Name: Arthroscopic Subacute AC Joint Reconstruction Using the Dog Bone™ Button and Allograft
Uploaded: 2015-05-19T00:00:00Z
Channel: Arthrex
Description: Peter Millett, MD, (Vail, CO) demonstrates his arthroscopic technique for a subacute AC joint reconstruction using the Dog Bone™ Button, FiberTape ® and an allograft wrap around the coracoid. He utilizes a new adjustable AC guide to drill 3 mm tunnels in the clavicle and coracoid and uses a Switching Stick and Obturator to facilitate arthroscopic allograft passage around the coracoid.

<p>Peter Millett, MD, (Vail, CO) demonstrates his arthroscopic technique for a subacute AC joint reconstruction using the Dog Bone™ Button, FiberTape<sup>®</sup> and an allograft wrap around the coracoid. He utilizes a new adjustable AC guide to drill 3 mm tunnels in the clavicle and coracoid and uses a Switching Stick and Obturator to facilitate arthroscopic allograft passage around the coracoid.</p>

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VID1-00213-EN | B | Arthroscopic Subacute AC Joint Reconstruction Using the Dog Bone™ Button and Allograft

Peter J. Millett

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Arthroscopic Subacute AC Joint Reconstruction Using the Dog Bone™ Button and Allograft

We're going to perform the shoulder arthroscopic AC reconstruction using cortical fixation buttons with a dog bone button and a clavicle button and a graft. Ac dislocation it's subacute. It's about six weeks old, and she's just not done well at all. With conservative treatment. You can see how unstable we did some floral views in here, and we're going to do an AC reconstruction of a right shoulder. So this is typical standard anterior portal that we use. Just make it a little bit high and a little bit on the lateral side. This is a five by seven millimeter blue Arthrex cannula I like this cannula because it slides in pretty easily. And then I'll take the shaver. We're going to use a tibialis allograft. It's being prepared now it's an eight millimeter graft. So we'll just clean up the joint here a little bit. You can see she has a little bit of arthritic changes already in her joint. So now the now the next step. Is to open the rotator interval. Typically here's the middle glenohumeral ligament right here. So we'll stay above that. And we'll stay below the superior gluteal ligament. And we'll do a little opening here much like you do for a subcoracoid decompression or to expose the coracoid for a coracoid plasty. We'll open that space. Just cut the capsule here until we see the coracoid. And then we'll skeletonize the coracoid, which kind of has a relatively low coracoid. So it's going to be hard to work underneath it from this portal. So what I always do is create an accessory anterior inferior portal so that we can work down below this and clear all this out so we can pass our graft and we can drill through it safely. At this point, I usually just put the arm in a little bit of forward flexion. I'm going to put in an 8.25mm cannula. So we're going to come in from the front here. And I'm a little bit high there, so I'll come just a little bit below that. Okay. This is an 8.25mm cannula. We'll come in from the front right there just behind the conjoint tendon and a coracoid. Next step is then to switch to a 70 degree scope so we can see medially. Now using this low portal I can get safely underneath the coracoid here and clean out all the tissues. I want to get down until I can really see along that anterior scapular body. So I make sure that I'm posterior enough on the coracoid when I do my reconstruction, extend the arm a little bit. So there you can see where it's starting to go, just into the anterior scapular body here. And that's that tells us that we're right at the base of the coracoid. So you can see it right here. It's just starting to turn down. Now, what I'll do is I'll usually just roughen this up just a little bit, because this is where our graft is going to go. So we want it to heal to the bone. So I just roughen the cortex a little bit. I'll take a spinal needle and I'll try and just go medial to the coracoid process here. And I should be able to see it as it comes through at this point. This helps us to figure out where we need to make our superior incision. There's our spinal needle right there. So that tells us that's as far medial as we're going to need to be with our incision. So our superior incision is going to be about here is all we're going to need. Just a small about a 2.5cm incision. And that's going to be used to pass our graft. And then at this point I'll take the bovie and I'll just split the central portion of the clavicle about two centimeters. So the medial limb is going to go on the posterior side of the clavicle. So I'll clear off the periosteum here posteriorly and then the lateral limb, which would be the trapezoid ligament, is going to be anterior. So I'll clear that off here anteriorly. This is a special guide that we've made that allows it to pivot. The idea is for this to sit right under the coracoid right here. And then we can adjust the angle a little bit. But it can rotate a little bit to make sure it sits perfectly. So here you can see it's going in just percutaneously. You can see how it sits right in the base of the coracoid here. You can adjust how far you are medial by adjusting the amount of the see here. Now we're going to drill our pin. Now it should start to see it come out. There it is. And then we'll take the guide out. And we'll double check and make sure we like it. Good. So it looks like we're in the center of the coracoid. There. We There's our suture. We'll grab it and retrieve it here. We'll do is we'll thread our button in. So I'll just make a loop in the bottom one. I use the dog bone, which is a button specifically designed for fixation on the inferior surface of the coracoid. We've loaded the dog bone here with two strands of FiberTape, so it's very strong, and we've colored the ends of one of the strands so we can tell which strand is which. So we'll pull this through. All right. So now what I usually do is just take the button and put a KingFisher grasper on it to help guide it into place. Okay. So there it's going into place. There it's seated so you can see it's right on the bottom of the coracoid there. And now we're going to add a graft because it's more of a chronic situation. So I'll just clear up this subcoracoid space here so we can see. Well, what I've been using is a switching stick to pass the graft and some cannula dilators. So we'll come posteriorly to rebuild the conoid ligament. So you can see the switching stick coming in. We can just clear out some of the periosteum by the pectoralis minor. So the next step then is going to be to put an eight millimeter cannula dilator over that. So this actually serves as a soft tissue dilator so that the graft can pass easily. So I'll put a KingFisher grasper in through this low anterior portal here. So we'll put a FiberStick in from superior. We just leave the little inserter on. It makes it a little bit more rigid so it's easy to pass. And there we have our suture pass medial to the coracoid. That's the most difficult part. Once that's done, we'll just put a loop to put our graft around. Okay. And now we'll take our switching stick back. And this time we'll come in here to the clavicle and lateral to the coracoid, as you see here. And again we'll dilate it with a cannula dilator. So we make a soft tissue tunnel. We'll come in with our other FiberStick. This time it'll be a TigerStick so we can tell them apart. There we go. Again. Retrieve that out our anterior portal. So we're ready for our graft now. We've got our sutures all passed. We've created soft tissue tunnels, and now we can come through with our graft. And we usually use an eight millimeter graft. You can see it's a robust graft. When we used to drill holes in the clavicle, we were limited in our graft size because the graft had to fit through one of the bone tunnels. But now using this technique, just going around the clavicle, we can use a larger graft. And we don't have any risk of fracturing the clavicle from our tunnels. As it comes around Arthroscopically, you'll be able to see the graph come in here. And we don't have any any trouble passing it because we've already dilated it. And then we'll pull it out through that anterior cannula and then back up. And now laterally around the coracoid process you can see here it's going to come up lateral. Good. Now it's around everything. And it's right in that area that we bird the bone a little bit. So hopefully that will heal to the bone. And now it's just a matter of reducing the clavicle and fixing the graft. So we can take our scope out at this point. And all our work now is going to be on the top. So this is a cortical button contoured to fit on the top of the clavicle. We put the two strands that are together that are one pair through one side. And then we'll thread the other two through. Good. And now we'll reduce it. You can see here where the button is. And now what we'll do is we'll secure the button to itself. First step is to tie it down. So we've got one half hitch in it. My assistant will push down on the clavicle. Someone will push up on the humerus a little bit. The arm holder really helps with that. Feels reduced. We'll put two half hitches in it. Now we'll come in with floral and just check. Make sure that it's reduced fully. That looks like it's down. Knife, please. So now at this point we'll make sure our graph doesn't have any slack in it. And then we'll tie our graft to itself. Okay. Wonderful. So we can cut off the residual graft. You could potentially take these limbs and bring them over to the acromion if you wanted to. I don't typically do that. The graft sits on top of the not stacked, so it helps to protect it a little bit. So I'll take the fascia which I elevated off before, and I'll sew the graft into that to add some horizontal stability to the construct. As I close the fascia. So this is our final incision. It's about three to 3.5cm.

Arthroscopic Subacute AC Joint Reconstruction Using the Dog Bone™ Button and Allograft

Verwandte Seiten

Schulter

Rekonstruktionstechnik zur Versorgung chronischer Schultereckgelenksprengungen

Operationsverfahren

Schulter

Dog Bone-Button

Produkt

Schulter

FiberTape^® und TigerTape™

Produkt

Arthroscopic Subacute AC Joint Reconstruction Using the Dog Bone™ Button and Allograft

Verwandte Seiten

Schulter

Rekonstruktionstechnik zur Versorgung chronischer Schultereckgelenksprengungen

Operationsverfahren

Schulter

Dog Bone-Button

Produkt

Schulter

FiberTape® und TigerTape™

Produkt

FiberTape^® und TigerTape™