Arthrex offers a comprehensive plate and screw system designed to help treat all clavicle fracture classifications.

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The Clavicle Plate and Screw System is a comprehensive set of plates, screws, and instruments designed to treat midshaft and distal clavicle fractures. The stainless steel plates are low profile and precontoured with locking and nonlocking screw options in each plate. Secondary fixation to the coracoid is achieved through the plate using AC TightRope® implant technology, particularly the AC Dog Bone™ button.
The Knotless Distal Clavicle Plate Button TightRope implant is designed to be used in conjunction with any Arthrex distal clavicle plate and gives the surgeon knotless coracoid ﬁxation to help stabilize distal clavicle fractures.

The Arthrex® clavicle plates are used for fixation of the midshaft and in distal clavicle fractures. Stability of distal fractures can be enhanced by integrating coracoid fixation into the plate using a knotless clavicle plate button and a Dog Bone™ Button.

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Distal Clavicle Fracture Repair Using Coracoid Fixation

The Arthrex clavicle plates are ideally suited for fixation of mid-shaft and distal clavicle fractures. Stability of distal fractures can be enhanced by integrating coracoid fixation into the plate, using a knotless plate button and a dog bone button. Reduce the fracture and temporarily fix the pre contoured plate onto the clavicle. Place the drill guide into the appropriate plate slot and drill a bicortical hole. Measure for the screw length and insert the screw until it seats flush into the plate. Thread the distal drill guide into the plate and insert a guide sleeve. Leave the guide sleeve in place and drill a bicortical hole. Measure for screw length and insert the screw through the guide sleeve until it seats flush into the plate. Repeat for the other desired screws. Place the AC guide at the base of the coracoid. Place the drill sleeve in the plate slot and drill a three millimeters tunnel through the clavicle and coracoid. Remove the guide and retrieve a FiberStick through the drill. Shuttle the knotless TightRope loops through the bone tunnels and attach a dog bone button to the loops. Shuttle the loops until the dog bone button seats at the base of the coracoid. Cinch the Self-locking TightRope loops until the plate button seats into the plate. Cut the free suture limbs to complete the knotless repair.

Charles J. Jordan, MD (Miami, FL), demonstrates a distal clavicle fracture repair using a distal clavicle plate and distal clavicle Knotless TightRope® implant. The distal clavicle Knotless TightRope implant is passed through the clavicle and coracoid with a “push-through” technique for coracoclavicular fixation. The holes in all distal clavicle plates are designed to accommodate the distal clavicle Knotless TightRope implant.

Distal Clavicle Open Reduction Internal Fixation With a Distal Clavicle Plate and a Distal Clavicle Knotless TightRope® Implant

So today we're going to be doing an open reduction internal fixation of a clavicle fracture along with a coracoclavicular ligament disruption. This particular specimen has really great bony landmarks, but I generally try to cheat my incision a little bit inferior in order to gain better access to the coracoid. The coracoid process is just below. You can see the level of mobility here because of the simulated disruption of the coracoclavicular ligaments. And this is our fracture site. We've used a modified, what I call a modified compression clamp, where I've straightened the tines out of a reduction forceps or a towel clip, and made two pilot holes. And I've just been careful to keep it out of the way of where I'm going to place my fixation. I've chosen a superior distal clavicle plate. There's a cluster of screws at the distal end of the plate that accommodate 2.7mm screws. The proximal portion of the plate, the oblong holes, will accommodate a distal clavicle. Tightrope. So we'll start off with a bicortical screw. And I've measured from the drill. So I'm going to ask for an 18. We can also take this off and use a standard depth gauge. And again I'll take an 18. We'll use a non-locking screw first in order to bring the plate up against the bone. Okay. So now when we have provisionally fixed the distal side, depending on the amount of comminution, depending on the quality of the bone, 1st May want at this point to gain additional points of fixation before I use the medial oblong holes for compression. We elected to start off with three points of fixation in order to really anchor the distal portion of our clavicle plate down. Now, at this point I'll generally move to the proximal portion of the plate. One important thing to keep in mind is that I want to actively compress at the fracture site in order to achieve healing, and so I'm going to drill eccentrically. So what we'll do here is we'll get right up against the plate until I feel a little bit of tension, a little bit of push back on the plate. And then we're going to take the tack out and allow the plate to compress the fracture. And so in situations where you have really good bone quality or very good bony apposition, and you want to compress for a second time or compress further, you can bring a second screw up against the plate here. And once you get to the level of the oblong hole, you loosen this one. Now, the compression that you've already achieved is not going to recoil, because this screw is already holding it in that position. All it's going to do now is it's going to compress the fracture further distally. I filled the rest of the holes in the distal fragment with two seven locking screws. You'll also notice that the central screw that I had originally used, a cortical screw. I changed out to a locking screw. What we're going to do, basically, is place this pin through the hole in the plate down into the coracoid process, essentially judging the central location based on the position of my Homans. It's from time to time we will take a confirmatory X-ray. And basically I want to see that my guide Pin is aiming towards the center of the coracoid. And you can see very subtly that I just barely advanced through a couple of millimeters right in the center of the coracoid. The the angle of the image makes a big difference to you really want to get a good circular shot of the coracoid in order to know that you're down the center? The ideal position would be right there, just past the button, past the bone, but no further. So we're first going to remove the safety tab. I've loosened this. I'm going to remove the button and pull up. So what I will do is take the two limbs from each hole that are coming from each hole in the button, and just kind of give it a little sequential side to side pull and then take an x ray. The option of a knotless TightRope is really useful in this particular part of the body, being that the clavicle is such a subcutaneous structure, not having the prominence of a knot is very helpful.

Gregory S. DiFelice, MD, (New York, NY) demonstrates his technique for distal clavicle fracture repair utilizing a clavicle plate and knotless clavicle plate button. He applies trauma principles by using fluoroscopy to drill the clavicle and coracoid tunnels and to pass the knotless clavicle plate button, eliminating the need to access the underside of the coracoid.

Distal Clavicle Fracture Repair

Today we're going to talk about a new device, the Knotless clavicle plate TightRope. And you can see it here. We've had this developed more for the trauma surgeons and the guys who are dealing with twoby fractures that don't want to get involved with arthroscopy of the shoulder to pass their devices. And this makes it quick and simple and bases it off of a trauma approach, kind of like the old Bosworth screw, but with a modern day sports medicine take on it. Okay, so we can see here we've got a cadaver shoulder, and we've gone ahead and taken the liberty of placing a distal clavicle plate with just a couple provisional screws. And what I wanted to show you was the setup here. Typically, what I'll do is do this case in the beach chair position, and I'll bring the large fluoro machine in and I'll step inside the fluoro circle. So I'll stand here inside the arm and I'll fluoro from front to back. It only takes a few quick spot views. So if you're worried about dramatic amounts of exposure it's really not going to happen in happen in this case, because it's a fairly simple way of fixing these types of fractures. So what we'll do is line up the fluoro, get a good shot of the clavicle and the coracoid relationship, which is usually distorted a bit from the fracture. And then we'll line up where our drill pin is going to go when it comes through the drill hole. So we've lined up the plate so that our drill hole is directly over the coracoid, and we're going to put it in one of the oblong holes right there. This procedure bases everything off of the fact that at heart, we're all trauma surgeons, and we've all drilled bicortical into tenuous areas, and with care, we can avoid injuring the neurovascular structures. So what we're going to do is drill bicortical through the clavicle, and then we'll palpate the coracoid below us and then drill bicortical through that. Now we're coming through the coracoid one cortex and then the second cortex right there. As you can see nicely now our device here is rather simple. Distally we have an angled button with a knotless TightRope woven through it. Up top we have a handle and inserter. The button is held on by a threaded pin, and up top we have our plate button that will Nestle into the eyelet of the plate. So we're going to start to place our button. Now on Flora. We can see we've gone through the clavicle and entered the the coracoid. Now as we pass it down now we're passing through the coracoid there we've passed through the coracoid. And now we can release our button, unscrew the threads, take out the pin. Remove the red grommet that protects the sutures. We can take the button out of its little holder, undo the sutures, and now we can remove our handle. If we look inside the shoulder, we can see that the button has deployed nicely under the coracoid, and now it's really just a matter of cinching up our TightRope, which is pretty standard for all of us. And you can see how nicely that nestles down into the clavicle plate. And the final view shows the knotless clavicle plate. Tightrope that's been deployed just takes a few minutes to do. Some folks like to back it up with a half hitch or two, but you don't really have to. Given the studies that have been done on the TightRope, that's personal preference. Simply cut those sutures short and you're done with the deployment of that anchor. So here we have a nice clean trauma approach to twoby distal clavicle fractures where the ligaments have been torn. That allows you to get a nice flexible fixation between your plate and the coracoid distally. It's simple. It's easy. It's reproducible. And with the basic trauma skills that we all have can be done in a safe fashion.

Gautam Yagnik, MD, (Miami, FL) demonstrates his technique to treat distal clavicle fractures utilizing a Dog Bone™ Button with FiberTape® suture and augmented with an allograft wrap. Dr. Yagnik explains how this technique can be effective for distal clavicle fractures that are not amenable to plate fixation due to fracture location, severe comminution or ligamentous disruption.

Hi, my name is Gautham Yagnik. I'm going to be demonstrating fixation of a distal clavicle fracture using a dog bone for our primary fixation, as well as a allograft reconstruction for our CC ligament reconstruction. This technique is particularly useful when you have a very comminuted fracture or a very small lateral fragment, and you don't think that you would be able to get adequate fixation with a plate. We have a left shoulder. I use a standard bra strap or transverse incision here. I think this gives you a nice access to the distal clavicle as well as to the coracoid, which is important for this technique. Here's our fracture line. You can see our AC joint is here. So this lateral fragment is quite small. And this is a typical fracture pattern that you would see. And a lot of times this lateral fragment will be very comminuted as well. So getting adequate fixation with other forms of devices may be difficult things like a distal clavicle plate. So this gives you another alternative. I'll show you our technique here. For the first part of this procedure we use good fracture principles. Exposure fracture. Remove any interposed soft tissue so you can get a adequate reduction. And that's what you see here. So the next step in this technique is passing around the coracoid. As we're going to pass both FiberTape as well as a semitendinosus allograft around the coracoid. After you expose the fracture, the next step is to pass your tapes and graft around the coracoid. So I like to use this coracoid passer. It's a newer one that's in line. So it can help keep your incision small. You can go lateral to medial or medial to lateral using this device. In this case we went lateral to medial. We use a FiberStick as our shuttle. So for the next step we like to use this flexible obturator. It's a nice device here that can clear any soft tissue around the coracoid and prevent any soft tissue from from impinging or catching your graft or your tapes as they go around. So we're going ahead and passing our obturator. And once we get our obturator pass, we know that we have a nice clear path around the coracoid that will accommodate both our tapes and our graft. So in the next step here, we'll pass two fiber tapes, one blue and one tiger, as well as a second shuttle suture that will be used for our graft. So we'll pass the two tail ends so it creates a loop. So now we'll go ahead and use our our obturator to shuttle our sutures around the coracoid. So we got our two tapes that are passed around the coracoid our white and our blue. And then we have our shuttle suture here for our graft. So we'll go ahead and bring our graft onto the field, pass our graft around the coracoid. And then we're done with all our coracoid passage and we can focus on our fracture fixation. So this is our graft. It's a standard semitendinosus allograft prep here. I like to graft anywhere from 100 to 120mm, depending on the size of the patient. We use a FiberLoop on both sides to whipstitch the edges. We want at least 60 because I'd like to have some suture in the tunnel to to grab the screw. As we're going to place our screw down the center of the of the graft and compress it into the side. So here we go. We go ahead and pass our graft. And then we can kind of clamp these FiberTape together and clamp our graft together and place them off to the side while we prep the clavicle. So now we turn to our clavicle prep And the first thing I like to do is to drill our hole for our FiberTape sutures in our dog bone. This is going to be our primary form of fixation, so we want to get this as close to the fracture site as we can where there's good bone. So in this scenario, I think placing this about here will give us a nice spot for our pin. What we use here is a two for drill, and we create a two for bicortical hole through the end of the clavicle. For our second tunnel is going to be a six millimeter tunnel and that's going to accommodate our graft. This is going to be for our soft tissue fixation for this tunnel. I like to go at least 15mm medial to give us a nice bony bridge between the two tunnels. Sometimes you have to cheat this tunnel over a little more medial, depending on your fracture pattern and how comminuted your fracture is. But give yourself a nice, safe, soft, a nice, safe bony bridge here to minimize your risk of iatrogenic clavicular fracture. So in this case, we'll go approximately 18 or so millimeters. And this is where we'll create our our second hole. And again I center this right in the center of the clavicle. We leave this guide pin in here. So then we'll go ahead and use our six millimeter reamer over our guide pin to create our tunnel. And there you have your tunnel. So your clavicle prep at this point is is essentially complete. One thing we do like to do at this step is to use the chamfer from the UCL tray to open up the cortex here, as the cortex can be quite hard and you can have some sharp edges here. So this is the, the chamfer from the from the UCL set. It really countersinks and opens up, opens up this tunnel very nicely. It fits perfectly. Kind of rounds the cortical entrance for this bone tunnel and allows your graft to really sit down there and without the risk of cutting or amputating the graft. There is. So we'll go ahead and get our shuttle sutures. We can use a FiberStick here to go ahead and shuttle. Perfect. So we'll go ahead and and then we'll go ahead and repeat this step. Now we're ready to pass our tapes and our graft and start our final fixation. So another pearl here is I like to pass the tapes first. I think it's important to pass your fiber tapes first so that your graph sits anterior to your FiberTape, so there's no risk of compressing or over compressing your graph. And we're able to kind of takes a little bit of work to get it up through this two four drill hole. But you can get them. And then we go ahead and sequentially bring the slack out. Do the whites first and then we'll do our our blues. Before we go ahead and do our final tensioning there. We do want to pass our graph because once we tension down our dogbones, we won't be able to pass our graph. So we pass everything and then we do our final fixation. So as we go ahead and pass the graph, we go ahead and pass all our tails together. And once we get our tails through, we we pass both ends of the graphs and what usually again, we have a TigerWire on one side and a FiberWire on the other to help differentiate the two tails of the graph. So we kind of bring them up one at a time, with the thicker side usually going first. So now now we go ahead and pull one one end of the graph up first. And then we go ahead and pull our second end of the graph up as well. So it's sometimes a little bit of work to get these graphs up in there. And you do want it to be a little bit snug. So you get a nice fill of this tunnel. Now we've got everything passed and we're ready for our final fixation. So again, for for demonstration purposes, you wouldn't necessarily see this when you're doing the case live, but I think this is important to show you the, the construct from the undersurface. And what you have is you have your tapes running posterior. They're passed around the coracoid and coming up through your your 2.4mm drill hole. And then you have your graft, which is sitting anterior to the tapes around the coracoid and up through your six millimeter hole, reconstructing your soft tissue CC ligaments, which connect your coracoid to the undersurface of the clavicle. So now we're ready to tie our dog bone down. So we go ahead and separate our whites and our blues. And you can see, even without even putting our dog bone in, just the friction between the tapes inside, this 2.4mm hole is already compressing the fracture and reducing it. So now we're going to fix it. So this is our dog bone button. And we're going to pass our four limbs through. Once we pass all four limbs then we can start to to bring this dog bone down to the top of the clavicle here. And then it helps at this point to have your assistant kind of hold the dog bone exactly where you'd like it. I think placing it in this Orientation provides the maximum amount of compression, and you can see how it really hugs and contours very nicely to the clavicle. So we'll get our additional slack out both sides. And then what I'll do is go ahead and pick one of your tapes. In this case we're going to use the TigerTape. And we're going to go ahead and we're going to tie this down. So what by tying these sutures, what you're doing is you're reducing your medial fragment to your lateral fragment and reducing your fracture. It also provides a tremendous amount of compression across the fracture site. Then we go ahead and we tie our blues. Once we tie our dog bones down, you can see that we have a nice reduction of our of our fracture. Here's our AC joint. Here's our fracture line. We've brought the medial end down to the lateral end. We have compression across the fracture site, and now we go ahead and complete our biologic fixation with our graft, which adds a second point of stability to our construct and also recreates the soft tissue attachments between the coracoid and the clavicle. We make sure we get all the slack out of this graft, and then we can use the graft to help with our reduction. And what I like to do here is have my assistant first pull up to make sure they're getting any slack out of the graft, and then they will spread the graft here. So they're again compressing the medial end of the clavicle. To fix the graft we use a 5.5mm biocomposite tenodesis screw. And we go ahead and place this graft down right in the center of the graft and compress it into the wall. So this tenodesis screw is very helpful for that, because you have this metal tip that allows you to get down into the center of the tunnel. And at this point, you make sure your assistants are pulling the appropriate amount of tension here. And then you can go ahead and fix your graft. You can check it to make sure you're not proud. And then you go ahead and just pull this out. So this is your final construct here. You have your your dogbone with your fiber tapes that are providing your primary form of compression and fracture fixation. You have your biologic semitendinosus allograft providing your biologic second point of fixation and also recreating and reconstructing your coracoclavicular ligaments. And at this point, we go ahead and cut the graft flush to prevent any hardware irritation. So we do have a little pearl here for the notch stack. Sometimes these can be prominent. And in thin patients they can irritate. So one thing we've we've done recently which has really helped is we use we we use a free needle and we actually use these futures to help us with our deltoid repair. And it helps to bury the knot stacks. So let me show you that. And I like to use just a simple horizontal mattress configuration here. And this serves two purposes. One it's going to bury your knot stack. And the second thing is it's going to help you to repair your deltoid. So you can see this is already starting to to happen here. This little pearl is particularly helpful in helping to bury your knot stacks. And also to get a nice repair of your deltoid back down to your clavicle. And since we've been doing this, we have not had any issues with hardware irritation or not stack prominence. And that's your final construct.

Peter Millett, MD, MS, (Vail, CO) demonstrates arthroscopically assisted coracoid fixation to treat lateral clavicle fractures utilizing a clavicle plate and a knotless clavicle plate button. The plate button is preassembled with a knotless TightRope®‐like suture and is designed to be used with a Dog Bone™ Button and an Arthrex® distal clavicle plate. Dr. Millett shows how the combination of a plate and knotless coracoid fixation can give the surgeon a strong, knotless, low profile repair option to treat difficult lateral clavicle fractures.

Distal Clavicle Fracture Repair - Utilizing a Knotless Coracoid Fixation Device

My name is Peter Millett. I'm here at the Arthrex headquarters in Naples, Florida. Today we're going to demonstrate an arthroscopic CC fixation with integrated Knotless TightRope plate button for distal clavicle fracture. We have the Arthrex clavicle plate system. We have the plates here that are pre contoured and left and right, with different angles and different lengths available. We're going to demonstrate in this cadaveric demonstration using a distal clavicle plate which has multiple locking and non-locking screw options. In this cadaver one of the difficulties we have with distal clavicle fractures is sometimes it will also involve the CC ligaments. In order to perform CC fixation, you have to drill through the clavicle and through the coracoid. And this guide allows you to perform that. We have a three millimeter cannulated drill which will drill through this guide. And we'll remove the center cannulation. And then we can insert a TigerStick which will go through the center Cannulation that will allow us to shuttle a TightRope type device. This is a knotless device. There's an integrated plate button which will go on the proximal superior aspect. And there's a dog bone fixation button, which will go as a cortical fixation button on the coracoid surface on the bottom of the coracoid. This is a right shoulder. First step is to expose the distal clavicle. Usually we use a longitudinal incision from medial to lateral. Expose the fracture site. For this type of plate it's usually around the CC ligaments, which are about three and a half to four centimeters from the end of the clavicle. We'll reduce the fracture, obtain fixation with the plate medially and laterally as shown here. And then at this point, once this is reduced, we'll leave these center drill holes open here. And we can choose one of these for our CC fixation button. At this point we'll then go to a diagnostic arthroscopy. And in this case we have an arthritic shoulder. But we'll open the rotator interval. We'll go between the middle glenohumeral ligament and the superior glenohumeral ligament. Create an anterior portal as you see here. And then we can expose our coracoid process. This is 70 degree scope which really facilitates visualization using a trans articular approach. And you can see the base of the coracoid here as it approaches the anterior portion of the scapular body. And then we can see the medial aspect of the coracoid here and the lateral aspect here. And the base of the coracoid is where we want to place our drill hole for our CC fixation. So once that's been exposed, we'll take our drill guide. This is the adjustable drill guide. It's the same one we use for arthroscopic AC joint fixation that will fit through an eight millimeter cannula. And this is articulated so that it can rotate to fit the base of the coracoid. It also has a little arm on the distal aspect of the guide that can lock on the medial aspect of the coracoid. We can back our cannula up, ensure that we like our position, and then what we can do is we can just rotate the guide and figure out which hole we want to enter on the clavicle superiorly. So we'll lock it in place at this point, and then we'll make sure that we have good position on the base of the coracoid here. And at this point we can then drill the cannulated drill in place. So this will go through the plate through the bone of the clavicle which we just went through into the coracoid. And then it should exit right in that cutout in the drill guide. Good. Right. We can detach the Attach the drill, and then what we'll do is we'll screw the cannulation in, because sometimes we can get a little bone in there, and that would block us from placing our passing wires. So we just screw that in a little bit to advance the pin, make sure that there's no bone, remove the cannulation and we can take the guide out. At this point. Leave the drill in place. I'll come in with a KingFisher through my anterior inferior portal, and then we'll feed a TigerStick through the drill, retrieve that out our cannula, and then once we have that pass, now we can remove this drill. Sometimes you can remove it by hand. Sometimes we need to put the chuck on. So here you can see we've got a passing suture through the clavicle plate superiorly through the clavicle and through the coracoid. So we're going to shuttle this from superior to inferior. The button remains on top. There it goes. Good. Now what we can do is take the passing suture off. So the passing suture is off. Now, now we have a have a button. This is a dog bone button with slots on either side. We can lock that in anteriorly and posteriorly. And then at this point we will grab this with a KingFisher grasper and orient it lengthwise so it slides down the cannula easily. And then we'll pull the button superiorly. Just pass that through the cannula there and direct it in place. Good. So that's fixed on the bottom of the coracoid. And now at this point we'll then toggle it into position and it'll snap into the plate which I just felt it snap in. And at that point it's flush. And you have the additional fixation of the CC ligaments now of this device. And we can cut it. And that's flush. And you can place your additional screws here medially with the holes we didn't use for the button. And you can place additional screws laterally as needed. But you have the additional fixation of having CC fixation with the coracoid button inferiorly. There's a dog bone button there and then a superior button that's not listed. It's integrated into the plate.

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