Surgical Technique for Arthroscopy-Assisted Anatomical Reconstruction of Acromioclavicular and Coracoclavicular Ligaments Using Autologous Hamstring Graft in Chronic Acromioclavicular Joint Dislocations Bancha Chernchujit, M.D., and Prashant Parate, D.N.B.

Abstract: Injuries to the acromioclavicular (AC) joint are becoming common with contact sports and bike accidents. It is well known that in AC dislocations, the first structure to fail is the AC capsule followed by the trapezoid and conoid ligaments. The function of these ligaments must be restored to restore the anatomy and physiology of the AC joint to get the best results. Until now, no technique has emerged as the gold standard for restoration of the AC joint anatomy and function. In our technique, the stress is on recreating the anatomy to make it more individualized based on individual variations. This Technical Note describes a procedure to reconstruct the coracoclavicular ligaments and AC joint by an arthroscopy-assisted technique. Arthroscopy helps to diagnose additional intra-articular pathologies that can be treated simultaneously, and better preparation of the undersurface of the coracoid helps in bone-to-graft healing. Our approach is more individualized as clavicle tunneling is done according to the size of the coracoid base instead of a fixed distance. Vertical stability is provided by coracoclavicular ligament reconstruction, horizontal stability is provided by AC ligament reconstruction, and the articular disc is recreated by soft-tissue graft interposition, thus restoring the complete anatomy.

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njuries to the acromioclavicular (AC) joint are mainly seen in sporting activities in Western countries, whereas they are more common in falls from 2-wheelers in countries like Thailand and India, where 2-wheeler use is very common. AC dislocations are classified in type I to VI. Types I and II do well with nonoperative treatment, whereas types IV-VI need surgical intervention. Treatment for type III injuries is still controversial. There are many procedures described for surgical treatment of AC joint separations. Surgical treatment broadly falls into 2 categories. The first category is restoration of normal anatomy by

From the Department of Orthopaedics, Faculty of Medicine, Thammasat University, Pathumthani, Thailand. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 10, 2016; accepted January 18, 2017. Address correspondence to Bancha Chernchujit, M.D., Department of Orthopaedics, Faculty of Medicine, Thammasat University, Paholyothin Road, Klong Luang, Rangsit, Prathumthani 12121, Thailand. E-mail: bancha61@ yahoo.com Ó 2017 by the Arthroscopy Association of North America 2212-6287/16977/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.009

reconstruction of ligaments, whereas the second category is stabilization of the joint by altering the normal anatomy by bony procedures. Recently, shoulder arthroscopy has evolved more, and some arthroscopic techniques have also been described for stabilization of AC dislocation injuries. Arthroscopic procedures can detect any intra-articular pathology

Fig 1. The left shoulder is being operated on, with the patient in the beach chair position. The ipsilateral leg is also draped for graft harvest. The table is kept as low as possible, and the head is stabilized properly with supports.

Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e641-e648

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Table 1. Surgical Technique 1. The beach chair position is used for acromioclavicular (AC) reconstruction surgery. Kim’s portal (placed 2 cm on a line extended from the posterolateral corner of the clavicle towards the posterolateral corner of the acromion) is used for visualization. 2. Diagnostic arthroscopy is performed to check for any associated pathology. 3. An anterior portal is made in the rotator interval just inferolateral to the tip of the coracoid to reach the base of the coracoid. The bony undersurface of the coracoid is exposed and roughened with the help of a shaver blade for graft healing. 4. The arthroscope is removed, and an approximately 4- to 5-cm skin incision close to the anterior border of the clavicle extending laterally 1 cm beyond the AC joint is made. 5. The deltotrapezial fascia is dissected, and the clavicle is exposed. Soft tissue is cleaned from the anterior, lateral, and posterior borders of the clavicle for better mobilization to help in graft passage and reduction of the AC joint. 6. No. 5 ethibond is then passed under the coracoid from the medial side close to the bone. 7. The arthroscope is inserted again, and ethibond is retrieved lateral to the coracoid under vision using a hemostat. 8. A gauze piece is shuttled with the ethibond to make a space for the graft passage. Then the semitendinosus plus gracilis autologous graft is pulled under the coracoid along with 2 No. 5 Ultrabraid sutures. 9. The lateral 6 mm of the clavicle is marked and cut using a saw. 10. Both limbs of the graft are held vertically parallel to each other, and 2 points are marked on the clavicle, which will be approximately at the same distance as the width of the coracoid base. Two tunnels in the clavicle and one in the acromion are drilled as per graft size. 11. The undersurface of the acromion and clavicle is then cleaned for smooth graft passage. 12. A forward curved banana shape spectrum device is used to pass polydioxanone suture, and a loop of ethibond No. 2 is passed through the tunnels. 13. The graft is crossed, and the medial end is pulled through the lateral tunnel and vice versa. The stronger and thicker end of the graft is kept long for reconstruction of the AC ligament. 14. The graft is temporarily tied with itself. Ultrabraid No. 5 is passed through the endobutton, which is used as a cortical augmentation device to avoid cut-through. 15. Overreduction of the clavicle is done. 16. One assistant maintains the clavicle in overreduction, and the surgeon ties knots on the Ultrabraid. An endobutton should be pressed on the clavicle with artery forceps during knot tying so that it stays flush on the bone. 17. Reduction is checked again, and the graft is tightened and tied on itself using vicryl no 1. Ultimately, the strength of the construct is provided by graft healing, and Ultrabraid acts as a temporary support until the graft heals. 18. The longer end is then passed under the acromion, and it comes out superiorly over the acromion. The interposed graft acts as the disc that is normally present in the AC joint. When the graft is tightened, this pulls and maintains the lateral end of the clavicle in an overreduced position. 19. The graft is again tied onto itself using vicryl no 1. Good closure is done for deltotrapezeal fascia so that additional stability can be achieved.

associated with AC dislocation that may be missed in an open procedure.1 The clavicle connects the upper extremity to the thorax, and AC joint dislocation disrupts this link, which may cause problems in normal positioning of the shoulder and its function. To avoid this, reliable treatment that can restore anatomy and physiological

function is required. The AC joint moves in a superoinferior direction, which is controlled by the coracoclavicular ligaments, and in an anteroposterior direction, which is controlled by the AC joint capsule. The superior and posterior capsules are strong restraints to abnormal mobility at the AC joint. Anteroposterior movement is often overlooked and only superoinferior

Fig 2. The left shoulder is being operated on, with the patient in the beach chair position. Standard skin markings are done using bony landmarks (tip of coracoid, anterior and posterior border of clavicle, AC joint, lateral border of acromion, posterolateral corner of acromion, and spine of scapula). Kim’s portal is a used for arthroscopy, which is placed 2 cm on a line extended from the posterolateral corner of the clavicle towards the posterolateral corner of the acromion.

Fig 3. The left shoulder is being operated on, with the patient in the beach chair position. Kim’s portal is used for visualization, and a rotator interval portal is made just lateral to the acromion and used for instrumentation. The undersurface of the coracoid is roughened using a shaver blade, which helps in healing of the graft. Using a shaver blade ensures the bone is not damaged and the strength of the coracoid is maintained.

RECONSTRUCTION OF ACROMIOCLAVICULAR AND CORACOCLAVICULAR LIGAMENTS

Fig 4. The left shoulder is being operated on, with the patient in the beach chair position. An approximately 4 to 5 cm incision is made on the superior surface of the clavicle closer to the anterior border of the clavicle. Soft tissues are cleared from the posterior, lateral, and anterior border of clavicle. This helps in reduction of AC joint and does not cause any obstruction to graft passage.

stability is addressed in many procedures that address coracoclavicular restoration and ignore the AC anatomy. It is well known that in AC dislocations, the first structure to fail is the AC capsule, followed by the trapezoid and conoid ligaments. The function of these ligaments must be restored to restore the anatomy and physiology of the AC joint to get the best results similar to other ligament reconstruction surgeries. Our technique stresses the recreation of the anatomy to make it more individualized based on individual variations. This Technical Note describes a procedure to reconstruct the coracoclavicular ligaments and AC joint by the arthroscopy-assisted technique. The repair must be strong enough to support the upper limb. The

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Fig 6. The left shoulder is being operated on, with the patient in the beach chair position. A loop of ethibond is passed under the coracoid under vision from the medial to the lateral as close to the bone as possible. A gauze piece is shuttled using this loop, which helps to dilate passage for the graft. After the passage is created, the graft is shuttled using this gauze piece.

coracoclavicular ligaments are some of the strongest ligaments in our body. The use of a semitendinosus plus gracilis tendon graft ensures that strong ligaments are restored. Tunnels for placement of these ligaments in this technique are not made at a fixed distance because that distance can vary for people with different heights. Our approach is more individualized, and we make tunnels as per the width of the base of the coracoid, which can be assessed by holding the graft vertical after it is looped under the coracoid.

Surgical Technique Imaging and Diagnosis Clinical examination is of the utmost importance to diagnose AC dislocation. Inspection after appropriate exposure gives a lot of information. The AC joint is tender, and reducibility must be checked clinically. X-rays of both shoulders in standing position are an important diagnostic tool to classify injury and plan treatment. The stress view obtained by holding a weight of around 5 kg in both hands while in a standing position along with non-weight-holding x-rays help in the planning of treatment. Preoperative Set-Up The beach chair position is used for AC reconstruction surgery, and the ipsilateral knee is also prepared to harvest the hamstring graft (Fig 1).

Fig 5. The left shoulder is being operated on, with the patient in the beach chair position. Kim’s portal is used for visualization, and a rotator interval portal is made just lateral to the acromion and used for instrumentation. A loop of ethibond is passed under the coracoid under vision from the medial to the lateral as close to the bone as possible.

Exposure and Identification of Structures and Actual Procedure Surgical steps are demonstrated in Video 1, and Table 1 enumerates the steps. Kim’s portal (placed 2 cm on a line extended from the posterolateral corner of the clavicle towards the posterolateral corner of acromion) is used for visualization (Fig 2). Diagnostic arthroscopy is performed to check for any associated pathology. An

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Fig 7. (A) The left shoulder is being operated on, with the patient in the beach chair position. Kim’s portal is used for visualization. The graft along with 2 strong Ultrabraid threads is shuttled with a gauze piece, which was used to create a passage for the graft. The graft sits well under the coracoid. (B) The graft is pulled out in such a way that the stronger end of the graft is longer than the other end, which can be used to reconstruct the AC joint.

anterior portal is made in the rotator interval just inferolateral to the tip of the coracoid. Soft tissue in the rotator interval is cleaned to reach the tip of the coracoid process, which is then followed toward its base. The bony undersurface of the coracoid is exposed and roughened with the help of a shaver blade for graft healing (Fig 3). Use of a 70 arthroscope may provide better visualization of the base of the coracoid, but even a 30 arthroscope gives sufficient visualization when Kim’s portal is used. The arthroscope is removed, and an approximately 4- to 5-cm skin incision close to the anterior border of the clavicle extending laterally 1 cm beyond the AC joint is made. The deltotrapezial fascia is dissected, and the clavicle is exposed. Soft tissue is cleaned from the anterior, lateral, and posterior borders of the clavicle for better mobilization of the clavicle to help in graft passage and reduction of the AC joint (Fig 4). Number 5 ethibond is then passed under the coracoid from the medial side close to the bone. Care should be taken to avoid injury to nerves that are medial to coracoid. Then the arthroscope is inserted again and the ethibond is retrieved lateral to the coracoid under vision using a hemostat. An ethibond loop is thus placed under the coracoid (Fig 5). A gauze piece is shuttled with ethibond to make space for graft passage (Fig 6). Then a semitendinosus plus gracilis autologous graft (which is harvested by other team) is pulled

under the coracoid along with 2 No. 5 Ultrabraid sutures (Smith and Nephew, Andover, MA; Fig 7). Lateral 6 mm of clavicle is marked and cut using a saw (Fig 8). Both limbs of the graft are held vertically parallel to each other, and 2 points are marked on the clavicle, which will be approximately at same distance as the width of the coracoid base (Fig 9A). This is a more individualized approach as a fixed distance may not restore anatomy in every patient because everyone has different size bones. Two tunnels in the clavicle and one in the acromion are drilled as per graft size (Fig 9B). The undersurface of the acromion and clavicle is then cleaned for smooth graft passage. A forward curved banana shape spectrum device (ConMed Linvatec, Largo, FL) is used to pass polydioxanone suture, and the loop of ethibond No. 2 is passed through the tunnels. The graft is crossed, and the medial end is pulled through the lateral tunnel and vice versa (Fig 10A). The stronger and thicker end of graft is kept long for reconstruction of the AC ligament. The graft is temporarily tied with itself (Fig 10B). Ultrabraid No. 5 is passed through the endobutton (Smith and Nephew), which is used as a cortical augmentation device to avoid cut-through. Overreduction of the clavicle is done using a blunt and wide ended device like a tunnel dilator (placed medial to drill holes), which will stay on the clavicle while force is applied. One assistant maintains the clavicle in overreduction,

Fig 8. (A) The left shoulder is being operated on, with the patient in the beach chair position. The clavicle is exposed properly, and lateral 6 mm is marked with cautery. (B) The marked portion is cut using a saw, and the bone piece is removed.

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Fig 9. (A) Diagram showing marking of the lateral end of the clavicle for placement of tunnels. Points for making a tunnel are selected according to the width of the coracoid base. These points can be marked by holding the graft vertically with both limbs parallel to each other. This is a more individualized approach than using fixed distance marking. The tunnel in the acromion is made around 1 cm lateral from the AC joint. Tunnels are made in the center of the clavicle and acromion so that after fixation, both bones are aligned well. (B) The left shoulder is being operated on, with the patient in the beach chair position. Tunnels of appropriate size are made as per markings. Tunnels are made in the center of the clavicle and acromion so that after fixation, both bones are aligned well. (CC, coracoclavicular.)

and the surgeon ties knots on the Ultrabraid (Fig 10C). The endobutton should be pressed on the clavicle with artery forceps during knot tying so that it stays flush on the bone. Reduction is checked again, and the graft is tightened and tied on itself using vicryl No. 1 (Fig 10D). Ultimately, the strength of the construct is provided by

graft healing and the endobutton acts as a temporary support until the graft heals. An ethibond loop in the acromial tunnel is used to shuttle the graft into the acromial tunnel (Fig 11A). The longer end is then passed under the acromion, and it comes out superiorly over the acromion (Fig 11B). The

Fig 10. (A) The left shoulder is being operated on, with the patient in the beach chair position. Both limbs of the graft are crossed so that the graft close to the medial border of the coracoid comes out through the lateral tunnel and vice versa along with Ultrabraid sutures. (B) The graft is tied to itself in such a way that the stronger and longer end of the graft comes laterally for reconstruction of the AC joint. (C) A blunt ended device is used to maintain overreduction by applying force medial to both tunnels. This ensures that the clavicle does not fracture at the tunnels and that the surgeon has adequate space to operate. An endobutton is used as a cortical augmentation device, and Ultrabraid is tied on the button. (D) After primary stabilization with Ultrabraid over endobutton, the graft is tightened again and the knot is sutured using vicryl No. 1. The blunt device still maintains an overreduced position.

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Fig 11. (A) The left shoulder is being operated on, with the patient in the beach chair position. A loop of ethibond is passed in the acromial tunnel. It can be done using a wire passer spectrum device for shuttling threads. (B) The graft is pulled in such a way that it goes from the upper surface of the clavicle to the undersurface of the acromion and through the bone tunnel; it comes out on the superior surface of the acromion. This helps in further pulling the clavicle downwards, and soft tissue comes between the 2 bones and acts as an articular disc. (C) A blunt ended device is still used to maintain overreduction by applying force medial to both tunnels. The graft coming out from the acromion is pulled medially and tied with itself medially. After healing, this makes a strong support. (D) Diagrammatic representation of final construct. The graft crosses above the coracoid before passing through the clavicular tunnels. It is tied with itself, and then a longer and stronger graft is passed in such a way that it goes from the upper surface of the clavicle to the undersurface of the acromion and through the bone tunnel; it comes out on the superior surface of the acromion. Soft-tissue interposition can be seen between the 2 bones, which avoids pain from bone-to-bone contact.

interposed graft acts as the disc that is normally present in the AC joint. When the graft is tightened, this pulls and maintains the lateral end of the clavicle in an overreduced position. The graft is again tied on itself

using vicryl No. 1 (Fig 11C). This procedure the reconstructs coracoclavicular and AC ligaments and helps in the reduction of the AC joint (Fig 11D). Good closure is done for the deltotrapezeal fascia so that additional stability can be achieved (Fig 12). Preoperative and postoperative x-rays for this procedure are shown in Figure 13. Key points are discussed in Table 2. Tips and pearls are enumerated in Table 3.

Discussion

Fig 12. The left shoulder is being operated on, with the patient in the beach chair position. The graft stitched with itself using vicryl can be seen as a strong cord on the clavicle. Tight closure of the deltotrapezeal fascia provides additional support.

The shoulder joint is a very complex structure, with various dynamic and static stabilizers. The AC joint is the part of the shoulder joint that transfers the load of the upper extremity to the core of the body. The anatomy of the AC joint has been studied thoroughly, and various structures and their attachments have been measured so that anatomy can be restored when surgical treatment is opted for (Table 4). Normally the superior surface of coracoid is 11 to 13 mm from the inferior aspect of the clavicle. The AC joint has thin capsular ligaments all around that stabilize the joint.

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Fig 13. (A) Preoperative x-ray of the patient showing AC dislocation. (B) Postoperative x-ray of patient showing well-reduced AC dislocation.

The superior and posterior parts are the most important stabilizers. The trapezoid and conoid are 2 stout ligaments that run from the superior coracoid at the base to the undersurface of the clavicle connecting these 2 bones. There is variation in the distance of the attachment of the trapezoid and conoid ligaments from the lateral end of the clavicle, and it depends upon individual anatomy and bone size. The trapezoid ligament is more lateral and runs from the coracoid in an anterior, lateral, and superior direction to attach onto the clavicle undersurface, where it has broad insertion into the trapezoid line. The mean distance from the lateral end of the clavicle to the center of the trapezoid insertion is 25.9 mm. The mean width was found to be 11.8 mm. The conoid ligament is the more medial of the two ligaments. It originates from the coracoid angle and is posterior and medial to the trapezoid. The conoid runs medially and superiorly and attaches onto the conoid tubercle of clavicle. The mean distance from the center of the conoid insertion to the lateral end of the clavicle is 35 mm, and the mean width of the ligament is 25.3 mm. There are variations in these measurements depending upon the body structure of each individual. Table 2. Key Points 1. Arthroscopy performed before acromioclavicular (AC) joint reconstruction provides valuable information, and some patients have an additional pathology that can be treated simultaneously. 2. Roughening of the undersurface of the coracoid under direct vision is easy, and it helps in graft healing to bone under the coracoid in addition to clavicular tunnels. 3. Using a shaver blade for roughening the bone instead of burr ensures that the bone is not damaged and the strength of the coracoid is maintained. 4. Direction of the pull of the graft from the clavicle to the acromion helps to reduce the AC joint, and soft-tissue interposition acts like an articular disc, keeping both bones away from each other. 5. The longer and thicker limb of graft coming out of the clavicle tunnel should be used for reconstruction of the AC joint. 6. Excision of the lateral 6 mm of clavicle is enough to avoid bone contact between the clavicle and acromion in addition to softtissue graft interposition mimicking articular disc. 7. Use of an endobutton acts as cortical augmentation and avoids fracture or cut-through at the clavicle by increasing the surface area of pressure distribution.

Taller individuals have longer bones and increased distance, whereas shorter people have less distance between ligaments and from the lateral end of the clavicle. Restoration of anatomy is key to achieve success and good functional outcome in orthopaedic procedures as seen in various ligament reconstruction surgeries and joint restoration surgeries. There are different techniques described for acute as well as chronic dislocation of the AC joint. Until now, none of the techniques has emerged as the gold standard for restoration of the AC joint. The Weaver-Dunn procedure is one of the procedures performed regularly with some modifications as described in the literature. There is even an all-arthroscopic modification described for the WeaverDunn procedure.2 The Weaver-Dunn procedure is nonanatomical as it does not recreate but instead alters the anatomy. The procedure described in this article attempts to restore anatomy by reconstruction of all three ligaments, that is, the conoid, trapezoid, and AC ligaments. In this technique, the graft is passed from the superior surface of the clavicle to the inferior surface of the acromion, and then it is pulled out of the superior surface of the acromion and tied onto itself on the superior surface of the clavicle. This makes sure that there is graft interposed between the clavicle and acromion Table 3. Tips and Pearls 1. Tunnels in the clavicle and acromion should be in the same line so that after fixation with graft both bones are aligned appropriately. 2. Tying knots on Ultrabraid over endobutton with the clavicle in the overreduced position and the button pressed over the clavicle helps to achieve good reduction and maintains the reduction until graft healing. 3. Passing an ethibond loop in the acromial tunnel before coracoclavicular reconstruction is done may be helpful as ethibond can be easily identified and retrieved before the clavicle is reduced. After coracoclavicular reconstruction, the space between the clavicle and the acromion is reduced, but it is still possible to locate the threads. 4. Use of a wide ended blunt instrument to keep clavicle reduced is helpful as it will avoid point pressure, which may cause fracture. Reduction of force medial to drills in the clavicle gives better access for the surgeon to tie knots and avoids fracture at the drill holes.

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Table 4. Acromioclavicular (AC) Joint Anatomy Normally the superior surface of coracoid is 11 to 13 mm from the inferior aspect of the clavicle. The AC joint has thin capsular ligaments all around that stabilize the joint. The superior and posterior parts are the most important stabilizers. The trapezoid and conoid are 2 stout ligaments that run from the superior coracoid at the base to the undersurface of the clavicle connecting these 2 bones. There is variation in the distance of the attachment of the trapezoid and conoid ligaments from the lateral end of the clavicle, and it depends upon individual anatomy and bone size. The trapezoid ligament is more lateral and runs from the coracoid in an anterior, lateral, and superior direction to attach onto the clavicle undersurface, where it has broad insertion into the trapezoid line. The mean distance from the lateral end of the clavicle to the center of the trapezoid insertion is 25.9 mm. The mean width was found to be 11.8 mm. The conoid ligament is the more medial of the 2 ligaments. It originates from the coracoid angle and is posterior and medial to the trapezoid. The conoid runs medially and superiorly and attaches onto the conoid tubercle of clavicle. The mean distance from the center of the conoid insertion to the lateral end of the clavicle is 35 mm, and the mean width of the ligament is 25.3 mm.

and acts similar to the articular disc that is present in native joint. When the graft is tightened, the direction of pull maintains the clavicle in a reduced position. We do not rely on fixed distances from the lateral end of the clavicle because this distance will vary from person to person. In our technique as described, the distance between the 2 holes is decided by the width of the base of the coracoid, which can be assessed by holding the graft vertical and both limbs parallel to each other. Two points are marked on the clavicle to drill holes according to graft size. This is a more individualized approach. Distal clavicle resection causes increased horizontal translation. A 5-mm resection of the distal clavicle is enough to avoid contact with the acromion. The AC capsule resection also leads to an increase in horizontal

Table 5. Advantages and Disadvantages Advantages 1. Anatomy is recreated. 2. Minimum implants are used. 3. Other associated pathologies that can be addressed by arthroscopy can be addressed simultaneously. 4. Soft-tissue interposition at AC joint ensures that bone-to-bone contact between the clavicle and acromion is avoided. Disadvantages 1. Arthroscopy-assisted procedure may increase cost over open procedure alone. 2. The long-term results of this technique need to be evaluated.

translation. Reconstruction of the AC capsule gives better results in terms of horizontal stability.3 We removed a 6-mm bone piece of the lateral end of the clavicle and found it to be a safe margin to avoid bone contact. This also allows graft interposition to mimic articular disc. Soft-tissue graft fixation using square knots and graftto-graft stitching gives better stability or at least equivalent biomechanical strength instead of interference screw fixation.4 In this technique, No. 5 Ultrabraid is used for additional fixation. Use of an endobutton acts as a cortical augmentation device and spreads the pressure over a larger area so that the chances of cutthrough are reduced. The threads are tied first with the clavicle held in an overreduced position so that reduction is maintained. The button is pressed on the clavicle while threads are tightened so that it does not become loose. The graft is then pulled and tied to itself and then stitched with ethibond No. 5. This gives good stability to the reconstruction. The thicker limb of graft is kept longer so that it can be used to reconstruct the AC ligament. This graft is tied back to itself after passing through the acromion. Closure of the deltotrapezeal fascia gives additional stability to reconstruction. It was found that reconstruction of the coracoclavicular plus AC ligaments using an autologous semitendinosus graft gives better clinical and radiological outcomes when compared with the reconstruction of coracoclavicular ligaments. Horizontal AC joint stability is better restored after reconstruction of all 3 ligaments.5 The advantages and disadvantages of this procedure are enumerated in Table 5.

References 1. Brand JC, Lubowitz JH, Provencher MT, Rossi MJ. Acromioclavicular joint reconstruction: complications and innovations. Arthroscopy 2015;31:795-797. 2. Keener JD. Acromioclavicular joint anatomy and biomechanics. Oper Tech Sports Med 2014;22:210-213. 3. Boileau P, Old J, Gastaud O, Brassart N, Roussanne Y. Allarthroscopic Weaver-Dunn-Chuinard procedure with double-button fixation for chronic acromioclavicular joint dislocation. Arthroscopy 2010;26:149-160. 4. Beitzel K, Sablan N, Chowaniec DM, et al. Sequential resection of the distal clavicle and its effects on horizontal acromioclavicular joint translation. Am J Sports Med 2012;40:681-685. 5. Ashjian RZ, Southam JD, Clevenger T, Bachus KN. Biomechanical evaluation of graft fixation techniques for acromioclavicular joint reconstructions using coracoclavicular tendon grafts. J Shoulder Elbow Surg 2012;21: 1573-1579.

Surgical Technique for Arthroscopy-Assisted Anatomical Reconstruction of Acromioclavicular and Coracoclavicular Ligaments Using Autologous Hamstring Graft in Chronic Acromioclavicular Joint Dislocations.

Injuries to the acromioclavicular (AC) joint are becoming common with contact sports and bike accidents. It is well known that in AC dislocations, the...
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