Learn the Acromioclavicular joint reconstruction with allograft and Arthrex Dog Bone suture buttons surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Acromioclavicular joint reconstruction with allograft and Arthrex Dog Bone suture buttons surgical procedure.
AC joint (ACJ) injuries are usefully classified using the Rockwood grading system, which considers the extent of injury to the ligamentous structures that support the ACJ (the capsule; the coraco-clavicular (CC) ligaments, the extent of displacement, and the extent of shoulder girdle muscle stripping and interposition between the distal clavicle and the acromion process of the scapula; the grading is described in more detail in the Overview section of the Arethrex Tightrope technique, which can be found at Arthroscopic repair of acute Acromioclavicular Joint Separation with the Arthrex TightRope system
There are two separate elements of the CC ligament complex, the conoid ligament (which passes from the “knuckle” at the base of the coracoid to a broader insertion on the undersurface of the clavicle, like an upside-down cone, forming the postero-medial part of the CC ligament complex) and the trapezoid ligament (which is more of a sheet, passing antero-laterally from the upper border of the coracoid to the undersurface of the clavicle).
Grade I and II injuries are initially treated non-operatively in the anticipation of restoration of good function; residual local pain can be treated in the same way as degenerative ACJ conditions with steroid injections for symptomatic control or excision of the distal clavicle. Injuries with wider displacement of the distal clavicle or soft tissue interposition (grades IV, V, and VI) are best acutely treated operatively.
The management of grade III injuries remains controversial, with many surgeons performing surgery acutely in high-level athletes and manual labourers, to more reliably restore function at an earlier stage.
In chronic symptomatic ACJ separations the use of soft-tissue graft techniques can be desirable to promote biological neoligament formation; soft tissue grafts can also be used in acute cases.
Arthroscopically-assisted techniques can be used and offer the advantages of the opportunity to assess and if necessary address concomitant intra-articular injuries, less invasive surgical dissection and better cosmesis.
Reported complications include loss of ACJ reduction, fracturing of the clavicle and the coracoid, and hardware prominence with skin irritation.
This operative technique describes using a single suture-button system, with Fibertapes and Dog-bone buttons (Arthrex), which has a few distinct advantages.
A semitendinosus allograft is is looped around the clavicle and the coracoid to anatomically and biologically reconstruct the CC ligaments in all cases; by looping the graft around the coracoid base rather than passing it through bone tunnels, a larger diameter, and so stronger, graft can be used without risk of fracture through the bone tunnels that would have been needed for trans-osseous tendon allografting. The graft also covers over the superior clavicle button, so reducing hardware prominence.
Readers will also find of interest the following OrthOracle techniques:
Arthroscopic repair of acute Acromioclavicular Joint Separation with the Arthrex TightRope system
Open reconstruction of acromioclavicular joint using Arthrex Tightropes.
LARS ligament reconstruction stabilisation acromioclavicular joint
Open excision of acromioclavicular joint (Mumford procedure)
My thanks to Mr Socrates Kalogrianitis FRCS (Tr & Orth) who is recorded performing this technique.
INDICATIONS
The AC joint is stabilized by static and dynamic stabilizers. The static stabilizers include the capsule and AC ligaments (superior, inferior, anterior, and posterior), the coracoacromial (CA) ligament, and the coracoclavicular (CC) ligaments (conoid and trapezoid). The dynamic muscular stabilizers include the trapezius and deltoid.
The need for acute surgery is largely determined by the Rockwood grade of injury.
The Rockwood classification of AC joint instability reflects the sequential loss of AC stabilizers and is useful in directing treatment.
A grade I injury involves a strain of the AC ligaments only.
A grade II injury involves disruption of the AC ligaments but the CC ligaments are intact.
In a grade III injury both the AC and CC ligaments are disrupted but the deltotrapezial fascia is intact, and displacement is <100%.
In a grade IV injury the AC and CC ligaments are disrupted and the lateral clavicle is displaced posteriorly into or through the trapezius muscle.
A grade V injury is similar to a type III, but the deltotrapezial fascia is stripped from the clavicle allowing superior displacement from 100% to 300%
Type VI injuries are very rare and represent complete AC dislocations with the lateral clavicle displaced inferior to the coracoid and the conjoined tendon.
Due to the wide displacement of the clavicle and potential for soft tissue interposition between the clavicle and the acromion, surgery is needed for Rockwood G IV-VI injuries. Conversely, for Rockwood GI-II injuries, non-surgical treatment will give good results and rapid recovery for most patients.
The management of Rockwood G-III injuries depends on the individual patient’s needs, so shared-decision making with the patient is important, balancing the more quicker and more predictable recovery period following acute surgery against the potential for surgical morbidity and complications. The procedure itself is likely to be very similar whether undertaken acutely or delayed, other than there being a greater likelihood of needing to excise the distal clavicle with delayed surgery. Patients where quick return to overhead use of the hand is needed may benefit from early surgery.
SYMPTOMS & EXAMINATION
Localised pain and tenderness, with prominence of the lateral clavicle. It is important to assess the condition of the rotator cuff to ensure there is no associated injury by assessing for impingement signs and cuff strength (in particular supraspinatus, with resisted abduction, and subscapularis, with the lift-off (ability to bring hand backwards from the buttock) and/or belly press signs), which is easier with delayed presentations; have a low threshold for obtaining an ultrasound or MRI scan to assess cuff integrity if there is any concern.
Use a finger palpate between the coracoid and the under side of the distal clavicle to assess for tenderness below the lateral clavicle, which indicates injury to the coraco-clavicular (CC) ligaments.
IMAGING
Plain film imaging is often all that is needed, to ensure the injury is purely soft-tissue to the ACJ capsule and ligaments, rather than a lateral clavicle fracture (in which case the coraco-clavicular ligaments (CC ligaments) may well remain attached onto the lateral fragment). In adolescents, remember the possibility of a physeal injury with an inferior periosteal sleeve. If the clinical examination has raised concern about a possible rotator cuff injury, then an ultrasound or MRI may be helpful (which could also assess the CC ligaments and in adolescents the possibility of a periosteal sleeve injury); if there is a lateral clavicle fracture, imaging of the CC ligaments and possibly a CT scan may be required to plan surgery.
ALTERNATIVE OPERATIVE TREATMENT
There is no sensible alternative to coraco-clavicular ligament reconstruction if the extent of injury or the patient’s circumstances indicate surgical treatment. A direct repair is not possible in most circumstances. If ligament reconstruction is to be undertaken, open or arthroscopic-assisted procedures to reduce and stabilise the AC joint can be undertaken, with a number or proprietary devices available to hold the reduction while the ligaments heal; some allow tissue in-growth, and some are designed to allow separate repair of the conoid and the trapezoid elements of the CC ligaments, although to date there is no good evidence that this will improve the surgical outcome. If there is a lateral clavicle fracture, using a device or system that will allow fracture fixation (plate) and separate CC ligament reconstruction without the two devices conflicting is important; the Acumed lateral fracture plate can accommodate the Acu-Sinch anchor and tape through one of the plate holes, but other implant combination can achieve the same outcome.
NON-OPERATIVE MANAGEMENT
Non-surgical treatment is preferred for acute Rockwood GI-II injuries, and to date there is no compelling evidence for universal recommendation of either surgical or non-surgical treatment of G-III injuries (with a decision to be made in conjunction with the individual patient).
CONTRAINDICATIONS
Apart from the usual contra-indications for surgery in patients with associated medical conditions or systemic compromise due to associated injuries, given delayed surgery can be undertaken, acute reconstruction should not be considered in the presence of active infection or gross contamination of the surgical field.
Important points to consider pre-operatively:
Assess clinically the reduction of the dislocated ACJ. If it is not reducible then excision of the distal end of the clavicle may be needed, potentially open.
It is always useful to assess clinically the contralateral (normal) ACJ and use it as a guide for the operative reduction; there is a considerable range of normal prominence.
I do not routinely excise the distal end of the clavicle as it contributes to horizontal stability of the ACJ; however, if reduction is not possible, or if there is evidence of significant chondral injury to or pre-exisiting degeneration of the ACJ, I have a low threshold for limited distal clavicle excision even in acute cases.
Intra-operative fluoroscopy can be useful especially to assess joint reduction and implant positioning, particularly during your first few cases.
In relatively acute cases, ‘over-reduction’ of the ACJ is possible and potentially beneficial as some loss of reduction post-operatively is not uncommon through creep. In chronic cases ‘over-reduction’ usually is not possible.
Avoid in-line traction on the arm as this will exacerbate the ACJ deformity in both vertical and horizontal planes; the surgical assistant or arm positioner (if used) should instead be used to ‘push’ the arm upwards, so helping in the reduction of the ACJ.
Having the ACJ almost reduced before the application of the arthroscopic jig greatly helps in creating the bony tunnels in the right positions. In grossly unstable ACJs, provisional K-wire reduction using stout wires inserted through the lateral border of the acromion into the reduced distal clavicle helps to keep the joint reduced during application of the jig.
Following surgery, the reconstruction needs to be supported for the first 6 weeks with a sling and the elbow supported at all times; passive and active-assisted range of motion exercises can be undertaken with gravity minimised, such as supine. Some surgeons advocate use of an abduction brace, but this does not seem necessary.
Scapular setting exercises should be undertaken from the outset as the shoulder will tend to protract while in a sling, carrying the risk of secondary impingement symptoms.
After 6 weeks, the arm can be weaned from the sling, but only anti-gravity resistance should be undertaken.
At 12 weeks, band resistance can be re-introduced, progressing to weights, but heavy loading and, in particular, impact loading should be avoided until 16 weeks.
Sports can be re-introduced between 12 and 16 weeks depending upon the nature and level of the sport; impact and overhead sports should be avoided until 16 weeks.
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.
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, though not statistically different.
Conservative management was though significantly cheaper.
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 almost twice as high.
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
