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Open reconstruction of acromioclavicular joint using Arthrex Tightropes

    Overview

    Learn the Open reconstruction of acromioclavicular joint using Arthrex Tightropes surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open reconstruction of acromioclavicular joint using Arthrex Tightropes surgical procedure.
    Injuries to the acromioclavicular (AC) joint are common, making up approximately 4 to 9% of injuries to the shoulder girdle.
    AC injuries frequently occur during sporting activities, particularly contact pursuits or those with a significant risk of falling, such as cycling. Injuries to the ACJ are 5 times more common in men with a peak incidence in the 20’s to 30’s. The injury typically occurs as a consequence of an inferior force on the lateral portion of the shoulder but may occur as a consequence of force exerted on the humerus.
    In general surgical intervention will confer an improvement in cosmesis and may improve function particularly during overhead activities.
    Acute stabilisation is generally considered to be within 2-3 weeks of injury. Beyond this time frame the capacity for the ligaments to heal or scar at an appropriate length following a reduction and stabilisation procedure is likely to be compromised.
    Numerous alternative procedures have been developed for the management of these injuries in the younger and more active patient. The AC Tightrope (Arthrex) reconstruction was developed originally as an arthroscopic technique by Mr Duncan Tennent (St George’s Hospital, London). This is detailed on OrthOracle at https://www.orthoracle.com/library/arthroscopic-repair-acute-acromioclavicular-joint-separation-arthrex-tightrope-system/. The technique uses a modification of the ankle Tightrope device to reduce and stabilise the coraco-clavicular relationship whilst the coraco-clavicular ligaments heal. The implant acts as a temporary stabiliser and is not designed to provide long-term stability of the ACJ. Subsequent research has supported the benefit of using a double Tightrope technique in terms of strength and stability. The arthroscopic technique though requires a familiarity with arthroscopic shoulder surgery, as well as the availability of the associated arthroscopic equipment, and this may limit its use in a general trauma setting.
    The open technique I describe in this technique offers a number of advantages over the arthroscopic technique upon which it is based. Importantly it is an anatomically straightforward open approach which does not require a sub-coracoid dissection. This may minimise the risks to the adjacent neurovascular structures which are at risk with sub-coracoid and coracoid loop techniques. Additionally direct visualisation of the coracoid minimises some of the technical complications of this type of procedure including tunnel misplacement and coracoid fracture. Unlike some other devices, such as a hook plate, routine implant removal is not required using an Arthrex Tightrope. It is also worth noting that cosmetically there is little difference between the scars associated with the open and arthroscopic techniques.
    Non specific complications of CC ligament reconstruction include; scar, infection (approximately 1-4%), irritation from implant prominence requiring implant removal, ACJ discomfort requiring subsequent ACJ excision, post operative gleno-humeral joint stiffness (frozen shoulder approximately 5-8%), fracture (coracoid or clavicle), failure and loss of reduction, calcification of the CC ligaments, anaesthetic risks and neuro-vascular damage.

    Indications

    INDICATIONS
    Indications for acute ACJ stabilisation remain controversial.
    The anticipated indication is a significantly displaced and unstable ACJ injury (Rockwood Type III to V).
    Acute surgical stabilisation should occur within 2-3 weeks of injury.
    Indications include potential improvement in function, particularly with overhead activities, although the evidence remains controversial, correction of Scapula-Thoracic malposition and dysfunction and an improvement in the cosmetic appearance of the shoulder.
    Typically acute stabilisation is considered in the young and active population. Consideration should be given to bone quality and risk of failure with increasing age.
    Appropriate consent is required including a discussion of the risks and benefits of surgery as well as the alternative options and in particular conservative treatment.

    SYMPTOMS & EXAMINATION
    The symptoms are usually of pain and dysfunction. There is typically a clear deformity of the ACJ with inferior and anterior displacement of the Scapula and Gleno-humeral joint relative to the clavicle. Although it is often considered that the clavicle rides up, the principal displacement is of the Scapula. The Scapulo-Thoracic symmetry is often lost with prominence of the infero-medial border of the Scapula.
    If pain will allow, it is useful to bring the arm in to cross-body adduction and observe whether the acromin crosses under the clavicle or that the clavicle over-rides the acromion. This crossing over supports significant instability of the ACJ (ISAKOS modification Type IIIB) and a relative indication for acute stabilisation.
    Any associated injuries, particularly neuromuscular injuries, should be identified and investigated appropriately.
    IMAGING
    Plain radiographs – 3 view shoulder series (AP, Lateral and Axillary views).
    Occasionally instability of the ACJ may become more apparent with time on subsequent imaging.
    Further imaging such as MRI is not routinely indicated unless further associated injuries are suspected.
    CLASSIFICATION
    The classification of AC joint injuries typically progresses to reflect the anatomical structures considered to be sequentially effected during the injury. Specifically the Acromio-clavicular (AC) ligament is initially injured which is then followed by the Coraco-clavicular (CC) ligaments in more severe injuries. The resulting degree of displacement is also factored into the classification.
    The Rockwood classification remains widely used with most ACJ injuries falling in to Type I to V.
    Type I injuries reflect a sprain of the AC ligaments without displacement or deformity.
    Type II injuries reflect rupture of the AC ligaments and with the CC ligaments preserved.
    Type III injuries reflect rupture of both the AC and CC ligaments with significant deformity of between 25 and 100%. A modification has been suggested separating Type III injuries into IIIa and IIIb reflecting over-riding for the distal clavicle on the acromion in cross-body adduction and a more unstable injury.
    The Type IV injuries involve posterior displacement of the clavicle into or through the trapezius muscle.
    Type V injuries are involve disruption of the AC and CC ligaments as well as the Deltoid and Trapezius muscle attachments.
    Type I and II injuries and may be treated conservatively and symptomatically with with rest, analgesia, a sling for comfort and physiotherapy.
    The management of type III injuries remains controversial and requires a careful discussion of potential risks and benefits.
    Type IV and V injuries involve disruption of both the AC and CC ligaments and are typically considered reasonable but not absolute indications for surgical intervention.
    ALTERNATIVE OPERATIVE TREATMENT
    There are numerous alternative operative techniques including; Artificial grafts, such as the Lockdown or Lars Ligament ( detailed on OrthOracle at https://www.orthoracle.com/library/lars-ligament-reconstruction-stabilisation-acromioclavicular-joint/) reconstruction and Hook plate fixation.
    The Weaver-Dunn procedure is one of the classic surgical treatments for ACJ injuries where the function of the CC ligaments is replaced by a transfer of the acromio-clavicular ligament to the distal clavicle. This allows the late reconstruction of ACJ injuries.
    NON-OPERATIVE MANAGEMENT
    Conservative management is in the form a sling for comfort with mobilisation as pain allows and rehabilitation and physiotherapy. A return to activities is dependent on symptoms.
    CONTRAINDICATIONS
    Contraindications include a wound or infection at the operative site and fracture of the coracoid. Smoking may adversely affect healing and increase the risk of failure.

    Setup

    A single dose of prophylactic antibiotics is given at induction.
    The patient is placed in a relaxed beach chair position. A T-Max or alternative shoulder attachment may be used. The effected shoulder is placed clear of the table or over a radiolucent section to allow intra-operative imaging of the shoulder. The head is placed on a head-ring or support and secured with a facemark or tape placed at least 1cm above the eyebrows. A ‘J’ Board is placed on the affected side to maintain the position of the arm. The contralateral arm is secured in a relaxed and safe position on a small arm table, avoiding any pressure on the ulnar nerve in particular.
    Appropriately sized Thrombo-Embolic Stockings (TEDS) and Flowtrons are applied unless contra-indicated.

    Operation – 1

    A single dose of prophylactic antibiotics is given at induction.
    The patient is placed in a relaxed beach chair position. A T-Max or alternative shoulder attachment may be used. The effected shoulder is placed clear of the table or over a radiolucent section to allow intra-operative imaging of the shoulder. The head is placed on a head-ring or support and secured with a facemark or tape placed 1cm above the eyebrows. A ‘J’ Board is placed on the affected side to maintain the position of the arm. The contralateral arm is secured in a relaxed and safe position on a small arm table.
    Appropriately sized Thrombo-Embolic Stockings (TEDS) and Flowtrons are applied unless contra-indicated.

    The landmarks of the acromion (A), coracoid (B) and distal clavicle (C) are marked.

    An oblique skin incision of approximately 5cm is marked over the distal clavicle extending medially towards the coracoid.

    The hand, arm and shoulder are prepared and draped allowing the arm to be moved freely. The whole of the shoulder and base of the neck to the sterno-clavicular joint should be exposed.

    0.25% Chirocaine with adrenaline is administered subcutaneously along the incision and down on to the tip of the coracoid.

    The skin is opened with sharp dissection. The skin window is then mobilised with cutting diathermy. Cutting diathermy is utilised for the majority of the dissection beyond the skin layers. The delto-trapezial fascia is exposed and then opened along the length of the clavicle extending across the superior ACJ capsule. The superior ACJ capsule may already be disrupted and the distal clavicle denuded as part of the injury.

    One of the advantages of the technique is that it avoids the requirement to dissect under the coracoid and thereby minimises the risk of damage to the neurovascular structures in proximity to the coracoid and in particular the brachial plexus and its branches as well as the axillary vessels and their branches. The musculocutaneous nerve is particularly at risk as it enters the conjoint tendon during the passage of hooks or loops around the coracoid.
    However, great care needs to be taken to avoid inadvertent damage to the neurovascular structures when drilling through the inferior cortex of the coracoid. A fresh sharp drill is advised and the drill should be advanced slowly just penetrating through the inferior cortex of the coracoid, avoiding over penetration.
    Two 4mm drill hoes are made through the coracoid. The first is placed posteriorly at the base of the coracoid. The drill should be passed through the middle of the coracoid and typically angled slightly anteriorly. The second drill hole is placed approximately 5 mm anterior to the first in the long axis of the coracoid. Again the drill should pass through the middle of the coracoid and typically angled slightly anteriorly. It should be noted that the long axis of the coracoid is not typically in the AP plane.
    Placement of the coracoid drill holes is crucial and most reported Tightrope failures are due to technical issues in tunnel placement. The concerns are principally of implant cut out and potentially coracoid fracture.
    It is worth visualising as straight a path as possible for the intended Tightropes through the clavicle and coracoid in the reduced position rather than in the displaced position. The intention being to create as straight a path as possible whilst optimising tunnel position to avoid cut out of the buttons and reduce stress or fretting on the implant.
    Once satisfactory drill holes have been achieved the retractors are removed for the time being.

    The superior aspect of the clavicle is then exposed with 2 small Hohmann retractors placed posteriorly (C).
    Two 4mm drill holes are then placed through the clavicle starting just posterior to the longitudinal mid-axis. The holes are placed approximately 2cm and 4cm from the lateral margin of the clavicle (B), reflecting the approximate origin of the Trapezoid (lateral) and Conoid (medial) ligaments.
    The drill holes should be aimed towards the pre-drilled holes in the coracoid as they lie in relation to the reduced clavicle (A). The medial hole is typically drilled in a somewhat anterior and lateral direction and the lateral hole in a somewhat anterior and medial direction.
    The undersurface of the clavicle may be stripped of soft tissue as part of the injury. If this is not the case the undersurface of the clavicle should be cleared sufficiently to allow the guide wires to be retrieved as they are passed through the clavicle.

    Once the delto-trapezial fascia has been divided the distal clavicle is and ACJ are exposed. The trapezius may be released posteriorly but the deltoid origin anteriorly should be preserved as much as possible.

    The oblique fibres of deltoid are exposed. The position of the coracoid is confirmed by palpation and a split is made in the deltoid fibres starting from the anterior edge of the clavicle, just medial to the coracoid.
    The deltoid split is extended obliquely in the line of the fibres, again using cutting diathermy, using a West self-retainer to separate the fibres as the split is developed.
    The coracoid should be palpated through the split to confirm the safe development of the split above the coracoid.
    Just under the deltoid there is typically at least one vessel crossing the surgical field from medial to lateral which is worth identifying and cauterising.
    Care should be taken through out given the proximity to the brachial plexus and axially vessels under the coracoid.

    The superior surface of the coracoid is again palpated. The tip of the coracoid is identified and exposed with a Langenbeck retractor (CT). The origin of the conjoint tendon (short head of biceps and coracobrachialis can be palpated). The superior aspect of the coracoid is dissected and this extended medially and laterally to identify the margins of the coracoid. The Pec Minor and CA ligament are preserved. A small Hohmanns’ retractor placed carefully on the medial (PM) and lateral margins (CA) of the coracoid.
    A further Langenbeck retractor is placed posteriorly to expose the base of the coracoid and insertion of the CC ligaments (P). Clear visualisation of the entire superior aspect of the Coracoid can thereby be achieved.

    The two ACJ Tightropes (Arthrex) boxes are opened. Two Tightropes and the two Nitinol passing wires are required.
    The Tightrope implant is composed of a round clavicular button (D) and an oblong Coracoid button (B) with a blue Fibrewire pulley suture (C). In addition there are two white sutures on the Coracoid button (A) and a white handling suture around the pulley sutures (E). The implant should ideally be held and manipulated by the white sutures to avoid inadvertent and premature tightening of the implant.

    The Nitinol guide wire is placed through the medial clavicular hole (A) and retrieved with care using a clip from under the clavicle (B). It is preferable to pass the wire such that is only just though the clavicle but can still be grasped just it appears through the inferior cortex. If more wire is passed through the clavicle it tends to get caught on the surrounding sift tissue and may be more difficult to retrieve.
    One should be aware of the surrounding neurovascular structures which are potentially at risk, including the brachial plexus and its branches as well as the subclavian vessels and the associated branches. With appropriate care these structures should be well outside the surgical field.

    Once the medial wire has been passed the process is repeated with the lateral wire.
    The medial wire is shown passing through the superior cortex of the clavicle (A) and out of the inferior surface above the coracoid (B) and the lateral wire is being introduced through the superior surface of the clavicle (C) prior to being retrieved from the undersurface.

    Once the wires have been passed the white lead coracoid-button suture of the first Tightrope is secured through the medial Nitinol loop.

    The medial Nitinol wire (B) is then pulled through the clavicle with the white lead suture (A).

    The white lead suture (A) is used to pull the oblong coracoid button through the clavicle.
    A degree of counter tension should be maintained on the trailing white coracoid-button suture (B) to maintain the alignment of the button with the clavicle tunnel and to prevent the button flipping during passage through the clavicle.


    In addition to pulling the white lead suture it is helpful to place a finger on the suture under the clavicle to direct the traction on this suture inferiorly rather than anteriorly.

    Once the Coracoid button is through the clavicle the Tightrope can be pulled through until the clavicle button is flush with the superior surface of the clavicle.

    Once the Tightrope is through the clavicle the white coracoid-button sutures can be removed. The white handling suture should be retained.

    The process is then repeated with the lateral Tightrope.

    Once both Tightropes have been passed successfully through the clavicle and the white leading sutures on the coracoid-button are removed, the superior surface of the coracoid is again exposed by again placing two small Hohmann retractors on the medial and lateral borders of the coracoid with a Langenbeck retractor anteriorly.
    The coracoid drill holes are again identified and the direction of the tunnels confirmed. A closed Gillies forceps may be helpful in confirming the tunnel placement.

    The coracoid button of the medial Tightrope is carefully held at one end with a clip and the opposite end of the button placed in the posterior coracoid tunnel. The button should still be visible flush with the superior surface of the coracoid.

    A closed Gillies forceps is then used to push the button through the coracoid tunnel in one smooth movement. The Gillies forceps should pass through the coracoid tunnel without significant resistance. Once the button has been pushed through the tunnel to the undersurface of the coracoid the button should flip spontaneously securing itself against the undersurface.


    Once the coracoid button has been passed through the coracoid, traction can be applied on the white handling suture (A). The coracoid button should flip and provide a secure fixation against which firm force may be applied.
    Once a satisfactory hold has been confirmed from the medial button the tension on the handling suture can be released and the process repeated with the lateral button.
    Once the buttons have flipped successfully tension does not need to be maintained.
    If the button comes free out of the coracoid as tension is applied to the handling suture re-confim the direction of the coracoid tunnel and repeat the deployment process. Correct passage can normally be confirmed by the easy passage of closed Gillies forceps through the coracoid tunnel without being obstructed by the button.

    Operation – 2

    The Tightropes are tightened by alternating traction on the sutures (A & B) and by so doing the relationship between the Coracoid and Clavicle is restored.
    It is desirable to do so incrementally with small pulling movements. Once one is secured the other is then tightened in the same way.
    The ACJ should be checked to ensure there is no soft tissue interposition that might impair reduction of the joint.
    The two Tightropes should then be snugged down again.
    Care should be taken not to over tighten the devices and the position should be confirmed on intra-operative imaging.

    The Tightropes are secured with a series of alternating half hitches. It is desirable to use multiple knots to provide a secure hold and to produce a long ‘tail’ which can then be laid flat under the subsequent fascial repair. A short ‘tail’ will tend to be more prominent and is more likely to cause irritation.

    The Deltoid split does not need to be closed but care should be taken to repair any deltoid detachment. The Delto-trapezial fascia and superior ACJ capsule are closed carefully and repaired with a sturdy absorbable suture such as 1 Vicryl (Ethicon).

    The subcutaneous tissues are closed with a light absorbable suture such as 2/0 Vicryl (Ethicon).

    The skin is closed with an absorbable monofilament such as Monocryl (Ethicon) as a knotless closure with the tails brought out through the skin.

    The wound is covered by Steri-Strips (3M) and an absorbent gauze dressing.

    The wound is covered with an occlusive Opsite (Smith and Nephew) type dressing. The arm is then placed in a Polysling.

    The Tightrope pulley system is such that the sutures do not need to be held under tension but can be released and the reduction confirmed by intra-operative imaging in both the AP and Axial planes.
    Further adjustments of the Tightrope can then be made. It should be noted that tightening of the Tightrope is typically straightforward but loosening of an over tightened implant is more difficult.

    Pre-operative plain radiographs consistent with an ACJ dislocation reflecting disruption of the AC and CC ligaments.

    Intra-operative imaging should confirm the correct deployment of the Tightrope implants and a satisfactory reduction of the ACJ in an AP and axial plane.
    The coracoid-buttons should deploy on the under surface but are frequently slightly angled reflecting the curved or V shape undersurface of the coracoid.
    The clavicle buttons should be flush with the superior aspect of the clavicle.

    A true axial view may be difficult to achieve but a satisfactory alignment of the anterior edge of the clavicle with the anterior acromion should be confirmed on intra-operative imaging.

    Post Operative

    Prior to discharge from hospital the patient is instructed in underarm hygiene and mobilisation of the hand,wrist and elbow. Pendular movements and external rotation of the shoulder and active mobilisation of the elbow are pursued.
    Review is arranged in the fracture clinic at 2 weeks to remove the OpSite (Smith and Nephew) dressings and Steri-Strips (3M). The Monocryl (Ethicon) stitch ends can then be trimmed at the level of the skin. Check radiographs are taken at this stage (AP shoulder, Scapula Lateral and Axillary views).
    Further clinical review and radiographs are undertaken at 6 weeks. At that stage the patient is able to come out of the sling and pursue active mobilisation of the shoulder avoiding significant resistance and elevation of the arm above shoulder height until 3 months.
    Further clinical review and radiographs are typically taken at 3 months. A return to full sporting activities is typically permitted at 6 months, providing rehabilitation has progressed appropriately.
    A more accelerated rehabilitation may be pursued but as with other ligamentous injuries there may be an increased risk of failure and re-rupture.

    Recommended Reading

    Open reduction and tunnelled suspensory device fixation compared with non-operative treatment for type III and type IV Acromioclavicular joint dislocations: ACORN prospective randomised controlled study. Murray IR et al J Bone Joint Surg Am. 2018 Nov 21;100(22):1912-1918.
    This is one of the few randomised controlled trials relating to ACJ injuries. 60 patients with type III and IV injuries were randomised to either non operative management or open double Tightrope fixation consistent with the technique described above.
    There was no significant difference in function at 1 year between the groups (DASH and OSS).
    16% of those those randomised to conservative management failed conservative management and crossed over to surgical stabilisation. Pain was the typical reason for cross over with one patient requesting surgery on the basis of the cosmetic deformity. The functional outcome of these patients was worse than those undergoing acute stabilisation.
    There were no intra-operative or wound complications and no infections.
    Functional recovery was faster with conservative management and return to sport at 12 months was potentially better with conservative management (85% vs 73%, not statistically different).
    Conservative management was significantly cheaper (£796 versus £3359).
    It concluded that SLF was an effective means of reducing and stabilising the ACJ but that it did not confer a significant advantage at 1 year and was not routinely indicated in type II and IV injuries.

    Post-operative outcomes and complications of suspensory loop fixation device versus hook plate in acute unstable acromioclavicular joint dislocation:a systematic review and meta-analysis. Arirachakaran A et al. J Orthop Traumatol. 2017 Dec;18(4):293-304.
    This review compared the results of Loop Suspensory Fixation (LSF) with Hook plate fixation(HP). The LSF studies were of mixed devices just over half used a single device (13/25) and more than half were arthroscopically assisted procedures (13/24).
    The quality of studies being reviewed was noted to be limited with 31 case series being included and the follow up was limited to 1-2 years.
    The conclusion was that LSF may have higher shoulder function post surgery (although the difference was considered statistically significant) and lower shoulder pain (which did appear statistically significant) than HP fixation. However the post operative complications were 1.7 times higher.
    Subgroup analysis suggested that double bundle techniques had higher functional scores and lower pain scores and that arthroscopic techniques appeared to have higher pain scores.

    The management of acute acromioclavicular dislocation. A randomised controlled trial. Bannister G et al. J Bone Joint Surg Br. 1989 Nov;71(5):848-50.
    This early study randomised 60 patients to conservative management or surgical stabilisation with a coracoclavicular screw fixation.
    Conservative management was associated with an earlier return to work and sport. The outcomes were otherwise comparable apart from in those patients with more than 2cm of displacement in whom the outcome was better with early surgical intervention.

    Reference

    • orthoracle.com

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