Arthroscopic Coracoclavicular Ligament Reconstruction Using Biologic and Suture Fixation

Presented in this report is a modified arthroscopic approach to acromioclavicular joint reconstruction via suture and allograft fixation. An arthroscopic approach is used to expose the base of the coracoid by use of electrocautery. After an open distal clavicle excision is performed, clavicular and coracoid tunnels are created under arthroscopic visualization as previously described by Wolf and Pennington. The myotendinous end of a semitendinosus allograft is sutured to a Spider plate (Kinetikos Medical, San Diego, CA). The tendinous end of the graft is prepared with a running baseball stitch. A Nitinol wire with a loop end (Arthrex, Naples, FL) is used to pass 2 free FiberTape sutures (Arthrex) and the leading sutures from the tendinous end of the graft through the clavicular and coracoid tunnels, exiting out the anterior portal. One of the FiberTape sutures is retrieved with a grasper and passed over the anterior aspect of the distal clavicle. The second FiberTape suture and the allograft are passed over the distal end of the resected clavicle. While the acromioclavicular joint is held reduced, the FiberTape sutures are tied to the plate and the allograft is tensioned medially until the plate is embedded against the superior surface of the clavicle. The tendinous end of the graft is secured to the superior surface of the clavicle with a Bio-tenodesis screw (Arthrex) medial to the clavicular tunnel.     

关节镜辅助喙锁悬吊固定联合改良Weaver-unn手术治疗陈旧性肩锁关节脱位

目的探讨关节镜辅助喙锁悬吊固定联合改良Weaver-Dunn手术治疗陈旧性肩锁关节脱位的疗效。 方法2016年3月至2017年3月,对8例陈旧性肩锁关节脱位的患者采用关节镜下喙锁间隙悬吊固定联合改良Weaver-Dunn手术,术后随访6~18个月。测量术后即刻与末次随访时的喙锁间隙差值,评估复位丢失情况,采用疼痛视觉模拟（VAS）评分及加州大学洛杉矶分校（UCLA）评分评价患者肩关节功能。 结果术后末次随访时患者喙锁间隙与术后即刻喙锁间隙差值为（0.41±0.26）mm,VAS评分为2.88分,UCLA评分为（173.6±11.3）分,患者肩锁关节丢失率低、术后疼痛及功能均得到明显改善。 结论关节镜辅助喙锁固定联合改良Weaver-Dunn技术治疗陈旧性肩锁关节脱位有较好的疗效。     

Arthroscopic Suprascapular Nerve Release at the Suprascapular Notch in a Cadaveric Model: An Anatomic Approach

Arthroscopic release of the suprascapular nerve at the suprascapular notch, to our knowledge, has rarely been described. The purpose of this study was to evaluate the feasibility and relevant anatomic landmarks in a cadaveric model that can be identified arthroscopically for reliable and reproducible arthroscopic release of the superior transverse scapular (STS) ligament. In 8 fresh-frozen cadaveric shoulders, arthroscopic release of the STS ligament was performed. The acromioclavicular joint is first identified while viewing through a posterior subacromial portal. The distal clavicle is then followed medially until the most lateral portion of the coracoclavicular (CC) ligaments (trapezoid ligament) is identified. The most medial margin of the CC ligaments (conoid ligament) is identified, and the trapezoid and conoid ligaments are dissected and identified individually. The conoid ligament is followed inferiorly and medially to the base of the coracoid. At the base of the coracoid, the confluence of the trapezoid and conoid ligaments (CC) and the STS ligament is identified. The STS ligament can be identified coursing horizontally across the field of view. The STS ligament may be incised by use of dissecting scissors through a lateral, accessory lateral, or accessory posterior portal, releasing the suprascapular nerve.     

Biomechanical analysis of acromioclavicular joint dislocation repair using coracoclavicular suspension devices in two different configurations

BackgroundThe best treatment option for some acromioclavicular (AC) joint dislocations is controversial. For this reason, the aim of this study was to evaluate the vertical biomechanical behavior of two techniques for the anatomic repair of coracoclavicular (CC) ligaments after an AC injury.ResultsGroup I reached a maximum force to failure of 635.59 N (mean 444.0 N). The corresponding force was 939.37 N (mean 495.6 N) for group II and 533.11 N (mean 343.9 N) for group III. A comparison of the three groups did not find any significant difference despite the loss of resistance presented by group III.ConclusionAnatomic repair of coracoclavicular ligaments with a double system (double tunnel in the clavicle and in the coracoid) permits vertical translation that is more like that of the acromioclavicular joint. Acromioclavicular repair in a “V” configuration does not seem to be biomechanically sufficient.     

A modified method of coracoid transposition for the treatment of complete dislocation of acromioclavicular joint

Objective:To eport a new method of coracoid transpostiton for the treatment of complete dislocation of acromioclavicular joint and to evaluate its efficacy.Methods:We modified Eewar‘s surgical method as follows:(1)Two small incisions,a transversal incision on the acromioclavicular joint and a longitudinal incision on the coracoid ,were made instead of a conventional large arc incision from the acromion to coracoid.(2)The foreign body in the acromioclavicular joint was cleared out.Thechondral surface at the lateral segment of clavicle was resected to form a pseudarthrosis and meanwhile the residual joint capsule and ligaments were repaired.(3)The coracoid was moved to the anteroinferior edge of the clavicle instead of the anterior margin and (4)the coracoid was moved to the lateral border of the clavicle instead of the superior border of the coracoclavicular ligament.Results:The follow-up duration in 30patients of the series was from6to 72months(mean41months).Functional assessment was carried out by the criteria delineated previously by Karkson,in which Grade Awas in 24 cases,Grade Bin4cases,and Cin2.Conclusions:This modified technique,having less postoperative complications and less injuries to tissues and according well with the requitement of biomechanics,can achieve a stable reduction of acromioclavicular joint with a good functional and cosmetic result and thereore is preferable to use clinically on a large scale.     

Biomechanical comparison of reconstruction techniques for disruption of the acromioclavicular and coracoclavicular ligaments

Injuries to the acromioclavicular joint are common. For selected injuries, operative reconstruction is recommended. The purpose of the current study was to compare three reconstruction procedures: (1) nine strands of woven polydioxanonsulphate (PDS II) suture passed through the clavicle and around the coracoid; (2) procedure No. 1 with 50% of the coracoacromioclavicular ligament placed through 2 clavicular drill holes; (3) No. 5 Merselene tape passed through 2 drill holes in the clavicle and acromion, with 50% of the coracoacromial ligament transferred to the clavicle. Fourteen fresh frozen human shoulders were tested using a 6 degree-of-freedom testing device. The intact shoulder showed significantly less displacement than any of the reconstructions. Merselene tape plus ligament showed the largest displacement, and PDS II braid plus ligament showed the least displacement. None of the procedures reconstituted acromioclavicular joint stiffness to intact state levels, though improved acromioclavicular joint stiffness was noted with a PDS braid plus ligament.     

Anatomie der akromiokorakoklavikulären Region

Background

The acromioclavicular (AC) joint connects the acromion with the lateral end of the clavicle and constitutes an important load-transmitting element between the upper extremity and the skeleton of the trunk.

Aim

This review discusses functional aspects that relate the AC and the coracoclavicular (CC) ligaments to AC joint instability and lateral clavicle fracture.

Results

In terms of stability the AC and CC ligaments play a pivotal role for this region. Under normal conditions the restraint system is balanced and becomes unbalanced in cases of injury such as AC joint instability or lateral clavicular fractures. Skeletal injuries frequently affect the ligaments with their usually sharp-angled insertion sites, which alters the function of the restraint system. As a consequence these injuries lead to multidirectional dislocating forces acting on the scapula in relationship to the lateral end of the clavicle. Previously, special attention was given to the vertical dislocation of the lateral clavicle, whereas less attention was paid to other factors which could lead to dislocation in other directions. Therefore, in this review emphasis is placed on the anatomical principles of multidirectional dislocation of the AC joint the fractured lateral clavicle.

Conclusion

Current clinical classification schemes fail to sufficiently include these multidirectional dislocating forces; however, they have to be considered when choosing the appropriate treatment modality. Thus, understanding the anatomical and functional context of the AC/CC region is essential for a sound management of AC joint injuries and fractures of the distal clavicle.

     

Surgical treatment of acromioclavicular dislocation: a review of 39 patients

Results after the operative treatment of 39 total (Type III) acromioclavicular (AC) dislocations are reported. The operation consisted of suture of the acromioclavicular and coracoclavicular ligaments and transfixion of the AC joint with an AO/ASIF malleolar screw passed through the acromion into the lateral end of the clavicle. The screw was removed at an average of six weeks after the operation. In 36 patients re-examined after a mean of 4 years, the overall results were good in 92 per cent of cases. The range of flexion and abduction was excellent (over 170 degrees) in 90 per cent. Stress radiographs revealed persisting subluxation of the AC joint in 6 patients and persisting dislocation in 1. Signs of osteoarthrosis were seen in 4 patients and signs of osteolysis in 12. Radiological signs of osteolysis correlated well with incongruity of the AC joint but not with the clinical function. Radiological signs of osteoarthrosis in the AC joint, however, correlated with a poor clinical result: all patients with a fair or poor clinical result had signs of osteoarthrosis in the AC joint. Except for one, all patients returned to their preoperative occupations within an average of two months.     

Treatment of acromioclavicular joint separation: suture or suture anchors?

This investigation compared the stability of 2 methods of fixation for acromioclavicular (AC) joint separations. A complete AC joint separation was simulated in 6 matched pairs of fresh-frozen human cadaveric shoulders. One specimen from each pair was repaired with two No. 5 nonabsorbable braided sutures passed around the base of the coracoid and the other with 2 suture anchors preloaded with the same suture material placed into the base of the coracoid process. The specimens were cyclically loaded for 10(4) cycles to simulate our early postoperative rehabilitation protocol for coracoclavicular repairs. Before cycling, the repairs had a mean superior laxity of 1.68 +/- 0.44 mm for the sutures alone and 1.23 +/- 0.31 mm for the suture anchors. After 10(4) cycles, the laxity was 1.32 +/- 0.59 mm and 1.33 +/- 0.94 mm, respectively. These differences were not statistically significant (P =.2). This study demonstrated that similar stability can be achieved for coracoclavicular fixation with suture anchors or with sutures placed around the base of the coracoid for the treatment of AC joint separations. The clinical relevance includes the following: (1) the potentially diminished risk of neurovascular injury with the use of suture anchors compared with the passage of sutures around the base of the coracoid and (2) the potentially reduced surgical time associated with the use of suture anchors.     

肩锁关节解剖学研究和临床意义

目的研究肩锁关节骨性和静态稳定结构,为肩部手术提供详细形态学资料。方法对26例成人新鲜尸体标本进行解剖,观察肩锁关节解剖形态并测量相关骨性标志和韧带的形态学参数。结果锥状韧带和斜方韧带锁骨止点中心到锁骨远端距离分别为(43.67±6.30)mm和(25.25±3.06)mm,止点宽度分别为(16.92±4.25)mm和(10.33±1.32)mm。锥状韧带长度为(15.54±3.32)mm,角度为(-116.25±10.90)°;而斜方韧带长度为(9.63±2.28)mm,角度为(75.42±11.37)°。锥状韧带和斜方韧带喙突止点相距(8.96±3.00)mm,而锁骨止点距离(13.08±3.50)mm,两条韧带呈"V"形结构。结论本研究获得了肩锁关节及其周围组织的详细形态学参数,为该部位手术提供解剖学资料。进行锁骨远端手术时应避免损伤锥韧带和斜方韧带止点,切除锁骨远端应不超过10mm以避免损伤斜方韧带。行喙锁韧带重建时要注意重建其"V"形解剖结构,以更好恢复其生理功能。     

Arthroscopic Stabilization of Neer Type 2 Fracture of the Distal Part of the Clavicle

With regard to the anatomic basis of Neer type 2 fractures of the distal part of the clavicle, a clavicle fracture is associated with a coracoclavicular conoid ligament disruption. We describe an arthroscopic-assisted surgical procedure to stabilize the fracture and reconstruct the ligament. Surgery is performed with the patient in the beach-chair position. Through a 2-cm incision perpendicular to the direction of the fracture, we perform suturing around the fracture. During the arthroscopic procedure, the coracoid process is exposed by opening the rotator interval and the medial part of the capsule. The knee of the coracoid process should be exposed via an anterolateral portal for the arthroscope. Then, by use of an acromioclavicular joint stabilization device from Arthrex (Naples, FL), a hole is placed through the knee of the coracoid process. FiberTape suture (Arthrex) is passed around the clavicle and through the knee of the coracoid process. The intra-articular sutures are pulled out through the upper incision on top of the clavicle. Tightening of the 2 knots is performed at the same time. This arthroscopic-assisted surgery allows for total recovery of shoulder function, without the inconvenience of device migration or acromioclavicular joint lesions reported with other procedures.     

双束Endobutton解剖重建喙锁韧带治疗肩锁关节脱位的早期随访研究

目的观察解剖重建喙锁韧带治疗Rockwood Ⅲ及以上肩锁关节脱位的临床疗效。 方法选取22例肩锁关节脱位患者,其中男15例、女7例,新鲜脱位16例,陈旧性脱位6例,Rockwood Ⅲ型7例、Ⅳ型1例、V型14例。手术方式选择为双束Endobutton解剖重建技术。分别于术后3、6和12个月行疼痛视觉模拟评分及Constant肩关节功能评分,摄双侧肩关节正位X线片,测量患侧及健侧喙锁间距。 结果此研究平均随访时间为（17.7±4.0）个月。疼痛视觉模拟评分从术前的平均5.0分下降到术后12个月的0.2分,Constant肩关节功能评分从术前的平均44.3分提高到术后12个月的93.7分。患侧喙锁间距从术前的平均21.0 mm下降到术后12个月的8.5 mm。所有病例随访过程中均无肩锁关节再脱位、锁骨喙突骨折等严重并发症发生。 结论双束Endobutton解剖重建喙锁韧带是安全可靠的新术式,其应用于Rockwood Ⅲ-V型新鲜或者陈旧性肩锁关节脱位的手术治疗取得了良好的临床效果。     

A Salvage Procedure for Failed Weaver-Dunn Reconstruction

THE PROBLEM: The failure rate after surgical acromioclavicular (AC) joint stabilization is of up to 10%. For revision, several techniques including modifications of the Weaver-Dunn procedure have been suggested. However, patients with failure of such revision techniques represent a special challenge due to the altered anatomic relationships and the lack of stabilizing structures. THE SOLUTION: In this respect, a case of several failed AC joint reconstructions is reported in which a doubled semitendinosus graft was used. The use of either biological autograft or artificial material has been suggested in the literature. However, especially the use of an autograft or allograft tendon has been supported by biomechanical studies. SURGICAL TECHNIQUE: A semitendinosus graft was harvested, passed through a clavicular and a coracoid tunnel, and subsequently doubled around the medial clavicle and the medial coracoid hook. A second pair of tunnels in the distal part of the clavicle and the coracoid was used for tying a 2-mm Fiber-Wire (Arthrex Inc.) cerclage. Then, the tendon graft was sutured beyond itself with # 2 Ethibond (Ethicon Inc., Johnson & Johnson). Consecutively, the deltotrapezial fascia was doubled and closed up with inverted # 1 sutures. After skin closure the left arm was immobilized in a sling. RESULT: 12 months after surgery, the patient was free of pain, presenting with a Constant Score of 87/100 and a Neer Score of 94/100.     

Minimalinvasive Akromioklavikulargelenkrekonstruktion (MINAR)

Objective

Reduction and retention of an acromioclavicular (AC) joint dislocation with a button/suture augmentation cerclage (Flip tack, Karl Storz, Tuttlingen, Germany).

Indications

Dislocation of the AC joint (Rockwood III and V). Chronic instabilities in combination with autogenous replacement of the coracoclavicular ligaments. Lateral clavicular fracture with rupture of the coracoclavicular ligaments.

Contraindications

Patients in poor general condition. Local soft-tissue infection. Low-degree dislocation of AC joint (Rockwood I und II). Fracture of the clavicular shaft. Chronic instabilities without ligament replacement.

Surgical Technique

The coracoid process is exposed by a 3 cm long skin incision. A hole is drilled through the coracoid process with the help of a specific aiming device. The suture cerclage is connected to two buttons. One of the buttons is then pushed through the coracoid process. The button is flipped and the suture thereby fixed to the coracoid process. The other anchor is pulled through a hole in the clavicle and the cerclage is secured with a surgical knot after reduction of the AC joint.

Postoperative Management

Application of an abduction splint for 4 weeks (15°).

Results

23 patients with an acute luxation of the AC joint were operated with a minimally invasive coracoclavicular cerclage (five patients with Rockwood type III and 18 patients with Rockwood type V). Mean operative time was 28.6 min. Perior postoperative complications such as nerve and vascular injuries, thoracic injuries, infection, thrombosis, and embolism did not occur. The mean Constant Score was 94.1 points (73–100 points) after a mean of 23.3 months (18–28 months). In two cases, a slight loss of reposition of less than half of the clavicle width in comparison with the contralateral side was observed.     

Editorial Commentary: Acute Repair of the Acromioclavicular Joint Capsule and Ligaments and Deltotrapezial Fascia Could Allow Biological Healing of High-Grade Acromioclavicular Separation—Coracoclavicular Ligament Graft Augmentation Could Be Indicated if Time to Surgery Is Greater Than 3 Weeks

Surgical management of chronic acromioclavicular joint (ACJ) dislocations is a matter of controversy. In the acute setting of high-grade acromioclavicular separation, if a surgical repair of the ACJ capsule and ligaments and deltotrapezial fascia could allow biological healing of the ligaments themselves, this could be enough to restore the functional biomechanics of the joint; unfortunately, this is not true for chronic cases. In the latter situation, a surgical technique using biological augmentation such as autograft or allograft should be preferred. Time is very important for this injury, and a chronic lesion should be considered when treatment is being performed 3 weeks after trauma. The graft should be passed around the base of the coracoid or through a tunnel at the base of the coracoid itself and then at the level of the clavicle as anatomically possible to reproduce the function of the native ligaments. However, some studies have shown that passing the graft at the base of the coracoid and wrapping it around the clavicle could also achieve satisfactory outcomes. An arthroscopic technique, when used in combination, could be great to treat the associated lesions, which have a reported percentage between 30% and 49%. Finally, to restore the biomechanics of the ACJ, however, reconstruction of the acromioclavicular superior and posterior capsules together with the deltotrapezial fascia seems to be very important.     

Biomechanical study of the ligamentous system of the acromioclavicular joint

The ligamentous structures of the acromioclavicular joint were studied by gross examination and quantitative measurement in twelve human cadaver specimens. Distances between insertions at various extreme positions of the clavicle were studied with the biplane radiographic technique. Ligamentous contributions to joint constraint under displacements were determined by performing load-displacement tests along with sequential sectioning of the ligaments. Twelve modes of joint displacement were examined. The acromioclavicular ligament acted as a primary constraint for posterior displacement of the clavicle and posterior axial rotation. The conoid ligament appeared to be more important than has been previously described. That ligament played a primary role in constraining anterior and superior rotation as well as anterior and superior displacement of the clavicle. The trapezoid ligament contributed less constraint to movement of the clavicle in both the horizontal and the vertical plane except when the clavicle moved in axial compression toward the acromion process. The various contributions of different ligaments to constraint changed not only with the direction of joint displacement but also with the amount of loading and displacement. For many directions of displacement, the acromioclavicular joint contributed a greater amount to constraint at smaller degrees of displacement, while the coracoclavicular ligaments, primarily the conoid ligament, contributed a greater amount of constraint with larger amounts of displacement.     

Injuries of the acromio- and sternoclavicular joint--surgical or conservative treatment?

At the acromioclavicular (AC) joint we distinguish between horizontal instability caused by damage to the AC ligament from vertical instability caused by damage to the coracoclavicular liagments. The most common mechanism of injury is direct force resulting from a fall onto the point of the shoulder. The injury is classified according to the amount of damage brought about by a given force. Horizontal and vertical instability have to be evaluated by special radiographic views. Types I and II are treated by a sling worn for a few days and the application of ice bags. In type III injuries the patient's age, job and acitve pursuits determine whether or not surgery is indicated. In type IV-VI injuries we always perform the operation. We use a resorbable cerclage between the clavicle and the coracoid process and suture all torn ligaments. In the sternoclavicular joint too, the ligamentous stability is of the utmost importance. The sternoclavicular ligament limits the ante- and retroversion of the clavicle, while the costoclavicular ligament limits the upward movement. The direction of subluxation or luxation has to be evaluated by means of an oblique view X-ray with a cephalic tilt of the tube through 40 degrees or by a computed tomogram. In the case of an acute injury closed reduction should always be attempted. Open recuction should only be performed in cases of persistent posterior luxation, because of the numerous complications that are possible in such cases.