The patient is placed in the beach-chair position, and the upper extremity
is draped free (Fig. 2).
Interscalene regional block anesthesia is routinely performed in all patients.
A vertical skin incision is made from just posterior to the acromioclavicular
joint to the tip of the coracoid process along the Langer lines
(Fig. 3). After development of
subcutaneous flaps, a longitudinal incision is made in the condensation of the
deltotrapezial fascia, which overlies the reduced position of the clavicle.
After the acromioclavicular joint has been identified, the intra-articular
disc is removed and the distal end of the clavicle is exposed subperiosteally.
A 5 to 8-mm segment of the distal aspect of the clavicle is then resected with
an oscillating saw. The anterior portion of the deltoid is then split distally
for a distance of up to 4 cm in the direction of its fibers
(Fig. 4). A stay suture is
placed at the end of the split to prevent propagation and protect the axillary
nerve. The coracoacromial ligament is identified and carefully protected. With
the deltoid flaps retracted, the base of the coracoid process is exposed and
the anterior subdeltoid space is developed. The conjoined tendon attached to
the tip of the coracoid process is also identified and exposed
(Fig. 5). If the tip of the
coracoid process is located inferiorly, the original incision may be extended
distally for an additional 2 cm. A Langenbeck retractor is used to dissect and
harvest the lateral half of the tendon and to deliver it out of the incision.
By flexing the elbow, the tendinous lateral half of the conjoined tendon is
relaxed and more easily presented into the wound, facilitating its division 4
to 5 cm distal to the tip of the coracoid process
(Fig. 6). While the
acromioclavicular joint is held in the reduced position, the distance between
the end of the clavicle and the tip of the coracoid process is measured. The
length of the graft should be at least 1 cm greater than this distance. The
conjoined tendon flap is then divided with scissors and is transposed
proximally under the deltoid to the acromioclavicular joint. The muscle fibers
are carefully trimmed from the transposed tendon. The distal end of the
clavicle is then reduced to the desired position. The conjoined tendon graft,
which will be sutured into the stump of the clavicle, is sectioned at the
level of the distal end of the clavicle. A number-2 Ethibond suture (Ethicon,
Somerville, New Jersey) is placed into the tendon with a whipstitch to achieve
secure fixation (Fig. 7).
The base of the coracoid process is then exposed subperiosteally and
cleared of soft tissue, and two suture anchors with double-loaded number-2
Ethibond sutures are screwed into the base of the coracoid process
(Fig. 8). The two suture
anchors are positioned, with one superficial and one deep, on the base of the
coracoid process. Two small drill-holes are placed in the anterior one-third
of the clavicle at a point directly over the coracoid process. The sutures
from the suture anchors that later will be tied are then pulled through the
holes in the clavicle (Fig. 9).
Two additional small drill-holes are placed on the superior surface of the
clavicle 5 mm medial to the cut distal end. Both ends of the suture from the
conjoined tendon graft are pulled through the two holes separately
(Fig. 10). By reducing the
distal end of the clavicle and holding it in position, the end of the
conjoined tendon is pulled into the canal of the distal end of the clavicle
and the traction suture is tied over the upper surface of the distal aspect of
the clavicle. Sutures from the suture anchors are then securely tied over the
superior surface of the distal end of the clavicle to protect the graft
(Fig. 11). The deltotrapezial
fascia and the deltoid split are carefully repaired
(Fig. 12), and a routine wound
closure is performed over a drain.
Postoperatively, the shoulder is protected in a sling for six weeks.
Passive forward elevation and external rotation are begun at three weeks, and
resistive strengthening exercises are subsequently added at six to eight weeks
postoperatively. Patients are advised to avoid contact activities for six
months after the operation (Fig.
13).
CRITICAL CONCEPTSINDICATIONS:Rockwood type-IV and V acromioclavicular dislocations.Chronic (i.e., more than three-week-long) type-III dislocations with
unresolved pain or with persistent functional loss after conservative
treatment for at least three months.Acute (i.e., less than three-week-long) type-III dislocations in female
patients with an unacceptable cosmetic deformity. Patients are informed that
the bump is exchanged for an incision scar that may be concealed by
undergarments or other clothing.Revision surgery that requires a long tendon graft for adequate
reconstruction.CONTRAINDICATIONS:Acromioclavicular dislocations with a concomitant coracoid fracturePrevious surgery involving a coracoid transfer for the treatment of
shoulder instabilityPITFALLS:Distal clavicular resection: No more than 1 cm of the distal end
of the clavicle should be removed. The end of the distal part of the clavicle
should be rasped and smoothed to avoid irritation of the surrounding
tissue.Placement of the suture anchors: The suture anchors should be
placed at the insertion site of the coracoclavicular ligament. In patients
with a very narrow coracoid process base, in which parallel placement of the
suture anchors is not possible, the two suture anchors can be separated in the
anteroposterior direction and angled as needed to achieve secure purchase in
the bone. The suture anchor should not be placed too anteriorly into the
coracoid process near the tip, and it should not be screwed too deeply into
the coracoid process. A protruding anchor tip will impinge on the
subscapularis and cause crepitus and pain. Although nonabsorbable suture is
used to maintain the reduction, late resorption of the clavicle through the
areas of suture passage was not seen in our series.Harvest of the conjoined tendon: The anterior subdeltoid space
should be developed thoroughly to provide ample exposure of the conjoined
tendon. Only the tendinous part is desired for transfer; thus, the harvested
portion is located anteriorly and laterally. The medial half of the tendon
should be avoided so as to prevent injury to the musculocutaneous nerve.Graft length: The length of the graft is determined according to
the reduced acromioclavicular joint. The conjoined tendon graft is sectioned
just at the level of the distal end of the clavicle. Because the transposed
graft will be sutured into the canal of the distal end of the clavicle, a 2 to
3-mm overreduction of the joint will be achieved subsequently after the suture
has been tied on the superior surface of the clavicle. Nonetheless, it is
important to not overtighten the coracoacromial space during suture anchor
fixation.AUTHOR UPDATE:No changes have been made in the surgical procedure since publication of
the original article.
CRITICAL CONCEPTS
INDICATIONS:
Rockwood type-IV and V acromioclavicular dislocations.Chronic (i.e., more than three-week-long) type-III dislocations with
unresolved pain or with persistent functional loss after conservative
treatment for at least three months.Acute (i.e., less than three-week-long) type-III dislocations in female
patients with an unacceptable cosmetic deformity. Patients are informed that
the bump is exchanged for an incision scar that may be concealed by
undergarments or other clothing.Revision surgery that requires a long tendon graft for adequate
reconstruction.
Rockwood type-IV and V acromioclavicular dislocations.
Chronic (i.e., more than three-week-long) type-III dislocations with
unresolved pain or with persistent functional loss after conservative
treatment for at least three months.
Acute (i.e., less than three-week-long) type-III dislocations in female
patients with an unacceptable cosmetic deformity. Patients are informed that
the bump is exchanged for an incision scar that may be concealed by
undergarments or other clothing.
Revision surgery that requires a long tendon graft for adequate
reconstruction.
CONTRAINDICATIONS:
Acromioclavicular dislocations with a concomitant coracoid fracturePrevious surgery involving a coracoid transfer for the treatment of
shoulder instability
Acromioclavicular dislocations with a concomitant coracoid fracture
Previous surgery involving a coracoid transfer for the treatment of
shoulder instability
PITFALLS:
Distal clavicular resection: No more than 1 cm of the distal end
of the clavicle should be removed. The end of the distal part of the clavicle
should be rasped and smoothed to avoid irritation of the surrounding
tissue.Placement of the suture anchors: The suture anchors should be
placed at the insertion site of the coracoclavicular ligament. In patients
with a very narrow coracoid process base, in which parallel placement of the
suture anchors is not possible, the two suture anchors can be separated in the
anteroposterior direction and angled as needed to achieve secure purchase in
the bone. The suture anchor should not be placed too anteriorly into the
coracoid process near the tip, and it should not be screwed too deeply into
the coracoid process. A protruding anchor tip will impinge on the
subscapularis and cause crepitus and pain. Although nonabsorbable suture is
used to maintain the reduction, late resorption of the clavicle through the
areas of suture passage was not seen in our series.Harvest of the conjoined tendon: The anterior subdeltoid space
should be developed thoroughly to provide ample exposure of the conjoined
tendon. Only the tendinous part is desired for transfer; thus, the harvested
portion is located anteriorly and laterally. The medial half of the tendon
should be avoided so as to prevent injury to the musculocutaneous nerve.Graft length: The length of the graft is determined according to
the reduced acromioclavicular joint. The conjoined tendon graft is sectioned
just at the level of the distal end of the clavicle. Because the transposed
graft will be sutured into the canal of the distal end of the clavicle, a 2 to
3-mm overreduction of the joint will be achieved subsequently after the suture
has been tied on the superior surface of the clavicle. Nonetheless, it is
important to not overtighten the coracoacromial space during suture anchor
fixation.
Distal clavicular resection: No more than 1 cm of the distal end
of the clavicle should be removed. The end of the distal part of the clavicle
should be rasped and smoothed to avoid irritation of the surrounding
tissue.
Placement of the suture anchors: The suture anchors should be
placed at the insertion site of the coracoclavicular ligament. In patients
with a very narrow coracoid process base, in which parallel placement of the
suture anchors is not possible, the two suture anchors can be separated in the
anteroposterior direction and angled as needed to achieve secure purchase in
the bone. The suture anchor should not be placed too anteriorly into the
coracoid process near the tip, and it should not be screwed too deeply into
the coracoid process. A protruding anchor tip will impinge on the
subscapularis and cause crepitus and pain. Although nonabsorbable suture is
used to maintain the reduction, late resorption of the clavicle through the
areas of suture passage was not seen in our series.
Harvest of the conjoined tendon: The anterior subdeltoid space
should be developed thoroughly to provide ample exposure of the conjoined
tendon. Only the tendinous part is desired for transfer; thus, the harvested
portion is located anteriorly and laterally. The medial half of the tendon
should be avoided so as to prevent injury to the musculocutaneous nerve.
Graft length: The length of the graft is determined according to
the reduced acromioclavicular joint. The conjoined tendon graft is sectioned
just at the level of the distal end of the clavicle. Because the transposed
graft will be sutured into the canal of the distal end of the clavicle, a 2 to
3-mm overreduction of the joint will be achieved subsequently after the suture
has been tied on the superior surface of the clavicle. Nonetheless, it is
important to not overtighten the coracoacromial space during suture anchor
fixation.
AUTHOR UPDATE:
No changes have been made in the surgical procedure since publication of
the original article.