Arthroscopically Assisted Acromioclavicular and Coracoclavicular Ligament Reconstruction for Chronic Acromioclavicular Joint Instability

Abstract

Acromioclavicular (AC) joint injuries are common injuries, especially in the young and active, male population. AC joint injuries account for 12% of all injuries of the shoulder girdle in the overall population. Although conservative treatment is recommended for Rockwood type I and type II injuries, there is controversial debate about optimal treatment for type III injuries. High-grade injuries are typically treated operatively to avoid painful sequelae. A vast number of different surgical methods have been described over the past few decades. Recent advances in arthroscopic surgery have enabled the shoulder surgeon to treat acute and chronic AC lesions arthroscopically assisted. Clinical studies have already shown good and reliable results. Although surgeons agree that a biological augmentation is required to minimize the risk of recurrent instability in chronic cases, a gold standard still needs to be defined. We present an arthroscopically assisted biological augmentation technique to reconstruct the AC and coracoclavicular ligaments, protected by a button-suture tape construct for chronic AC joint instability. The presented arthroscopic biological augmentation technique uses less and/or smaller drill holes in the clavicle and coracoid than previously described, thus reducing weakening of the bony structures. At the same time it enhances both horizontal and vertical stability.

Fig 1

Beach chair position, right shoulder, arthroscopic view from the posterior portal. An anteroinferolateral working portal is established within the rotator interval, and a flexible passport cannula (PC) (Arthrex, 4 cm) is inserted to facilitate suture and graft management.

Fig 2

Beach chair position, right shoulder, arthroscopic view from the posterior portal. A high trans-supraspinatus portal is established directly behind the long head of the biceps. The arthroscope is then switched into this portal for better visualization of the subcoracoid space. Care must be taken not to damage the rotator cable. (HH, humeral head; KN, knife; SSP, supraspinatus tendon.)

Fig 3

Beach chair position, right shoulder, arthroscopic view from the trans-supraspinatus portal. Under direct visualization the undersurface of the coracoid is skeletonized (undersurface of coracoid base [CB]) using a radiofrequency device (RD) (OPES, Arthex) through the anteroinferolateral portal.

Fig 4

Beach chair position, right shoulder, arthroscopic view from the trans-supraspinatus portal. A drill guide is used to place a K-wire (KW) through the distal clavicle at the level between the conoid and trapezoid ligament insertion and through the central portion of the coracoid base (CB) using an aiming device (AD).

Fig 5

Shoulder model, right shoulder, after the confirmation of correct positioning through fluoroscopy. The K-wire is overdrilled using a cannulated 4-mm drill (CD) and the K-wire is removed.

Fig 6

Beach chair position, right shoulder, arthroscopic view from the trans-supraspinatus portal. A suture passing device (PD) is inserted through the cannulated drill (CD) and removed through the anteroinferolateral portal using a conventional grasper. (CB, coracoid base.)

Fig 7

Shoulder model, right shoulder; the strands of the suture tape (ST) (FiberTape, Arthrex) are inserted into a cortical fixation button (DogBone, Arthrex) outside the anteroinferolateral portal. The 2 strands of the suture tape and the Ethibond sutures of one graft end (GR) are threaded inside the passing device (PD).

Fig 8

Beach chair position, right shoulder, arthroscopic view from the trans-supraspinatus portal; using a passing suture, strands of a suture tape (ST) (FiberTape, Arthrex) along with the Ethibond sutures of one end of the graft are pulled through the bone tunnel from inferior to superior through the anteroinferolateral portal. (CB, coracoid base.)

Fig 9

Beach chair position, right shoulder, arthroscopic view from the trans-supraspinatus portal; the cortical fixation button (DogBone [DB], Arthrex) is positioned at the undersurface of the coracoid process (CB) and above the graft by pulling on the suture tapes.

Fig 10

Shoulder model, right shoulder, view from the anterosuperior portal; the free end of the graft (GR) is pulled superiorly in front of the clavicle using a grasper (e.g., FiberTape Retriever, Arthrex). (DB, DogBone; ST, suture tape.)

Fig 11

Shoulder model, right shoulder, view from above; the free end of the graft (GR) is pulled superiorly in front of the clavicle using a grasper (e.g., FiberTape Retriever, Arthrex). (ST, suture tape.)

Fig 12

Shoulder model, right shoulder, view from above; after the acromioclavicular joint is reduced, the 2 strands of the suture tape (ST) are knotted over a second cortical fixation button (DB) on the distal clavicle. After correct joint reduction is confirmed by fluoroscopy, the free ends of the graft (GR) are also knotted together over the clavicle leaving one long end.

Fig 13

Shoulder model, right shoulder, view from above; two 4-mm drill holes are placed through the acromion in the craniocaudal direction, approximately 1 cm lateral to the AC joint line. (AC, acromioclavicular; DB, DogBone; GR, graft; KW, K-wire; ST, suture tape.)

Fig 14

Beach chair position, right shoulder, arthroscopic view from the posterior portal, subacromial, inserted K-wire (KW) through the acromion (A).

Fig 15

Shoulder model, right shoulder, view from the lateral portal; a shuttle wire (PD) is needed to pull the graft (GR) into the subacromial space through the anterior acromial drill hole. (ST, suture tape.)

Fig 16

Shoulder model, right shoulder, view from the lateral portal; using a shuttle suture (PD), the graft (GR) is pulled into the subacromial space through the anterior acromial drill hole. Next, again a passing wire (PD) is used to pull the graft (GR) upward through the posterior drill hole. (ST, suture tape.)

Fig 17

Beach chair position, right shoulder, arthroscopic view from the posterior portal; using a shuttle suture, the graft (GR) is pulled into the subacromial space through the anterior acromial drill hole. Next, again a passing wire is used to pull the graft upward through the posterior drill hole. (A, acromion.)

Fig 18

Beach chair position, right shoulder, arthroscopic view from the posterior portal, subacromial graft placement (GR) after shuttling. (A, acromion.)

Fig 19

Shoulder model, right shoulder, view from above; the ends of the suture tapes (ST) and the end of the graft (GR) are knotted together, thus creating a trapezoidal acromioclavicular graft augmentation. The free ends are cut.

Fig 20

Shoulder model, right shoulder, view from the anterosuperior portal; the ends of the suture tapes (ST) and the end of the graft (GR) are knotted together, thus creating a trapezoidal acromioclavicular graft augmentation. The free ends are cut.

Fig 21

Shoulder model, right shoulder, view from above; graft (GR)/suture tape (ST)/DogBone construct after knotting and cutting the free ends.

Fig 22

Conventional anteroposterior radiographic view before surgery.

Fig 23

Conventional anteroposterior radiographic view after surgery.

Fig 24

Shoulder model, right shoulder, view from inferior, showing looping one strand of the graft (GR) in front of the clavicle and the other end through the coracoid base and distal clavicle. After knotting both ends above the clavicle, the longer strand is used to create the AC augmentation. (AC, acromioclavicular; DB, DogBone.)