Arthroscopic-Assisted Acromioclavicular Joint Reconstruction Using the TightRope Device With Allograft Augmentation: Surgical Technique

Arthroscopic Anatomical Acromioclavicular Joint Reconstruction using a Button Device and a Semitendinosus Graft

Objective

To report a new technique for anatomical acromioclavicular (AC) joint reconstruction.

Methods

In order to minimize such complications, the authors describe a new anatomical and biological AC joint repair. This technique aims to provide greater stability by using two anatomically placed clavicular tunnels and a combined construct with a double endobutton cortical fixation for primary stabilization, and to be biologically advantageous by using an autologous semitendinosus (ST) tendon graft. Additionally, the coracoclavicular ligament reconstruction is complemented with an AC joint cerclage and capsular reinforcement, which will protect the biological construction in its initial stage of healing.

Results

This technique provides adequate primary and secondary biomechanical stability by passing both a semitendinosus autogenous graft and a double endobutton device, through anatomically placed and small diameter clavicle holes, without the need for coracoid drilling. Our technique showed encouraging results regarding pain resolution, range of motion, and function. At final follow‐up we experienced excellent results with average pain score of 1.6, and average ROM of 159° of forward flexion, 160° of abduction, 68° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 87 and a Subjective Shoulder Value of 89 points. This technique also achieved perfectly acceptable radiographic results, with an average coracoclavicular distance increase of 0.8 mm. Regarding complications, our sample showed one case of AC join subluxation, two cases of internal saphenous nerve injury, and two partial graft tears at the suture‐button interface, with none of these requiring surgical revision.

Conclusion

This technique is advantageous in treatment of acromioclavicular joint dislocation and can be performed in both the subacute and chronic setting.

Anchorless Acromioclavicular and Coracoclavicular Ligament Repair Using a Graft-Passing Instrument to Pass Suture Under the Coracoid

Acromioclavicular joint separation is a common shoulder injury. Grade I and II separation may be treated nonoperatively, whereas higher grades tend to require surgical intervention. Various repair techniques have been described in the literature, with no consensus on the gold standard. This Technical Note describes our use of a graft-passing instrument to pass suture under the coracoid during an anatomic reconstruction of both the acromioclavicular and coracoclavicular ligaments. Although this approach is technically challenging, it avoids coracoid drilling and requires smaller-diameter clavicle and acromion drilling. Furthermore, using suture instead of graft material increases the cost-effectiveness of the procedure.

Suture augmentation of acromioclavicular and coracoclavicular ligament reconstruction for acute acromioclavicular dislocation

The objective of this report was to introduce a new suture augmentation of coracoclavicular (CC) and acromioclavicular ligament reconstruction for acute Rockwood grade III to V acromioclavicular dislocations.From January 2015 to January 2019, 43 patients with Rockwood III to VI acute acromioclavicular dislocations were retrospectively reviewed. For comparison, another series of 28 patients treated with double Endobutton technique from January 2011 to December 2014 were reviewed. A P < .05 was considered statistical significance.The mean follow-up period of the 2 series were 39.69 ± 7.42 months (range, 24-54 months) and 37.86 ± 8.23 months (range, 26-48 months) (P > .05), respectively. There were significant differences regarding CC space (11.62 ± 2.54 mm vs 16.78 ± 5.53 mm; P < .05), CC reduction loss (5.56 ± 4.73 mm vs 26.25 ± 4.42 mm; P < .05), and acromioclavicular space (6.89 ± 1.87 mm vs 7.95 ± 2.37 mm; P < .05). There were significant differences regarding the disabilities of the arm, shoulder, and hand questionnaire (3.3 ± 2.8 vs 5.32 ± 4.37; P < .05) and University of California-Los Angeles shoulder rating scale (31.19 ± 2.48 vs 29.24 ± 2.48; P < .05). The excellent to good percentages were 100% (n = 32) and 85% (n = 23), respectively.In conclusion, the suture augmentation of acromioclavicular and CC ligament reconstruction is a reliable technique for acute acromioclavicular dislocation with minimal complications.Type of study/level of evidence: Therapeutic IIa.

Outcomes of acromioclavicular joint dislocation using tightrope arthroscopy

BACKGROUND

Based on different treatment outcomes and different treatment methods for acromioclavicular dislocation, we decided to evaluate the treatment outcomes of acromioclavicular joint dislocation using tightrope arthroscopy.

METHODS

This retrospective cross-sectional study was performed on patients with acromioclavicular joint dislocation referred to Alzahra Hospital in Isfahan and Abadan-Iran from 2015 to 2017. Information that was assessed included age, sex, type of dislocation (Figure 1), duration of injury, cause of injury, complications such as osteoarthritis, changes in the distance between the joints, as well as the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were collected after 6 months of surgery.

RESULTS

There was a significant relationship between horizontal change instability and type of injury that 9 cases (60%) of type 5 of injury and 0 of type 3 had horizontal change instability (P=0.01). There was a reverse significant correlation between ASES score and duration of injury (r=-0.58, P=0.01).

CONCLUSION

Acromioclavicular joint dislocations could successfully be treated with the TightRope system. We also showed that patient's pain and functions are diversely correlated with injury durations.

[Arthroscopically-assisted treatment of acute and chronic dislocations of the acromioclavicular joint : A prospective clinical trial]

BACKGROUND

Injuries of the acromioclavicular joint (ACJ) are frequent and often occur during sports. While arthroscopically-assisted stabilization of acute injuries of the ACJ is a well-established procedure, there is not much data available for arthroscopically-assisted stabilization of chronic injuries of the ACJ.

OBJECTIVES

This study assesses clinical and radiological results of arthroscopically-assisted stabilization of acute and chronic injuries of the ACJ.

MATERIALS AND METHODS

Thirty-six patients with acute and chronic injuries of the ACJ were assessed in a prospective clinical trial. Twenty-five patients with acute injuries (group A) and eleven patients with chronic injuries (group B) were included in this study. Patients of group A were operated using two suture-button systems, while patients of group B received one suture-button system and an autologous gracilis tendon graft.

RESULTS

In group A, the mean preoperative Constant score rated 38, and the ASES score rated 34. At follow-up the Constant score (92) and the ASES score (89) had improved. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (15.8 mm) in comparison to the contralateral shoulder (10.9 mm). In group B, the preoperative Constant score measured 57. It improved to 72 points at follow-up. The ASES score improved from 39 to 72 points in the same period. Panorama views revealed an increased coracoclavicular distance of the affected shoulder (18.9 mm) in comparison to the contralateral shoulder (12.4 mm).

CONCLUSIONS

Stabilization of acute injuries of the ACJ with two suture-button systems is related to very good shoulder function after one year. The native coracoclavicular distance cannot be restored with this procedure. Stabilization of chronic injuries of the ACJ with a suture-button system and an autologous gracilis tendon graft is related to improved shoulder function after one year. However, shoulder function cannot be fully restored with the stabilization technique presented.

Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis

Purpose

To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval.

Results

Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%).

Conclusions

Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants.

Clinical Relevance

Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.

Novel Double Endobutton Technique Combined with Three-Dimensional Printing: A Biomechanical Study of Reconstruction in Acromioclavicular Joint Dislocation

Objective

To reconstruct the acromioclavicular (AC) joint using an adjusted closed‐loop double Endobutton technique via a guiding locator that was applied using three‐dimensional (3D) printing technology. At the same time, the reliability and safety of the novel double Endobutton (NDE) were tested by comparing the biomechanics of this technique with the TightRope (TR) approach.

Methods

This retrospective study was conducted between January 2017 and January 2019. The Department of Anatomy at Southern Medical University obtained 18 fresh‐frozen specimens (8 left and 10 right; 12 men and 6 women). First, the guiding locators were applied using 3D printing technology. After preparation of materials, specimens were divided into an NDE group, a TR group, and a normal group. In the NDE and TR groups, the navigation module was used to locate and establish the bone tunnels; after that, the NDE or TR was implanted. However, the Endobuttons were fixed while pressing the distal clavicle downwards and the length of the loop could be adjusted by changing the upper Endobutton in the NDE group while the suture button construct was tensioned and knotted after pressing down the distal clavicle in the TR. Finally, load testing in anterior–posterior (AP), superior–inferior (SI), and medial–lateral (ML) directions as well as load‐to‐failure testing in the SI direction were undertaken to verify whether the NDE or TR had better biomechanics.

Results

In the load testing, the displacements of the NDE and TR groups in the AP, SI, and ML direction were significantly shorter than those of the normal group (P < 0.05). In the load‐to‐failure testing, the ultimate load of the NDE and TR groups had significantly higher increases than the normal group (722.16 ± 92.04 vs 564.63 ± 63.05, P < 0.05; 680.20 ± 110.29 vs 564.63 ± 63.05, P < 0.05). However, there was no statistically significant difference between the two techniques for these two tests (P > 0.05). In the NDE group, four of six failures were a result of tunnel fractures of the coracoid, while two of six were due to suture breakage. In the TR, three failures were due to coracoid tunnel fractures, one was a result of a clavicle tunnel fracture, and the rest were due to suture breakage. In the normal group, half of the failures were a result of avulsion fractures of the conical ligament at the point of the coracoid process, and the other three were due to rupture of the conical ligament, fracture of the distal clavicle, and fracture of the scapular body.

Conclusion

As for the TR technique, the stability and strength of the AC joint were better in patients who underwent reconstruction using the NDE technique than in the intact state.

Arthroscopic Acromioclavicular Joint Treatment With Coracoclavicular Fixation and Allograft Coracoclavicular Ligament Reconstruction for Acute Acromioclavicular Dislocations

Treatment of severe acromioclavicular joint injuries remains controversial and has evolved over the past 4-plus decades. Although several variations on reconstruction exist, an ideal technique will likely use a combination of coracoclavicular ligament reconstruction with suture backup stabilization, minimal drill holes to reduce the risk of fracture, arthroscopic-assisted guidance for anatomic graft and suture placement in and around the coracoid, and fluoroscopic-aided reduction to ensure an anatomic acromioclavicular joint. The objective of this Technical Note is to describe an arthroscopic-assisted coracoclavicular ligament reconstruction with allograft using fluoroscopically guided and cerclage-controlled anatomic reduction of the acromioclavicular joint.

Challenges in Treating Acromioclavicular Separations: Current Concepts

Injuries to the acromioclavicular joint constitute approximately 3.2% of shoulder injuries. Although the overall goal of treatment continues to be return to activity with a pain-free shoulder, the treatment of acromioclavicular joint separations has been fraught with conflict since the earliest reports in both ancient and modern literature. Accurate diagnosis and classification are important to determine the optimal treatment. Nonsurgical therapy remains the mainstay for treatment of low- and most mid-grade injuries, although recent biomechanical and biokinetic data might suggest that patients are more affected than traditionally thought. High-grade injuries often necessitate surgical intervention, although little consensus exists on the timing or technique. New surgical techniques continue to evolve as more biomechanical data emerge and kinematic understanding improves. Challenges associated with management of this injury abound from diagnosis to reconstruction.

Acromioclavicular joint injuries: diagnosis, classification and ligamentoplasty procedures

Acromioclavicular (AC) joint injury is a frequent diagnosis after an acute shoulder trauma – often found among athletes and people involved in contact sports.

This injury occurs five times more frequently in men than in women, with the highest incidence in the 20- to 30-year-old age group. Patients usually complain of pain and tenderness over the shoulder, particularly over the AC joint.

Depending on the degree of injury, the clavicle may become prominent on the injured site.

The original classification was described by Rockwood and Green according to the injured ligament complex and degree and direction of clavicular displacement.

Many surgical procedures have been described; among these are screws, plates, muscle transfer, ligamentoplasty procedures and ligament reconstruction using either autograft or allografts.

With the advancement of shoulder arthroscopy, surgeons are much more capable of performing mini-open or arthroscopically-assisted procedures, allowing patients an earlier return to their daily living activities. However, the results of conventional open techniques are still comparable.

The introduction of new arthroscopic equipment provides a great variety of surgical procedures, though every new technique has its own advantages and pitfalls. Currently there is no gold standard for the surgical treatment of any type of AC injury, though it should be remembered that whenever an arthroscopic technique is chosen, the surgeon’s expertise is likely to be the most significant factor affecting outcome.

Cite this article: EFORT Open Rev 2018;3:426-433. DOI: 10.1302/2058-5241.3.170027

Arthroscopic fixation of acute acromioclavicular joint disruption with TightRope™: Outcome and complications after minimum 2 (2-5) years follow-up

PURPOSE

To evaluate the midterm results of arthroscopic reconstruction of acute acromioclavicular (AC) joint disruption using TightRope™ system.

METHODS AND MATERIAL

We retrospectively assess the results of 24 patients of acute AC joint dislocation who were operated using TightRope system. Constant and University of California, Los Angeles (UCLA) scores and coracoclavicular distance were calculated pre- and postoperatively. Data was entered into MS excel and analyzed using the SPSS version 17.

RESULTS

The mean follow-up was 39.45 months. Constant and UCLA scores were significantly increased postoperatively. Six patients had partial loss of reduction within 3-6 months and two patients had a failure of construct. Constant score was significantly lower in these patients.

CONCLUSION

TightRope reconstruction of the AC joint is a reproducible and safe alternative to many other techniques of AC joint reconstruction. Early subluxation remains a concern and may reflect the need for technique modification.

Editorial Commentary: Is Posterior Distal Clavicle Beveling for Chronic Nonincarcerated Type IV Acromioclavicular Separation a Sufficient Treatment?

While low-grade acromioclavicular injuries can be managed nonoperatively, high-grade separations may result in persistent pain or functional decline and require surgical intervention. The authors of "Posterior Distal Clavicle Beveling for Chronic Nonincarcerated Type IV Acromioclavicular Separations: Surgical Technique and Early Clinical Outcomes" present a case series reporting convincing results concerning functional outcomes and early return-to-sport rates for this rather rare condition. While this technique seemed to work well in this small series of patients, in our opinion, this procedure should be reserved for use in exceptional cases only.