Saudi Journal of Sports Medicine

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 15  |  Issue : 1  |  Page : 46--50

Modified technique for anatomic acromioclavicular joint reconstruction


Vikram Sapre, Samir Dwidmuthe, Sidharth Yadav 
 Department of Orthopaedics, NKPSIMS & LMH, Digdoh Hills, Nagpur, Maharashtra - 440 019, India

Correspondence Address:
Samir Dwidmuthe
25, Irrigation Staff Ho So, Survey Nagar, Ring Road, Nagpur - 440 022, Maharashtra
India

Abstract

Introduction: Acromioclavicular (AC) joint reconstruction using a tendon graft with clavicular tunnels and with/without coracoid tunnels is a treatment of choice for injuries more severe than Grade III. We are reporting a modified technique of AC joint reconstruction using tendon graft and endobutton loop in nine patients at mean follow-up of 18 months. Materials and Methods: Nine patients with an average age of 36 years (25-55 years) underwent this procedure between October 2011 and June 2013 at this hospital for Grade III or more AC joint injury. In all the patients, the semitendinosus graft was used to recreate coracoclavicular and AC ligaments with the added fixation with fiberwire tied over an endobutton over the clavicle. Results : At the mean follow-up of 18 months the average American Shoulder and Elbow Surgeons score was 89.06 (Range 69.99-96.66) and constant score was 89.77 (Range 75-97). According to constant score four patients had excellent, four had good, and one had satisfactory post-operative function according to constant score. One patient had minimal (0.5 cm) loss of reduction and one had a superficial infection. Both this complication did not affect the final outcome. Conclusion: This technique is near anatomic with added advantage of protecting the repair with fiber wire suture and also reducing the risk of clavicular fracture with endobuttion placed on the superior surface of clavicle. It also avoids the risk of coracoid fracture.



How to cite this article:
Sapre V, Dwidmuthe S, Yadav S. Modified technique for anatomic acromioclavicular joint reconstruction.Saudi J Sports Med 2015;15:46-50


How to cite this URL:
Sapre V, Dwidmuthe S, Yadav S. Modified technique for anatomic acromioclavicular joint reconstruction. Saudi J Sports Med [serial online] 2015 [cited 2019 Oct 23 ];15:46-50
Available from: http://www.sjosm.org/text.asp?2015/15/1/46/149538


Full Text

 INTRODUCTION



Acromioclavicular (AC) joint is linked between shoulder girdle and axial skeleton through the rib cage. It also serves the purpose of suspending the scapula through the coracoclavicular (CC) ligaments (conoid and trapezoid). AC and CC ligaments help in resisting the anterior and superior migration of the lateral end of the clavicle respectively. Capsule resists the inferior migration of clavicle. AC injuries are classified by Rockwood et al. based on the amount of displacement. Type I and II AC dislocations are managed conservatively. There is a general consensus regarding operative management of Type IV, V and VI Rockwood AC joint dislocations with ambiguity for surgical treatment for Type III dislocation. [1] Surgical and operative treatment for Type III AC joint injury has shown almost similar results in most of the studies. Currently, the surgery is offered to patients with heavy demand of the shoulder joint, like in athletes and manual laborers. The traditional surgeries for AC joint disruptions like Bosworth's Screw, Modified Weaver-Dunn procedure, based on transfer of CC ligament to clavicle, has been associated with a high rate of recurrence of deformity and complications. [2] Additional screw fixations have not improved the results due to implant related complications. Hence, the emphasis then shifted to more anatomic reconstructions of CC ligaments. Various grafts were used to replicate anatomy of CC joint. Thomas et al.[3] compared five different techniques for reconstruction of AC joint and concluded that anatomic AC joint techniques gives biomechanically more stringer construct when compared to traditional techniques. A systematic reviews of published literature for treatment of AC joint injury concluded that there is no demonstrable evidence in favor of any one of the technique of AC joint reconstruction. [1]

Fraschini et al. [4] compared results of AC joint reconstruction using ligament augmentation and reconstruction system (LARS), Dacron vascular prosthesis and conservative treatment. They found that the surgical treatment gives better results. High complication rates were reposted with use of Dacron prosthesis as compared to LARS. Cook et al. [5] retrospectively reviewed results of CC ligament reconstruction using artificial graft passed through single clavicular tunnel. They have found very poor results with this technique in the form of early loss of reduction and need for re-surgery in many patients. Tendon grafts were then come into picture. Today almost more than 100 methods of AC joint reconstruction are reported in the literature without any one of them being proven to be a gold standard.

 Materials and Methods



We conducted this prospective study to analyze the results of the modified technique of AC joint reconstruction using a suture loop and endobutton. Patients with isolated Grade III and more severe injuries as per Rockwood classification were included in this study. Patients with associated fracture in the same extremity were excluded. Diagnosis of AC joint injury was based on clinical examination and antero posterior radiograph with 20΀ of cephalic angulation[Figure 1].{Figure 1}

Surgical technique

The surgery was performed in beech chair position after administering general anesthesia. Bony landmarks, AC joint, corocoid process and acromion were marked. Incision was placed 3 cm medial to the lateral end of the clavicle along the langers lines starting from the tip of the coracoid process. This gives a better cosmetic scar. Subcutaneous tissue was dissected to expose deltoid trapezius attachment. The lateral end of the clavicle was skeletanized by taking full thickness incision in the attachments of deltoid and trapezius. The clavicular tunnels were created according to anatomical landmarks for conoid and trapezoid ligaments as described by Xue et al. [6] The site of conoid tunnel was marked with elctrocautery, 45 mm medial from the lateral end of the clavicle, 6 mm anterior to the posterior border of clavicle. The tunnel was prepared with 4.5 mm canulated drill passed over a guide wire. The trapezoid tunnel prepared 15 mm lateral to previous tunnel at the center of clavicle. Ten mm of the lateral end of clavicle cut with the help of oscillating the saw. The posterior tip of the clavicle chamfered carefully to avoid impingement. The coracoid process is exposed through a longitudinal spilt in the deltoid insertion. Satinsky clamp used to pass a leading suture around the base of the coracoid process. The semitendinosus graft harvested and whipstitches are taken at both the ends. The graft was passed around the coracoid process and then through the clavicular tunnels along with a number 2 Fiber wire suture. The clavicle was reduced by pushing it posteriorly and inferiorly. The reduction is secured by tying the fiber wire suture over endocutton [Figure 2]. Then, the graft ends are sutures over each other. The remaining graft was passed through the tunnels created on acromion process laterally to recreate AC capsule and ligament [Figure 3] and [Figure 4]. The reduction was confirmed with the image intensifier. The wound was closed in layers over a drain after achieving hemostasis. Sterile dressing applied. The shoulder was protected in a pouch for 8 weeks. Pendulum exercises were allowed for first 4 weeks. Active assisted abduction started after 4 weeks up to 90΀. Muscle strengthening started after 8 weeks. Return to routine activity was allowed at 12 weeks. All the patients were followed up at 3, 6, 9, 12 months and every year thereafter. Radiological assessment was done at 12 months to assess loss of reduction [Figure 5],[Figure 6] and [Figure 7].{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 RESULTS



Nine patients underwent this procedure between October 2011 and June 2013 at this hospital for Grade III or more AC joint injury. Average age of the patient was 36 years (25-55 years). All the patients were followedup regularly for average18 month{Figure 7}s (Range 9-30 months). American Shoulder and Elbow Surgeons (ASES) and constant score were analyzed in the month of March 2014. We used constant score and ASES score to analyze the results [Table 1]. Constant score uses pain (15 points), Activities of daily living (points 20), ROM (points 40) and power (points 25) to assess shoulder function. ASES score is a subjective score calculated using a questionnaire regarding activities.{Table 1}

The average ASES score was 89.06 (Range 69.99-96.66) and constant score was 89.77 (Range 75-97) at the last follow-up [Table 2]. According to constant score four patients had excellent, four had good, and one had satisfactory post-operative function according to constant score.{Table 2}

We had some complications in these cases. One patient had minimal (0.5 cm) loss of reduction. He had a good post-operative outcome with constant score 89.99 and ASES score 89 at 18 months follow-up. Superficial wound infection noted in one patient, but it did not affect the post-operative result. He had an excellent outcome with ASES score 89 and constant score 92. We did not notice any clavicle osteolysis, clavicle fracture, coracoid fracture and shoulder stiffness at mean follow-up of 18 months.

Constant score of 91-100 was graded as excellent, 81-90 as good, 71-80 as satisfactory and 61-70 as adequate outcome.

 DISCUSSION



Anatomic CC ligament reconstruction is based on the idea of recreating the ligaments exactly as they are. [1],[2],[3] In cadaveric computed tomography (CT) scan based study, it has been found that drilling the line of conoid and trapezoid ligament in clavicle would result into cortical breach in almost 90% of cases. [7] Non collinear drilling technique at site of attachment of CC ligaments would result in to less chances of cortical breach and more anatomic reconstruction of ligaments.

Drilling coracoid tunnel for reconstruction of CC ligament is difficult with high incidence of cortical breach and corocoid fracture. [6],[7],[8] This may result in failure to attain reduction intra operatively or early loss of reduction. In a CT scan based study of transclavicular-transcorocoid drilling technique, it has been found that this results into non anatomic placement of coracoid tunnels with high incidence of medial cortical breach. [7] Doubts are being raised regarding the necessity of creating coracoid tunnel for graft passage versus coracoid sling technique which has given good results. Milewski et al. [8] retrospectively reviewed 27 cases of anatomic AC joint reconstruction using allogenic and autograft tendon. They reviewed 10 cases with coracoid tunnel and 17 cases of coracoid sling. They found a high incidence of complication with coracoid tunnel (80%) as compared to sling technique (35%). In the first group two patients had coracoid fracture, five had loss of reduction and one had failure of fixation. In sling group, they reported three cases of clavicle fracture, two cases of loss of reduction and one case of adhesive capsulitis. They concluded that newer techniques have high complication rates more in coracoid tunnel technique. They emphasized the real danger of clavicle fracture, while drilling two tunnels in clavicle. We did not have any case of clavicle fracture or capsulitis in this series.

Tunnel positioning on clavicle for anatomic reconstruction of CC ligament is crucial for success of surgery. [8],[9] Cook et al. [9] have reported 28.6% (8/28) failure rate at an average of 7.4 weeks. Medialization of clavicular tunnels more than 30% of the clavicle length was seen as a predictor for early loss of reduction (a ratio of 0.292 vs. 0.248; P = 0.012). They have also concluded that proper tunnel positioning results into early return to duty when compared to malpositioned tunnels. They have recommended pre-operative tinplating to plan optimal placement of tunnels and conoid tunnel at 25% of the clavicle length from lateral order.

Our technique reduces the risk of clavicle fracture during surgery by adequately separating the tunnels with preoperative planning and fallowing bony landmarks intra operatively. We perceive that tying the suture loop over an endobutton helps in avoiding the stress concentration over the bone bridge between the two tunnels. Use of the suture loop has an advantage to avoid initial lengthening of graft in the healing phase and also earlier return to activity. We need to assess this surgical technique in more number of patients for long duration. Biomechanical studies in cadavers would useful to assess the strength of construct objectively.

 CONCLUSION



We conclude that this technique of reconstruction is anatomical, recreates the CC and AC ligaments avoiding need for coracoid tunnel with protection of the graft until it get vascularized and ligamentized. It gives satisfactory results at 18 months. Use of relatively cheaper implants is very much to an advantage in this continent of the world where availability of costly implants is sometimes difficulty due financial reasons. A long term review of cases is needed to point out advantage over methods currently used for AC joint reconstruction.

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