicle fractures in 6.5% of cases. A single CC tunnel technique with a 3-mm tunnel was described that reduced the risk of fracture.
However, the technique remains technically challenging, with the risk of improper tunnel placement resulting in loss of fixation. Our approach has thus been to avoid risk of fracture completely by using a tunnel-free technique for CC fixation.
demonstrated that the addition of AC joint fixation to CC fixation improved biomechanical performance, more closely mimicking the native mechanics. Clinically, Lädermann et al.
reported that combined open AC and CC reconstruction led to a 76% maintenance of reduction. However, fixation of the AC joint has previously been difficult or often completely ignored with arthroscopic-assisted techniques. Hachem et al.
described an arthroscopically assisted cerclage technique with drilling of the acromion from anterior to posterior to produce a figure-of-eight suture configuration at the AC joint but did not include graft reconstruction of the AC joint. Our technique provides an arthroscopic approach to achieving anatomic reconstruction of the AC ligaments. Cerclaging the AC joint provides anteroposterior stability,
whereas the allograft is used to restore the important superior ligaments. Others have described fixation between the anterior clavicle and acromion with anchors, but this technique does not restore the superior ligaments which are the most important aspect of the AC joint.
compared the biomechanical characteristics of isolated coracoid suture cerclage versus single tendon graft AC and CC joint reconstruction in a study of 6 paired cadaveric shoulders. The graft reconstruction provided greater anterior to posterior stability and greater load to failure. A more recent biomechanical study measured multiaxial stability when combining coracoclavicular reconstruction, modified Weaver–Dunn procedure, and acromioclavicular stabilization.
Results showed increased stability with multiple points of fixation. Based on studies such as this, and our poor experience with isolated suture fixation, we use a graft in all AC separations. Our preference, however, is to use an allograft rather than the coracoacromial ligament.
In our experience, the use of a tensioner appears to improve reduction compared with manual knot-tying.
Lower rates of graft failure have been observed in anterior cruciate ligament reconstructions performed with device assisted tensioning compared to manual reduction alone.
described an open tensionable technique using an allograft for both AC and CC reconstruction. Although we advocate tensioner use, we prefer an arthroscopic-assisted approach to lower the invasiveness of the procedure and provide the ability to address concomitant pathology, which is present in 39% to 53% of high-grade injuries.
Our proposed technique attempts to provide an arthroscopic-assisted approach to improve reduction quality via the tensionable construct and provide optimal stability through combined CC and AC joint fixation. Still, there are limitations to be considered. Manipulation around the coracoid carries the risk of neurovascular damage. Although we have not observed to date, clinical studies are required to prove that the drill tunnels in the acromion will not result in iatrogenic fracture. The technique is also somewhat technically demanding, requiring comfort with exposure of the base of the coracoid arthroscopically. Advantages and disadvantages are outlined in Table 2. Further studies analyzing this technique are needed to confirm clinical outcomes.
Table 2Advantages and Disadvantages of the AC Open Arthroscopy-Assisted Repair
Advantages
Disadvantages
Address concomitant lesions
Technically challenging to expose the coracoid
Improved reduction with a tensioner
Risk of neurovascular damage during passage medial to the coracoid
The video for an arthroscopically assisted cerclage fixation and biologic reconstruction of the coracoclavicular and acromioclavicular ligaments for acromioclavicular joint separation on a right shoulder in a patient in lateral decubitus position.
Better radiographic reduction and lower complication rates with combined coracoclavicular and acromioclavicular ligament reconstruction than with isolated coracoclavicular reconstruction.
Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations.
The authors report the following potential conflicts of interest or sources of funding: B.O.P. is a consultant for and receives royalties from Arthrex. P.J.D. receives royalties from and is a consultant and paid speaker for Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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