Clavicle and coracoid process drilling technique for truly anatomic coracoclavicular ligament reconstruction

doi:10.1016/j.injury.2013.06.022

Injury

Volume 44, Issue 10, October 2013, Pages 1314-1320

https://doi.org/10.1016/j.injury.2013.06.022 Get rights and content

Abstract

Background

High-grade acromioclavicular (AC) joint separations require surgical treatment, as conservative treatment may result in functional decline or persistent pain. Although many surgical techniques have been described in the literature, there is still no non-controversial gold standard procedure for AC joint dislocation. The different orientation of the two components of the coracoclavicular (CC) ligaments has been proven to account for different functions. However, the majority of the techniques reconstruct the CC ligaments with a single structure. The purposes of this study were to assess the feasibility of truly anatomic coracoclavicular ligament reconstruction (TACCR) and to determine the corresponding drilling parameter.

Methods

We constructed virtual three-dimensional (3D) models of 105 shoulders from computed tomography (CT) scan data by using SuperImage software. For each model, the attachment sites and footprint dimensions of the conoid and trapezoid ligaments were defined and adjusted according to previously defined anatomic parameters and individual measurement results. Virtual drilling and 3D measurement were carried out in each model separately. Guided by the drilling parameter, we performed TACCR on 24 shoulders from 12 whole cadavers after transecting the AC and CC ligaments.

Results

The collinear drilling technique was noted to breach the bone cortex of the clavicle and/or the coracoid process in 95 of 105 virtual models (90.5%). No cortical breach was observed using a non-collinear drilling technique. The anteversion angulation of the conoid–coracoid tunnel ranged from 10° to 15° (mean value 12.4°). The extraversion angulation of the conoid–coracoid tunnel varied from 5° to 10° (mean value 6.8°). The anteversion angulation of the trapezoid–coracoid tunnel ranged from 20° to 30° (mean value 25.2°). There were no failures when performing the non-collinear drilling technique on cadaver models.

Conclusions

The collinear drilling technique is not technically feasible for TACCR. For this reason, we recommend the non-collinear drilling technique, which provides the ability to prepare bony tunnels without any risk of cortical breach.

Clinical relevance

Based on this computer and cadaver model study, we have devised a novel drilling technique to restore the CC ligaments anatomically.

Section snippets

Computer model

We collected the whole-body computed tomography (CT) scan data of 196 patients suffering from multiple associated injuries due to a fall or a traffic accident between April 2008 and December 2012. Digital Imaging and Communications in Medicine (DICOM) data of 105 normal shoulders (51 left and 54 right) were chosen from these cases. The mean age was 32 years (range, 18–41 years), and 60 male and 45 female patients were included. Exclusion criteria included fracture of the clavicle and/or scapula

Results

The collinear drilling technique was noted to breach the bone cortex of the clavicle and/or the coracoid process in 95 of 105 virtual models (90.5%). No cortical breach was observed using the non-collinear drilling technique. The anteversion angulation of the conoid–coracoid tunnel ranged from 10° to 15° (mean value 12.4°). The extraversion angulation of the conoid–coracoid tunnel varied from 5° to 10° (mean value 6.8°). The anteversion angulation of the trapezoid–coracoid tunnel ranged from

Discussion

The first purpose of this study was to assess the technical feasibility of TACCR, which restored the native footprint anatomy of the conoid and trapezoid ligaments. The second goal of this study was to determine the risk of cortical breach and the corresponding drilling parameter using a CT-based, validated computer model.

The results of our study showed that the collinear drilling technique was characterised by an unacceptably high incidence of cortical breach (90.5%), while the non-collinear

Conclusion

The results of the current study suggest that the collinear drilling technique is not technically feasible for TACCR. For this reason, we recommend the non-collinear drilling technique, which provides the ability to prepare bony tunnels without any risk of cortical breach.

Conflict of interest

None.

Acknowledgements

The work was supported by the National Natural Science Foundation of China (No. 81071518), the Key Project Funded by Department of Public Health of Jiangsu Province (No. H200906) and the Project Funded by the Priority Academic Programme Development of Jiangsu Higher Education Institutions (JX10231801).

References (23)

M.B. Shaw et al.
Acromioclavicular joint sprains: the post-injury recovery interval
Injury
(2003)
R.K. Soni
Conservatively treated acromioclavicular joint dislocation: a 45-years follow-up
Injury
(2004)
D.C. Gerhardt et al.
Postoperative coracoid fracture after transcoracoid acromioclavicular joint reconstruction
J Shoulder Elbow Surg
(2011)
A.D. Mazzocca et al.
The anatomic coracoclavicular ligament reconstruction
Oper Tech Sports Med
(2004)
B.C. Carofino et al.
The anatomic coracoclavicular ligament reconstruction: surgical technique and indications
J Shoulder Elbow Surg
(2010)
Y.S. Yoo et al.
A biomechanical analysis of the native coracoclavicular ligaments and their influence on a new reconstruction using a coracoid tunnel and free tendon graft
Arthroscopy
(2010)
A.D. Mazzocca et al.
Evaluation and treatment of acromioclavicular joint injuries
Am J Sports Med
(2007)
R. Simovitch et al.
Acromioclavicular joint injuries: diagnosis and management
J Am Acad Orthop Surg
(2009)
R.J. Warth et al.
Acromioclavicular joint separations
Curr Rev Musculoskelet Med
(2013)
R.E. Debski et al.
Effect of capsular injury on acromioclavicular joint mechanics
J Bone Joint Surg Am
(2001)

L. Walz et al.

The anatomic reconstruction of acromioclavicular joint dislocations using 2 TightRope devices: a biomechanical study

Am J Sports Med

(2008)

Cited by (23)

Transcoracoid Drilling for Coracoclavicular Ligament Reconstructions in Patients With Acromioclavicular Joint Dislocations Result in Eccentric Tunnels
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To determine the location of coracoid inferior tunnel exit with superior-based tunnel drilling and coracoid superior tunnel exit with inferior-based tunnel drilling.
Fifty-two cadaveric embalmed shoulders (mean age 79 years, range 58-96 years) were used. A transcoracoid tunnel was drilled at the center of the base. Twenty-six shoulders were used for the superior-to-inferior tunnel drilling approach and 26 shoulders for the inferior-to-superior tunnel drilling approach. The distances to the margins of the coracoid process, from both the entry and exit points of the tunnel, were measured. Paired Student t-tests were used to compare the distance from the center of the tunnel and the medial and lateral coracoid border and the apex.
The mean difference for the distances between superior entry and inferior exit from the apex was 3.65 ± 3.51 mm (P = .002); 1.57 ± 2.27 mm for the lateral border (P = .40) and 5.53 ± 3.45 mm for the medial border (P = .001). The mean difference for the distances between inferior entry and superior exit from the apex was 16.95 ± 3.11 mm (P = .0001); 6.51 ± 3.2 mm for the lateral border (P = .40) and 1.03 ± 2.32 mm for the medial border (P = .045). Inferior-to-superior drilling resulted in 4 (15%) cortical breaks.
Both superior-to-inferior and inferior-to-superior tunnel drilling directed the tunnel from a more anterior and medial entry to a posterior–lateral exit. Superior-to-inferior drilling resulted in a more posteriorly angled tunnel. When using a 5-mm reamer and inferior-to-superior tunnel drilling, cortical breaks were observed at the inferior and medial margin of the tunnel exit.
Arthroscopic-assisted acromioclavicular joint reconstruction using conventional jigs may result in an eccentric coracoid tunnel, possibly introducing stress risers and fractures. To avoid cortical breaks and eccentric tunnel placement, open drilling from superior-to-inferior with a superiorly centered guide pin and arthroscopic visualization of a centered inferior exit should be considered.
Truly anatomic coracoclavicular ligament reconstruction with 2 EndoButton devices for acute Rockwood type V acromioclavicular joint dislocations: 5-year findings
2022, Journal of Shoulder and Elbow Surgery
To date, mid-term clinical and radiologic outcomes of treatment for acute Rockwood type V acromioclavicular (AC) joint dislocations using 2 EndoButton devices (Smith & Nephew, Andover, MA, USA) have not been reported in the literature.
We reviewed 25 patients (15 men and 10 women) with acute AC joint separations who were treated with truly anatomic coracoclavicular ligament reconstruction using 2 EndoButton devices between May 2013 and October 2015. Clinical assessments consisted of the visual analog scale score and the Constant score. Radiologic evaluation was achieved by measuring the coracoclavicular distance and AC distance. Previously, this same patient cohort was reviewed after 2 years of follow-up using similar methods.
All 25 patients were available for mid-term follow-up 5 years after the operation. The mean duration of follow-up was 76 ± 7 months (range, 66-90 months). Of the patients, 23 (92%) continued to be satisfied or very satisfied with the treatment results. The visual analog scale score and Constant score improved significantly when compared with the baseline scores (0 ± 0 and 96 ± 3, respectively, at 5-year follow-up vs. 5 ± 1 and 45 ± 6, respectively, postoperatively) and remained essentially unchanged when compared with the 2-year follow-up data (0 ± 0 and 96 ± 3, respectively, at 5-year follow-up vs. 0 ± 1 and 95 ± 3, respectively, at 2-year follow-up). On the 5-year radiographs, 3 patients (12%) demonstrated loss of reduction and 5 patients (20%) had calcifications noted. There was, however, no significant difference in clinical outcomes or patient satisfaction when comparing patients with radiographically abnormal findings vs. patients with anatomic reduction.
Truly anatomic coracoclavicular ligament reconstruction using 2 EndoButton devices results in satisfactory functional outcomes at 5 years postoperatively. In contrast to baseline, all cases improved significantly.
Treatment of a Failed Type V Acromioclavicular Separation Due to Coracoid Fracture: Revision of Acromioclavicular-Coracoclavicular Reconstruction and Coracoid Fixation
2021, Arthroscopy Techniques
Acromioclavicular (AC) injuries are common, especially in the young and active population. AC joint dislocations account for 8% of all joint dislocations and are even more common in contact sports. These injuries are graded as type I through type VI on the basis of the Rockwood classification method. Types I and II are generally treated without surgery whereas types IV, V, and VI are best treated operatively. Type III dislocations remain controversial in terms of treatment, and many surgeons recommend nonoperative treatment first and operative treatment in case of continued symptoms such as pain, instability, or shoulder girdle dysfunction. The goal of operative treatment is to restore AC joint stability, which involves addressing both the coracoclavicular and coracoacromial ligaments to achieve a desirable patient outcome. The objective of this Technical Note is to describe our technique for management of a failed acromioclavicular stabilization, treated with a coracoclavicular and AC joint capsular reconstruction using tibialis anterior and semitendinosus allografts.
Sagittal orientation of coracoclavicular ligament reconstruction affects the stability of surgical repair
2020, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
In a CT-based study, Coale et al8 showed that attempting to restore the footprints of the conoid and trapezoid ligaments using an anatomic transclavicular-transcoracoid drilling technique introduces significant risk of cortical breach and coracoid fracture. Knowing the orientation of the native ligaments is important because a true anatomic reconstruction using those angles is likely not possible using current techniques.38 Therefore, we measured the variability of the native anatomy and its effect on the orientation and stability of CC reconstructions in the sagittal plane.
The variation in the anatomic relationship between the coracoid and the clavicle affects the biomechanical stability of coracoclavicular ligament reconstruction (CCLR).
Three-dimensional computed tomography reconstruction of 85 patients was analyzed. Anatomic landmarks were used to derive the coracoclavicular sagittal reconstruction angle (sRA). The lateral concave angle, which indicated the shape of the distal clavicle, and the offsets between the clavicle and coracoid were also measured. To investigate the biomechanical effects of the sRA on CCLR, 7 computed tomography scans with different sRAs were 3D printed. Two reconstructions, a single trans-coracoclavicular tunnel and a looped reconstruction technique, were performed sequentially. Models were cyclically loaded at 70 N in the anterior, posterior, and superior directions.
The mean sRA was 68° ± 9.3° (range, 47°-85°). The superoinferior offset between the clavicle and the coracoid and the lateral concave angle positively correlated with the sRA (r = 0.359 and 0.837, respectively; P ≤ .001), whereas the anteroposterior offset had a negative correlation (r = −0.925; P < .001). The sRA had a negative correlation with the anterior displacement of the clavicle (rho = −0.96; P < .001) and a positive correlation with the posterior displacement for both surgical techniques (rho = 1.0; P < .001).
The anatomic orientation of the native coracoclavicular ligaments is highly variable in the sagittal plane. Low sagittal angles can reduce anterior stability, whereas high sagittal angles can reduce posterior stability of CCLR.
Anatomic Tunnel Placement Is Not Feasible by Transclavicular-Transcoracoid Drilling Technique for Coracoclavicular Reconstruction: A Cadaveric Study
2018, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Recently, 2 studies have reported the limitations of the transclavicular-transcoracoid drilling technique for CC ligament reconstruction. Xue et al.11 analyzed virtual tunnel models that were generated from 3-dimensional computed tomography scan data and noted that the collinear drilling technique, similar to our technique, breached the bone cortex of the clavicle and/or the coracoid process in 90.5% of models. Using similar computed tomography virtual models, Coale et al.12 reported a 91.3% rate of medial cortical breaching of the coracoid process.
To evaluate the feasibility of anatomic tunnel placement by a transclavicular-transcoracoid drilling technique and with reference to the coracoclavicular ligaments' insertional anatomy and their orientations.
We used 12 fresh-frozen human cadaveric shoulders (6 matched pairs; mean age, 70 years; age range, 51-82 years) to simulate intraoperative tunnel placement with the transclavicular-transcoracoid drilling technique. After both the conoid and trapezoid ligaments were identified, two 2.5-mm guide pins were inserted from the clavicle to the coracoid, passing the centers of the clavicular and coracoid insertions of the conoid and the trapezoid ligaments, in a collinear fashion to the orientation of both ligaments. The entry point of the drill at the clavicle and the exit point at the coracoid undersurface, as well as the tunnel orientations, were measured. Complications due to the procedure, including a breach of the bone cortex of the clavicle and/or coracoid process, were recorded.
The transclavicular-transcoracoid drilling technique for anatomic conoid ligament tunnel placement resulted in a medial cortical breach at the coracoid process in 6 of 12 shoulders. In the remaining 6 shoulders without a breach, the distance of the exit point from the medial cortex of the inferior coracoid process was only 3.6 ± 4.3 mm. For anatomic trapezoid ligament tunnel placement, no medial cortex breaching at the coracoid process occurred. However, the distance of the exit point was 3.1 ± 4.2 mm, indicating an eccentric location to the medial cortex of the coracoid process, similar to the conoid ligament.
This cadaveric study showed that anatomic tunnel placement by the transclavicular-transcoracoid drilling technique would not be feasible without breaching or almost breaching the medial cortex of the coracoid process.
The transclavicular-transcoracoid drilling technique for CC ligament reconstruction may not reproduce the anatomy of the CC ligaments but may place the coracoid process at high risk of fracture during tunnel placement.
Comparison of hook plate with versus without double-tunnel coracoclavicular ligament reconstruction for repair of acute acromioclavicular joint dislocations: A prospective randomized controlled clinical trial
2018, International Journal of Surgery
Citation Excerpt :
The muscle fibers were carefully trimmed from the transposed tendon and 3-0 antibacterial Vicryl sutures were used to whipstitch the tendon to enhance load strength. Tunnels were made using a 1.5-mm reamer at the insertion sites of the trapezoid and conical ligaments, as described by Xue et al. [6]. Double-loaded number 2 Ethibond sutures (Ethicon, Inc., Somerville, NJ, USA) were placed through the tunnels in the clavicle.
This study was designed to compare the surgical outcomes of a hook plate with double-tunnel coracoclavicular (CC) ligament reconstruction by conjoined tendon transfer versus single hook plate surgery for the repair of acute type of Rockwood type III and V acromioclavicular (AC) joint dislocations.
The study cohort included 62 patients with acute (within 6 weeks after trauma) Rockwood type III and V AC joint dislocations who underwent surgery from February 2012 to September 2015. The patients were randomly allocated to the ligament reconstruction group (LR group, n = 31) or the single hook plate group (HP group, n = 31). In both groups, reduction of the AC joint by hook plate and repair of the ruptured AC ligament with absorbable Vicryl sutures were performed homoplastically. The lateral half of the short tendon of the biceps brachii muscle and the lateral half of the flexor tendon were used to reconstruct the trapezoid and conoid ligaments, respectively. Differences in surgical duration, intraoperative blood loss, incision length, and total cost were compared between the two groups. Furthermore, the preoperative and postoperative visual analogue score (VAS), postoperative American Shoulder and Elbow Surgeons (ASES) score, Constant–Murley score (CMS), Karlsson score, complication rates, and patient satisfaction at the last follow-up were compared to evaluate the curative effects of the surgical treatments. Magnetic resonance imaging (MRI) after hook plate removal was used to evaluate the reconstructed ligaments and tendon-bone interface.
In total, 25 patients in the LR group and 26 in the HP group completed the follow-up. There were no statistically significant differences in age, sex, Rockwood type, placing time, total cost, and follow-up duration between the LR and HP groups (p > 0.05). However, as compared with the HP group, the surgical duration and incision length were longer in the LR group (92.08 ± 19.25 vs. 56.54 ± 21.29 min and 13.64 ± 0.90 vs. 6.65 ± 1.01 cm, respectively, p < 0.05). In addition, there was no significant difference in preoperative VAS scores, but the postoperative VAS score was lower in LR group than in the HP group (2.52 ± 1.19 vs. 4.12 ± 1.45, respectively, p < 0.05). Moreover, patients in LR group had a remarkable higher CMS and ASES score (89.56 ± 2.80 vs. 79.31 ± 4.97 and 92.60 ± 2.79 vs. 82.35 ± 3.44, respectively, p < 0.05). The overall excellent or good result rate, as evaluated by the Karlsson score, was 92.00% (23/25) and 50.00% (13/26), respectively (p < 0.05). MRI findings revealed good condition of the reconstructed ligaments and tendon-bone interface. The incidence of complications was lower and the satisfaction rate was higher in the LR group than in the HP group (1/25 vs. 16/26 and 23/25 vs. 14/26, respectively, p < 0.05).
The overall surgical effect of the use of a hook plate combined with double-tunnel CC ligament reconstruction is superior to single hook plate surgery for the repair of acute Rockwood type III and V AC joint dislocations.

View all citing articles on Scopus

View full text

Clavicle and coracoid process drilling technique for truly anatomic coracoclavicular ligament reconstruction

Abstract

Background

Methods

Results

Conclusions

Clinical relevance

Section snippets

Computer model

Results

Discussion

Conclusion

Conflict of interest

Acknowledgements

Injury

Injury

J Shoulder Elbow Surg

Oper Tech Sports Med

J Shoulder Elbow Surg

Arthroscopy

Evaluation and treatment of acromioclavicular joint injuries

Am J Sports Med

Acromioclavicular joint injuries: diagnosis and management

J Am Acad Orthop Surg

Acromioclavicular joint separations

Curr Rev Musculoskelet Med

Effect of capsular injury on acromioclavicular joint mechanics

J Bone Joint Surg Am

The anatomic reconstruction of acromioclavicular joint dislocations using 2 TightRope devices: a biomechanical study

Am J Sports Med