Arthroscopically Assisted Double-Loop Suture Repair for Acute Acromioclavicular Joint Disruption

Abstract

The surgical management of acute high-grade acromioclavicular (AC) joint (ACJ) injuries has evolved during the last decades. Numerous surgical techniques exist and recently arthroscopically assisted or all endoscopic techniques have gained popularity due to certain advantages. The goals of the new anatomic coracoclavicular ligament reconstruction techniques are to achieve anatomic reduction of the ACJ to allow and facilitate primary healing of AC and coracoclavicular (CC) ligaments, and also to minimize the risk of associated complications. We regularly use the open repair with double-loop sutures for the acute ACJ disruption, as described by Dimakopoulos et al. at 2006. In this surgical technique article, we present the arthroscopically assisted technique for the double-loop suture repair.

Fig 1

Beach chair position, right shoulder, outside view of arthroscopic portals. C, coracoid portal; MG, midglenoid portal; P, posterior standard portal.

Fig 2

Glenohumeral arthroscopy. Beach chair position, right shoulder, arthroscopic view from the posterior portal. Through the midglenoid portal as working portal, the rotator interval is opened (A) and the coracoid is dissected as much as the viewing from posterior portal allows (B), especially the lateral, superior, and inferior surface using a radiofrequency ablation device (Apollo RF MP90, Arthrex). A, anteriorly; C, coracoid; G, glenoid labrum; P, posteriorly; RI, rotator interval.

Fig 3

Coracoid dissection. Beach chair position, right shoulder, arthroscopic view from the posterior portal. (A) Through the midglenoid as working portal, the coracoid is further dissected on its inferior surface. (B) The coracoid portal is created with the outside-in needle technique just over the coracoid (red arrow). (C) The dissection of the medial side of the coracoid process is facilitated through the coracoid portal. (D) At the superior aspect of the coracoid towards its base, remnants of the torn coracoclavicular (CC) ligaments are identified and preserved when possible. C, coracoid, M, medially.

Fig 4

Passage of the sutures around coracoid base. Beach chair position, right shoulder, arthroscopic view from the anterolateral portal. (A) A suture is brought via coracoid portal to the medial side of the coracoid process (red arrow) and then is retrieved from midglenoid portal. (B) This shuttle relay suture brings four Ethibond No 5 sutures (Ethicon, Inc, Somerville, NJ) from the coracoid portal, around the base of the coracoid process, out to the midglenoid portal. In this way four limbs of the sutures are placed medially through the coracoid portal (red arrow) and four limbs laterally through the midglenoid portal (black arrow). C, coracoid; SR, suture retriever through midglenoid portal.

Fig 5

Subacromial arthroscopy. Beach chair position, right shoulder, arthroscopic view from the standard posterior portal. The RF ablation device (Apollo RF MP90, Arthrex) is used through the lateral portal to debride the subacromial space. A, acromion; L, laterally.

Fig 6

Dissection of acromioclavicular joint and lateral clavicle. Beach chair position, right shoulder, arthroscopic view from the lateral portal. (A) Through the midglenoid as working portal the inferior part of the acromioclavicular joint (ACJ) (red arrow) is debrided and exposed. (B) An accessory anterosuperior (AS) portal parallel to ACJ (black arrow) is created with the outside-in technique using a spinal needle (red arrow). (C) Through the AS working portal, the debridement of the ACJ and medial part of lateral clavicle proceeds. (D) Through the midglenoid as working portal, the underlying soft tissue of coracoclavicular space can be pushed down with a probe to facilitate the viewing and dissection. A, acromion; CL, medial part of lateral clavicle; ICL lateral clavicle.

Fig 7

Preparation of coracoclavicular space. Beach chair position, right shoulder, arthroscopic view from the anterolateral portal. (A) The coracoclavicular space is adequately debrided, and the lateral limbs of the four Ethibond sutures are visible and accessible (black arrow). The radiofrequency ablation device is through the midglenoid portal. (B) The lateral limbs of the Ethibond sutures (black arrow) are taken through the midglenoid portal to ensure their unhindered route and free them from surrounding soft tissue. CCf, coracoclavicular fascia CC, coracoclavicular space.

Fig 8

Clavicular bone tunnel. Beach chair position, right shoulder. Outside view showing the skin incision made at the superior aspect of clavicle at 2.5-3 cm from the acromioclavicular joint. The clavicle has been dissected and Hohmann retractors have been placed at the anterior and posterior clavicle borders. The four sutures have been placed on the midglenoid (lateral limbs) and anterosuperior (medial limbs) portals. AL, anterolateral; AS, anterosuperior; C, coracoid; MG, midglenoid portal.

Fig 9

Step 5. Clavicular bone tunnel. Beach chair position, right shoulder, arthroscopic view from the anterolateral portal. (A) A K-wire has been placed through the distal clavicle at the middle of its anteroposterior width (black arrow), at the level between the conoid and trapezoid ligament insertion directed toward the coracoid base. The optimal position of the K-wire is controlled arthroscopically. (B) The K-wire is overdrilled using cannulated drill (black arrow) gradually up to the 4.5-mm drill bit. (C) Using a wire and a shuttle suture, the lateral four limbs of the four Ethibond sutures (black arrow) are passed through the clavicular bone tunnel (red arrow). (D) Respective outside view for part C. The lateral four limbs of the 4 Ethibond sutures are passed through the clavicular bone tunnel (black arrow), and the medial limbs are passed through the anterosuperior portal (AS). (E) The suture retriever is used to bring two of the medial limbs of sutures (black arrow) just anteriorly to the clavicle and the other two limbs of the medial sutures (red arrow) will be passed directly posteriorly to the clavicle. (F) Respective outside view for part E. The lateral four limbs of the 4 Ethibond sutures are passed through the clavicular bone tunnel (black arrow). Two of the medial sutures are passed posteriorly (red arrow) to the clavicle and the other two anteriorly (dashed arrow). AS, anterosuperior portal; AL, anterolateral portal; C, coracoid process; CL, clavicle; Cp, coracoid portal; MG, midglenoid portal.

Fig 10

Step 6. Coracoclavicular fixation. Beach chair position, right shoulder. (A) Outside view. After reduction of the acromioclavicular joint, we tie the four suture pairs in order to reduce the ACJ on the anteroposterior and superoinferior direction. One of the anterior sutures (black arrow) is tied with the respective suture limb through the clavicular bone tunnel (red arrow). (B) Arthroscopic view from the anterolateral portal. Final construct after all the four pairs of the sutures have been tied. Two of the medial sutures are driven posteriorly (black arrow) to the clavicle and two anteriorly to the clavicle (red arrow). C, coracoid process; CL, clavicle.

Fig 11

Remnants of the superior capsule and then the deltotrapezial fascia are reconstructed with vicryl suture (white arrow). A, anteriorly, L, laterally, M, medially; P, posteriorly.