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VID1-003557-en-US | A | Twin Tail TightRope® Technique

Evan S. Lederman

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Twin Tail TightRope® Technique

Hi, my name is Evan Lederman from Phoenix, Arizona. Today we're going to talk about repair of AC separations with the twin tail TightRope device. Surgical repair of AC separations is indicated for high grade unstable AC separations. Grade 4 or 5 or grade three AC separations that are deemed to require surgical repair. Today's demonstration will be utilizing a left shoulder cadaver model for implantation of the twin tail TightRope device. Okay, so we've outlined we've outlined the anatomy of the shoulder. The circle represents the coracoid process, the anterior border of the clavicle, the lateral border of the acromion and the posterior border. Our incision is made from the coracoid process back in line, just medial to the AC joint. Step incisions carried down through skin. It's not a bad idea to inject the skin edges with some marcaine with epinephrine to try to reduce the bleeding. We like to elevate our skin flaps. We'll generally do this with electric cautery and make nice wide medial to lateral flaps above the fascia. Okay, now we'll put in a soft retaining retractor. Once we've elevated our flaps, we identify the posterior part of the clavicle and the anterior border of the clavicle. We'll identify our AC joint laterally, and we'll make an incision through the deltoid. Trapezius fascia. Generally done best with electrocautery. You can go the full length of your exposure and then elevate the deltoid off the anterior clavicle. Elevate posteriorly. Once the trapezius fascia is elevated sufficiently, we'll put in a another LP at 90 degrees to the first one. At that point, we'll get down. The. We'll elevate the deltoid completely off of the clavicle and identify the sub deltoid space. And then we take a retractor and slide it in to the sub deltoid space. And we're looking directly down on the coracoid process. In this cadaver model, we don't have a lot of preservation of the space between the coracoid and clavicle. But we'll get to the base of our coracoid process. We got guys out with an elevator in Electrocautery. We incise the lateral aspect down towards the glenoid and find the medial aspect in elevate as well. Once the top of the coracoid is identified, the elevator can be passed laterally until it goes underneath the coracoid and medially as well, just like you would do with any other AC joint procedure to free up that area. Once that is Exposed blunt retractors are placed. I like to take a hemostat. Place it from the lateral side underneath the coracoid, and feel the transition to the neck of the of the glenoid and the anterior scapula. And that transition zone is where you want your guidewire to exit underneath the clavicle. So by placing the hemostat underneath, you can feel your your exit point for your guidewire. We then put two blunt retractors to protect the underlying neurovascular structures. We then take a drill guide which is in the AC joint set, place it over the guidewire, leaving approximately one inch of guidewire showing so that you will not over penetrate with the guidewire. Place the guide. On the bone, aiming for your elbow joint and ensuring that your guide is sitting at the mid portion of your coracoid process. And aiming towards the mid portion of the coracoid process Underneath that you can palpate freely with your retractor and then drill. You can feel the exit frequently on your retractor and remove. We know we haven't penetrated deep because we calibrated it to the guide before insertion. The next thing we use is the 4.5mm cannulated drill bit. And we drill through, and then it's removed and the guidewire will generally remove with it. At this point we irrigate out the dust from the bone, and then we're ready to insert our TightRope device. Tightrope package comes packaged with the coracoid button placed where it says coracoid. The two clavicle buttons with their respective sutures placed as well and passing sutures. At this point, we remove the coracoid button. The clavicular buttons are left in their packages. That's going to be in the GraftNet as well, and we have our device ready for initial implantation. There's two choices that the surgeon has at this point in time. If they want to use Antegrade passage. They can pass a passing suture through the coracoid process, retract it underneath, and use this suture as a pull through suture. We'll show a push through technique where the coracoid button will be grasped with the hemostat. The coracoid button has a small tip. Small hole in the end of the button that can be used for a inserter. That can be available if the surgeon wishes to use it. The Inserter has a point that fits into the button and that can be used for insertion. And the button will push through. And you can. The surgeon can feel there's a pop when the button goes through, and then all sutures are grabbed and the button is pulled. Retrograde to fully seat. The device is now brought up to the shoulder for insertion of the coracoid button. The hemostat is used to gently grasp the metal only part of the device and avoid the sutures. The hemostat is then used to push the button into the bone tunnel. And then it's pushed through the bone tunnel, utilizing the dull backside portion of the guide pin or other suitable device that is less than 4.5mm in diameter. The guide pins are rounded back, will fit nicely against the button, and you can utilize that to push through. As the button goes through the coracoid, there will be a pop and the device gets deployed. We then pull the sutures in retrograde fashion, fully seating the button against the base of the coracoid process. If the surgeon wishes to, he can palpate the underside and ensure that the button is properly seated. At this point, the coracoid portion of the procedure is done. We'll remove the retractors that we have and take our attention to the clavicle. As you can see, the two arms of the TightRope device. One goes medially and one goes laterally, and they can be laid against the clavicle to get an idea of the orientation and position of the clavicle. Tunnels. The retractor is placed in the posterior aspect of the clavicle. I prefer to preserve the distal clavicle rather than resect it whenever possible, as this adds to fixation strength of the construct. So in the majority of cases, we will leave the distal clavicle untouched and simply do the the TightRope device. We then take a ruler, and we measure from the end of the clavicle. Approximately 40mm medially and 25mm medially. The lateral tunnel is at the junction of the anteromedial thirds of the clavicle, and the medial tunnel is at the junction of the posterior medial third. We can then take our TightRope device, line it up to our prospective tunnel positions, and see if it appears to be a concentric construct. Remember that the clavicle is somewhat trapezoidal in this location, and while the the tunnels are eccentric on the top of the clavicle, they're actually drilled through the center of the clavicle, exiting on the inferior surface. We'll start with our lateral tunnel. We'll initially drill once again with a guide wire. The guide can be used once again to control depth of penetration. The guide pin is then placed and drilled slightly, aiming towards the base of the coracoid process. We then drill over the guide wire with a 4.0 drill. And then the drill and guide wire are removed. The lasso is passed the antegrade fashion. The lasso wire is then retrieved. Once we have our lasso, we'll use this to shuttle the sutures back through the clavicle on the clavicular button. We have two sutures. We have the number five suture, which is the fixation suture, and the number two suture, which is the suture utilized to pull the button through. Do not pull on the blue sutures, or else the device will cinch and tighten. You need to pull on the white sutures. All sutures are then passed through the clavicle. And then pulled in retrograde fashion. Through the clavicle. Once it comes through. Separate your sutures and pull your free suture ends through. At this point, you want to grab your button with a hemostat. Yes. You want to make sure your sutures are not rotated or tangled. You want to grab the bottom end while pulling on the white shirt. You want to feed your clavicle button right up to the tunnel. And then pull it in a retrograde fashion through the clavicle. Once that's done, you can pull the rest of your sutures through and your button is deployed. Next, the medial tunnel will be drilled. Once again, we use our guidewire. We drill centrally. Slightly aiming towards the coracoid. Care should be taken to ensure that the sutures are not in lines of the of the drill because you don't want to drill your sutures and cut them. We then drill over with the four millimeter reamer. Our SutureLasso is then once again passed through the clavicle and the suture is retrieved. Once again, we pull all four sutures. All four suture limbs. Through the lasso and retrieve them. And then retrieve the free limbs of suture. The white passing suture is then isolated. We ensure that the sutures are not tangled or rotated underneath. The bottom of the button is then once again grasped. The clavicle button is then passed through the clavicle. Now the white suture. The white passing suture can be removed. [00:12:21] With Stephen ProEdge K-wires. The clavicle is then reduced. The clavicle can be reduced manually and held reduced by placing a retractor on top of it. It can be held reduced by the assistant surgeon in place, and the operating surgeon then grabs each limb of the TightRope device and sequentially pulls one limb, then the other limb. And works back and forth between the two devices. So then the sutures are sequentially back and forth tightened. We monitor. The position of the coracoid and acromion so that overreduction is not performed. The buttons can be then positioned in any position of the surgeon's choice. We prefer to position them along the long axis of the clavicle, so that they are not prominent on the edge, and then the sutures are tied. The sutures that can then be tied to themselves to lower the knot profile. At this point, to conclude the procedure, we will then repair. The acromioclavicular ligaments laterally. We then can use a number two braided suture, placing sutures through the capsule of the AC joint and then through drill holes or trans osseous sutures to the end of the clavicle to reinforce that construct. Closure is then performed of the deltoid, trapezium, fascia, subcutaneous tissue, and skin in standard fashion. The patient is discharged home the day of surgery. These procedures are routinely done as an outpatient. A well-padded supportive elbow sling is utilized for immobilization for approximately six weeks. Postoperatively. Motion is restored from 6 to 12 weeks. Progressive resistance exercises are begun after 12 weeks and return to play in 4 to 6 months, when full strength has been restored.

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