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Arthroscopic-Assisted Anatomic “BIPOD” for Chronic AC Joint Injuries

February 01, 2014

Contributors: Joe De Beer, MD; Stefan Schwienbacher, MD; Beat K. Moor, MD; Matthias Zumstein, MD; Matthias Zumstein, MD

We present a new technique: arthroscopic-assisted stabilization of acromioclavicular (AC) joint disruptions. The most common mechanism of injury is a direct blow against the lateral aspect of the shoulder with the arm adducted. The clinical exam shows a relatively raised seat of the clavicula, which is attributable to the lowered shoulder girdle. Palpation on the medial third of the clavicula on the patient's affected left side shows how the lateral end can be dragged down at a normal level. Palpation on the affected AC joint is painful. Routine preoperative images in AP, Neer, and axial views were made to rule out additional lesions. To measure vertical and horizontal instability, a panoramic view with a 5-kg weight and an Alexander view were done, respectively. Our new technique uses a combination of a 2-mm ultra-high-weight polyethylene-polyester tape (Fiberape, Arthrex) and a 20-mm open weave polyester tape (Neoligament, Xiros). This repair involves two distinct limbs, addressing both the coracoclavicular (CC) and the acromioclavicular ligaments, hence the term “BIPOD.” The repair is intended to restore both vertical and horizontal stability. The fiber tape provides the required stiffness, and the polytape is placed to prevent abrasion of the fiber tape against bone and to act as a scaffold for fibrous tissue ingrowth and ongrowth. The procedure is minimally invasive, image-intensifier-controlled, and does not require a routine secondary procedure such as the removal of plates and screws (as is associated with the hook plate procedure).

The patient is placed in the beach chair position. The upper left extremity is fixed by a mobile mechanical system (SPIDER, Smith and Nephew), allowing surgeons to change and fix the position of the upper extremity in any direction. The anatomical structures and the landmarks for the drill holes on the clavicle are drawn. The centers of the drill holes were defined at a ratio of 0.17 of the clavicle length for the trapezoid ligament, and 0.24 of the clavicle length for the conoid ligament. The corresponding distances from the lateral edge of the clavicle were calculated. A “coup de sabre” approach 3 cm to 4 cm between the insertions of the CC ligaments is done on the clavicula. The delto-trapezoid fascia is incised in line, and the clavicle is dissected epiperiostally. The corresponding anatomical landmarks measured from the lateral border of the clavicle at 24 mm and 44 mm medially from the lateral clavicular endpoint are drawn in on the bone, and two drill holes are made along the anatomical direction in the posterior third of the conoid in a 45° angle towards the coracoid.

After completing a standard diagnostic arthroscopy that shows us a normal biceps and an intact anterior and posterior pulley, the rotator interval is opened with electro-ablation placed through the anterolateral portal, and the coracoid undersurface is débrided of soft tissues. Visualization is enhanced by the use of a 70° scope through the posterior portal during this part of the procedure. Particular attention is directed at preserving the coracoacromial (CA) ligament laterally and not straying in the fat medial to the coracoid, avoiding injury to the suprascapular nerve, brachial plexus, and vessels. Now the primary shuttle-FiberWire suture is passed from lateral to medial around the coracoid behind the CA ligament insertion after spreading the tissue using a clamp. The shuttle-FiberWire is then passed through the medial drill hole from inferior to superior. Now the prepared and tubed Neoligament and Fibertape are shutteled up laterally to medially, and just the Fibertape (without the Neoligament) is shuttled laterally through the lateral drill hole subsequent to the passage of the primary shuttle-FiberWire suture. In this case involving a patient with chronic radiographic AC joint osteoarthritis, we performed a resection of the lateral clavicle. After arthroscopic subacromial débridement has been done through the lateral and anterolateral portal, the Neoligament and Fibertape are shuttled subacromially and subdeltoidal using a shuttle-FiberWire suture. The Fibertape and the rest of the loop must be knotted, and repositioning of the AC joint has been done under direct visualization and control with an image intensifier. The Neoligament loop is then passed from the cranial through the lateral clavicle drill hole and knotted subclavicular with the rest of the Neoligament loop to avoid skin irritation. The image intensifier control shows a complete repositioning.

After intensive irrigation, the deltotrapezoidal fascia is closed with Vicryl 1.0 suture. Subcutaneous and intracutaneous wound closure is done with Monocryl running suture. Intra- and postoperative radiographs show a correct anatomical repositioning with congruent AC joint lines. In postoperative rehabilitation, the patient is allowed to do active-assisted movements with a flexion limit of 60° for 3 weeks, followed by a flexion limit of 90° until week 6. External rotation is free; internal rotation up to the belly is allowed. Clinical and radiographic controls are made after 6 and 12 weeks and at 6 and 12 months.

Results for "Shoulder: Instability"

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