Name: Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Chronic AC Joint Separations Featuring the Bio-Tenodesis™ System
Uploaded: 2012-05-17T00:00:00Z
Channel: Arthrex

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DVD-1079 | A | Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Chronic AC Joint Separations Featuring the Bio-Tenodesis™ System

Augustus Mazzocca

Human

Robert Arciero

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

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Chronic AC Joint Separations Featuring the Bio-Tenodesis™ System

This is the AnaToemic coracoclavicular ligament reconstruction for chronic unstable acromioclavicular joint or AC separations. Well, here at the University of Connecticut, we've been able to do perhaps some landmark evaluation of AC joint reconstructions. One of the things that's happened is a more definitive anatomic relationship of the conoid and trapezoid ligaments. And then what we've done today is we've applied this basic science research in an attempt to improve the surgical results in the treatment of AC joint instability. If you want to focus on the important aspects of this procedure, first there needs to be a very meticulous exposure of the distal clavicle when you go through the deltoid trapezium interval and creating a very robust fascial capsular layer, if you will, or fascia periosteal layer that you can repair at the end. I think that's very, very critical. The second thing is the manner in which the distal clavicle is resected. I think we don't have to take the traditional two or 2.5cm, but in fact maybe 8 to 10 millimeter resection and then beveling posterior to prevent posterior impingement of the distal clavicle. That's another important surgical caveat. The next one is to expose the coracoid. And I think that that needs to be done inside that reflected deltoid muscle and fascial layer. Getting deep to that and exposing circumferentially around the coracoid for easier graft placement. The next caveat is perhaps the most important anatomically and perhaps biomechanically, and that is through the anatomic work to make sure that using a guidewire that you get as close to the tunnel orientation of the normal conoid and trapezoid ligaments. So if you notice how Gus did that with measuring 35mm medial from his distal clavicle resection and then angling superior posterior to anterior inferior, trying to reproduce the direction and alignment of that ligament and then correspondingly 15mm more medially, doing the same for the trapezoid ligament. The next caveat that's very important is pre tapping and those holes, and being sure that you can deliver or introduce the bio screws without difficulty so that you can get the screws to pass easier and still have a good fit. Today we have a chronic grade three in a 27 year old male. One of the reasons why there is so much force at the AC joint, and it stays persistently painful in some people, is because there's a constant load applied to it. The most important bony landmark that we'll see here is really the coracoid process. You can see his disrupted AC joint here and although not confirmed on the x rays, he has significant amount of trapezius pain, especially with forward elevation. Since we know from osteological measurements that the conoid and trapezoid ligaments are roughly 45mm medial to the lateral aspect of the clavicle. One thing to be aware of is that the coronoid ligament, or the more medial ligament, really is a posterior attachment, and the trapezoid ligament or the anterior more anterior ligament is more of a midline. So we will make a incision and Langer's lines from the coracoid process to the posterior aspect of the clavicle. Here is the anterior deltoid musculature and fascia. Here is the posterior aspect of our clavicle and the trapezius fascia and musculature. What we'll now do is do is make a horizontal incision, splitting this clavicle into two exact pieces and retract in its entirety, the deltoid and its fascia anteriorly, and the trapezius and its fascia posteriorly. There's the meniscal remnant that's in the AC joint. You can see the damage, how damage it is. This whole clavicle here is not the joint. The joint is just this part right here. So one centimeter over is to here. And then we want to cut this so that it doesn't posteriorly impinge into the spine of the scapula. Most people will try to cut this off. We do not recommend that at this time because this is the area that's involved with the joint. And then we posteriorly modify that. So now we'll take a rasp here and just smooth this off making sure there's no sharp edges. So remember, you want to be about 45mm medial or directly in line with the coracoid process right here to make our conoid and trapezoid. We're now exposing the underside of the clavicle for our placement of our tunnels and access to the coracoid process. What I'm doing now is tagging the undersurface of the deltoid, deltoid fascia, so that we can then repair this in a nice thick flap. So here is conoid going medial. And here's trapezoid going laterally. Laterally. More anteriorly. Conoid very posterior ligament. They're both coming from the base which is right down here. You can see that that's the base of the coracoid process right there. This device you can see it can either go from lateral to medial and up Or if you'd like, you can come down and go medial to the lateral. But we're going to go lateral to medial. We come in around the base and all we do is bring our wire through. And I'll take a fiber wire please. We take one and put it through straight. And then we take the other doubled over one of these ends. This will be our non-biologic fixation. We then take a loop of fiber wire and place that as well. And that's going to be to pass our graft. And now we will just extract the device and we'll pass our sutures around. The next step now will be to prepare our bone tunnels. Remember that we wanted to have our bone tunnels approximately 45mm away from the distal or the lateral edge of the clavicle, or 35mm away from the edge of our clavicle after excision. And as you as you can see, we are in the correct position. What we want to do then is drill our medial tunnel, medial to this to recreate the conoid and trapezoid, and then roughly 15mm away in the mid portion of our clavicle. Drill the trapezoid to drill more medial. And drill this conoid. You want to be in a more medial position. Occasionally, the head will get in your way so that you can move the patient's head to gain more medial access. We like to go at approximately a 45 degree angle pointed towards the coronoid process. Once again roughly 45 to 30 degrees. And we'll drill down. We try to parallel our bone tunnels. Our graft preparation. Right now you can use either allograft or autograft. We use Allograft. In this patient, you need to pretension a frozen allograft to eliminate the creep in the collagen bundles. We tubular ize it to make it stronger, and also so that it's easier to handle. We then will ream our bone tunnels according to its size. This graft measures 6.0mm. So we will start with a six millimeter tunnel. There you go. We do not ream out, we pull it out. One important thing to mention is the taper on the screws is significant. So if you feel as you do this procedure that you're getting a good bite on the first 1 or 2 screws of your tenodesis screw, you need to back it out and ream up by five millimeters. This set has five millimeter cannulated reamers to accommodate that. We put two passing sutures to ease our transition of our graph. And from the beginning you'll remember that we passed a loop as well. So now what we'll do is we'll take one end of our graph that we're going to take our loop that we passed earlier and put our one end of our graph through that. And now we'll pass this around the base of the coracoid process. We tap a hole for the interference screw fit. And we repeat the process for the trapezoid tunnel. Now we'll take two more sutures, please, to put down the bone tunnels for passing. Pull the graph through the tunnel and its non-biological counterpart. That's nice. So here's the Odysseus driver. Our 5.5mm screw. Make sure the thumb pads all the way back. We take our non-biological suture, put that in the nitinol wire, and you can hold that for me. And then we'll put that through the center portion of the screw, so that we have the ability to tie this over the cantellated portion of the screw. Once we're in, we need the tendon and the posterior aspect because we want the tendon as posterior as possible. We have our non-biological fixation through the screw itself, and now we will just insert the screw over the top of itself. We go all the way down till it's flush with the top of the clavicle, which looks good right there. Okay, now coming out. Because of the internal friction, oftentimes you have to mallet it out. Now, what we will do in one motion we're going to raise up the arm. Two we will reduce the clavicle onto the base of the coracoid. Tightening up the graft in a over reduction type maneuver. So once again we will repeat. We've created the conoid and trapezoid ligaments which are the ligaments. And as you can see from the position of our tunnels we tried to place those as posterior as possible, eliminating the ability of the clavicle to move posteriorly, impacting onto the base of the spine of the scapula, causing pain. Now we are reduced and you can see that you have the conoid and the trapezoid limbs recreating your bundles. So now we're tying down our non-biological portion that will help it heal. Then what we can do is sew these sideways to one another. Now we sew the two ends of the graph together. Now what we're going to do is our previously tagged suture on the deep portion of the deltoid fascia. As you can see here, will now be sewed or reattached to the trapezius fascia, which is right here with non-absorbable polyester polyethylene suture and then standard wound closure after that. Post-operatively. Again we have to have to allow for soft tissue healing in a tunnel. The patient will be placed into a shoulder immobilizer supporting the upper extremity for about six weeks, allowing gentle codman's and elbow and wrist exercises. Then we try to regain his range of motion and begin general cuff strengthening. Scapular muscle stabilizer strengthening program. After that, probably don't allow these guys to return to full sports activity or labor for about four months. For information on the Arthrex Surgical Skills Training program, contact Arthrex at one 800 933 7001 or visit the Arthrex website at arthrex.com. This program was sponsored by an educational grant from Arthrex incorporated.

Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Chronic AC Joint Separations Featuring the Bio-Tenodesis™ System

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