|Year : 2023 | Volume
| Issue : 1 | Page : 90-95
Open anatomical dual tunnel reconstruction of acromiao-clavicular joint using autogenous semitendinosus graft
Sai Venkata Sathwik Matta1, Anil Kumar Nathi2, Sivananda Pathri1, Baladitya Sarma Sista3, Varun Kumar Paka4, Jameer Shaik5, Chandana Pathri6
1 Department of Orthopaedics, King George Hospital, Visakhapatnam, Andhra Pradesh, India
2 Department of Orthopaedics, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
3 Department of Orthopaedics, Pinnacle Hospital, Visakhapatnam, Andhra Pradesh, India
4 Department of Orthopaedics, NIMRA Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India
5 Department of Orthopaedics, Chaitra Hospital, Eluru, Andhra Pradesh, India
6 Under Graduate, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
|Date of Submission||24-Aug-2022|
|Date of Decision||21-Oct-2022|
|Date of Acceptance||10-Nov-2022|
|Date of Web Publication||27-Dec-2022|
Anil Kumar Nathi
Department of Orthopaedics, GITAM Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: The primary constraint to the dislocation of an acromioclavicular (AC) joint is its ligaments. They prevent vertical and horizontal translations in the joint. Reconstruction of these ligaments is of prime importance for restoring the AC joint. There is uncertainty regarding the surgical treatment protocol for Rockwood's type III injury. Patients and Methods: We report a prospective cohort study on 20 patients aged between 15 and 45 years, presenting with Rockwood type III or higher rank of AC joint dislocation for open double-tunnel anatomical reconstruction of AC joint using autogenous semitendinosus graft. Patients were evaluated at the end of follow-up of 2 years using the Constant–Murley outcome scoring system. Results: Clinical and radiological evaluation performed revealed excellent results in 15, good in three, and fair in two, with no poor results recorded. Conclusion: Open double-tunnel reconstruction with semitendinosus graft is a vital technique for Rockwood type III or higher grade of AC joint dislocation management to deliver a pain-free shoulder with good strength, well-retained range of movements, and near normal regain of activities.
Keywords: Kirschner wire, luggage tag technique, single tunnel method, Zanca view
|How to cite this article:|
Sathwik Matta SV, Nathi AK, Pathri S, Sista BS, Paka VK, Shaik J, Pathri C. Open anatomical dual tunnel reconstruction of acromiao-clavicular joint using autogenous semitendinosus graft. J Orthop Dis Traumatol 2023;6:90-5
|How to cite this URL:|
Sathwik Matta SV, Nathi AK, Pathri S, Sista BS, Paka VK, Shaik J, Pathri C. Open anatomical dual tunnel reconstruction of acromiao-clavicular joint using autogenous semitendinosus graft. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:90-5. Available from: https://jodt.org/text.asp?2023/6/1/90/365290
| Introduction|| |
Acromioclavicular (AC) joint dislocations are observed in 1.8/10,000 people each year. It is associated with varying degrees of damage to one or more surrounding structures that include the coracoclavicular (CC) ligament, deltoid, and trapezius muscle attachments. The goal of treating an AC joint dislocation is to restore a pain-free shoulder with a reasonable range of movements, good strength, and minimal activity limitation. Rockwood's type III injury is the most prevalent form, with a lack of clarity on treatment options. Preexistent nonanatomical surgical methods such as Weaver–Dunn, modified Dewar, Cadenat, and Bosworth techniques have gone out of favor as a result of poorer outcomes in long-term follow-up studies. Anatomic restoration of the CC ligament using complex autogenous tendon grafts has been studied in recent years. The aim of this study is to evaluate outcomes of anatomic reconstruction of CC ligaments in Rockwood grade III or higher AC joint disruptions by semitendinosus tendon autograft with polyester suture no: 5 (ethibond) using the luggage tag technique.
| Patients and Methods|| |
A prospective study carried out between July 2019 and June 2021 on 20 patients aged between 15 and 45 years, admitted to our institute with Rockwood type 3 or higher grade of AC joint dislocation. Patients with AC dislocations of Rockwood type 1 and type 2, patients over the age of 45 years and those with a painless AC joint dislocation having a full range of motion following the dislocation were excluded from the study. Institutional ethics committee approval was taken before initiating the study. All the patients were included only after taking their written informed consent.
Preliminary clinical and radiological examination of all patients was done after a primary resuscitation if required. Temporary immobilization by a universal shoulder Immobilizer or sling support, analgesics for pain control, and other symptomatic treatments were followed. Preoperative radiological evaluation [Figure 1] of the joint included two views-anteroposterior views and Zanca view. Routine blood investigations included hemogram, blood sugar level, bleeding and clotting time, HbsAg, HIV, blood group, complete urine examination, chest radiograph, and electrocardiogram. Other preoperative and metabolic investigations for medical and anesthetic fitness were done.
|Figure 1: Preoperative radiograph (anterioposterior view) of a patient showing acromio clavicular joint dislocation on the left side. Elevation of the acromial end of the clavicle on the left side can be appreciated (indicated by the orange arrow) as compared to the normal right side|
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All surgeries were performed by or under the supervision of a single surgeon. The patient was operated on under general anesthesia in a supine position with slight elevation of the head and torso.
Graft harvest and preparation
In all patients, semitendinosus tendon graft was used for reconstruction. The graft was preferably obtained from the ipsilateral lower limb under the tourniquet [Figure 2]a and [Figure 2]b. The graft was ultrabraid railroaded, and the preparation was done with an alternate nonabsorbable, braided suture that was sutured into the ends of the graft with a Krackow running locking whipstitch.
|Figure 2: (a) Intraoperative image showing graft being harvested from ipsilateral limb. (b) clinical image of graft harvest retrieved from donor site before preparation|
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Anatomic reconstruction was done using the double-tunnel (20 patients) method. A vertical skin incision extending from the acromion superiorly to the tip of the coracoid distally was made with flaps raised far medially and laterally. Dissection was carried out to expose the pectoralis major muscle, the distal clavicle periosteum, and the superior AC joint capsule. The base of the coracoid was next exposed and lightly rasped to aid in biological integration and graft healing. The graft was passed using a right-angled artery forceps around the base of the coracoid posterior to the pectoralis minor tendon from medial to lateral to avoid injury to the underlying brachial plexus. The suture loop was then utilized to guide a graft loop under the coracoid's base. The two remaining limbs were twisted through the loop, which appeared on the opposite side of the coracoid's base (the luggage tag). The luggage tag is a technique, in which a loop of graft is passed under the coracoid, and the two remaining limbs are passed through that loop. The free limbs are then secured via bone tunnels in the distal clavicle. The graft's rigid attachment to the coracoid's base minimizes the chance of coracoid fracture.
Double-tunnel method [Figure 3]a two holes were made on the superior cortex of the clavicle at the footprint of the original posteromedial conoid and anterolateral trapezoid using a 4.5–mm drill bit. The two holes were about 15 mm apart, and the anterolateral hole was about 2–2.5 cm medial to the clavicle's distal end. The harvested graft was slung under the coracoid process after passing through the two drill holes.
|Figure 3: (a) and (b) Intra-operative images of dual tunnel method and graft placement using luggage tag technique|
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The joint was overreduced by 2 mm and the graft was sutured [Figure 3]b to itself with nonabsorbable braided polyester no. 5 (Ethibond) sutures. Nonabsorbable sutures were used to imbricate the remaining graft into the AC joint capsule. The periosteum, AC capsule, and pectoralis fascia were all stitched together. The subcutaneous tissue and skin were also closed in a layered approach. The distal clavicle was not removed regularly. For added support, a thin Kirschner wire was run from the acromion to the lateral end of the clavicle [Figure 4]a.
|Figure 4: (a) Immediate postsurgery X-ray of the patient with k wire used to hold the ac joint until graft is taken up. (b) Two years follow-up X-ray image of the same patient showing well maintained AC joint identical to the opposite normal joint|
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Postoperatively a universal immobilizer or chest arm strapping is used to keep the arm immobilized for the first 2 weeks till the pain abated allowing only elbow movements. During the 3rd and 4th-week uniplanar flexion, abduction, extension, and flexion exercises for the shoulder in caption posture were allowed. All patients had their K wire removed after 4 weeks. For the next 2 weeks patients were advised to do biplanar motion exercises.
All the patients were evaluated for the difference in range of motion of the shoulder at 6 weeks and during serial follow-up at 3 months, 6 months, 1 year, 1 ½ years, and 2 years using the Constant score. The patients were followed up for 2 years postsurgery [Figure 4]b. Radiological evaluations were performed at 6-, 12-, and 24-week intervals. The evaluation of the difference of the Constant score and the progress was evaluated at each follow-up w using paired t-test. P < 0.05 was considered to be of significance. The Constant score was not recorded preoperatively as only acute AC injuries were studied, and it was not possible to make an assessment at that time. Statistical analysis was performed using IBM SPSS Statistics for Windows, version V27.0 (IBM corp. Released 2020, Armonk, New York, USA).
During follow-up, patients [Figure 5] were examined in standing or sitting positions (weight of arm pulling downward). They were evaluated for the presence of direct pain, swelling, and point tenderness of AC joint. Cross-arm adduction test, active compression test (O'Brien), and resisted extension test Check for combined injuries to the glenohumeral joint. Neurovascular status, additional and adjoining injuries were assessed. Scapulothoracic evaluation included assessment of scapular position for scapular position and motion along with assistance and retraction test.
|Figure 5: Two-year follow-up clinical evaluation for recovery in the range of movements of shoulder suspected to be affected by injury, compared with opposite normal joints|
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| Results|| |
A total of 20 patients with Rockwood type 3 or higher grade underwent surgery involving anatomical reconstruction of AC joint using semitendinosus graft placed through a single or double tunnel technique. All the patients were successfully followed up for 2 years and none were lost in follow-up. All patients were assessed using the Constant–Murley outcome scoring system.
Patients' ages ranged from 15 to 45 at presentation with a mean standard deviation of 27.75 ± 6.81 years of age. Out of 20 patients, 17 were male (85%) and three were female (15%). The right side was involved in 13, while the left side was in 7 patients. The mechanism of injury majorly was a road traffic accident, i.e., 15 out of 20 patients reported a fall on the shoulder while traveling on a two-wheeler. The other causes were fall from height and injury to the shoulder while playing sports. The mean time taken between injury and surgery is 2.5 weeks. In our study, all the patients were active and highly demanding patients; hence, we had operated on the patients within 4 weeks of time since injury.
The mean constant score at 6 weeks follow-up was 84.2, and it went up to 95.1 after 6 months. The average constant score after 2 years of follow-up was 94.2. The improvement in the Constant score was significant according to the paired t-test. A comparison was made between the Constant score of the affected arm at 24 months follow-up with the normal arm. The mean Constant score of the normal arm was 98.4 ± 0.83 and the affected arm at 24 months follow-up for 20 patients was 95.2.
Patients were graded based on the difference in constant score between affected and normal shoulders at 2 years follow-up as excellent, good, fair, and poor. Excellent result was noted in 15 patients (Constant score difference less than or equal to 5 points between affected and normal shoulder). Results were good in three patients (difference of 6–10 points) and fair in two patients (difference of 11 and 20 points). The average Constant score at 2-year follow-up in double-tunnel patients was 94.6. The mean time to achieve painless full abduction was 6 months (range 5–8 months). The mean time reported for return to full recreational activity was 3.5 months (range 2–6 months).
Two patients presented with wound dehiscence. They showed improvement with oral antibiotics for control of infection. Secondary wound closure was needed in both of them. Wounds healed well in both patients. No cases of K wire back out or proximal migration were reported. There was no incidence of fracture of the lateral end of the clavicle and re-dislocation or graft breakage. Residual subluxation of the AC joint with the prominence of the clavicle was noticed in one patient. Functionally, the patient had results comparable to the mean, and the patient had a full range of motion with minimal difficulties in doing heavy activities. There was no donor site morbidity, with the patients having a range of motion of the donor knee joint being on an average being 0°–110°.
| Discussion|| |
AC joint dislocations are more common in younger males and are mostly a result of a direct fall on the shoulder. Tischer et al. in their study found that patients had a concomitant injury to the labrum, rotator cuff, or nearby fractures. Rockwood type I and II injuries are conservatively managed. There is uncertainty regarding the management of type III Rockwood AC joint dislocations. While some prefer surgery, others suggest a case-based approach. Various management options described in the literature include hook plate, screw fixation, CC fixation, anatomical, and nonanatomical reconstruction.
Earlier modes of fixation such as hook plate, lag screw, or cerclage wire were associated with complications such as hardware failure, hardware migration, fracture, or loss of reduction. Nonanatomical methods of fixation like the Weaver–Dunn procedure were associated with high-rate of recurrence and offered inferior quality of strength. The recent method includes the use of suture button around the clavicle and coracoid. It was found to be biomechanically close to the native ligament but was associated with high complication rates, including coracoid fracture. Open CC ligament reconstruction with biological augments is a useful option with good results but is limited by high complication rates.
Nonanatomical reconstruction techniques like the Weaver-Dunn method or modified Bosworth offer less biomechanical stability and relatively less resistance to anterior-posterior translation compared to anatomical reconstruction. They are associated with good functional Constant scores, but complications like foreign body reactions or screw loosening cloud this advantage. A secondary procedure is needed for screw removal before the initiation of shoulder mobilization.
In 2013, Beitzel et al. proposed the following five elements crucial to favorable outcome of surgery: (1) Anatomic reduction of the AC joint, (2) Repair or reconstruction of the CC ligaments, (3) Protection of the repaired or reconstructed area during the healing process, (4) Repair of deltoid or trapezial fascial injury if present and (5) Distal clavicular excision in the scenario of osteoarthritis of the AC joint.
Anatomical reconstruction of AC joint using autogenous semitendinosus graft closely resembles that of the native ligament in function. Costic et al. suggested that the semitendinosus tendon graft was comparable to CC ligament complex in relation to its structure and functional strength. Tauber et al. reported that the stability and load to failure offered by semitendinosus tendon graft were identical to that of the CC ligament complex.
Fukuda et al. postulated from his load-displacement experiments that AC ligaments restricted the posterior (89%) and superior (68%) translation of the clavicle. CC ligaments resist vertical translation, while the AC ligament resists horizontal translation. A meta-analysis by Gowd et al. showed a pooled complication rate of 14.2% in patients who underwent AC joint surgery. In 5.7% of the patients, a coracoid fracture was observed. Moatshe et al. noticed a complication rate of 10.3% in patients treated with free tendon transplants. Infection, clavicle fracture, and graft rupture were the complications observed in the study.
Spiegl et al., in their study, on the biomechanical strength of ac joint fixations found out that the size of the tunnel created relative to the width of the clavicle had an influence on strength of the clavicle. Tunnels of size around 6 mm had an effect on clavicles with <17.4 mm diameter causing a 30% reduction of their bone strength. As per this study, small clavicles were at increased risk of fracture when 6 mm tunnels were used. Dumont et al. found no difference in the failure strength of the clavicle in single or dual tunnel placement surgeries.
The luggage tag technique is believed to provide the necessary strength to hold the ac joint in place. The luggage tag graft configuration provides firm coracoid fixation simulating the native conoid and trapezoid ligament components. It restores stability in both coronal and sagittal planes in the distal clavicle. Beitzel et al. pointed out that by placing the residual graft over the AC joint and passing it to the acromion has improved its biomechanical results.
Carofino and Mazzocca, in their study, on anatomic reconstruction, reported an improvement of ASES to score 52 points preoperative to 92 postoperatively in their series on 17 patients. A revision rate of 17.6% was reported in this series due to pain, infection, or loss of reduction of the AC joint. Milewski et al. reported a coracoid fracture rate of around 80% when the tunnel was drilled through the coracoid. Millett et al. reported a 6.5% (2 patients) of clavicle fracture rate in his series on 31 patients with anatomic reconstruction.
Semitendinosus tendon graft reconstruction is associated with a risk of donor-site morbidity. Less chance of subluxation or dislocation with operative treatment as proposed by Bathis et al. Krueger-Franke et al. reported better clinical outcome and less postoperative pain in athletes he operated on in this series. Their postoperative score results were close to preinjury status.
Conservative management is associated with relatively unsatisfactory results in rockwood type III injuries of ac joint, as reported in studies by Schlegel et al., Tibone et al., and Glick et al. Smith et al. in their meta-analysis has stated that operative treatment is associated with better constant Murley scores. However, surgery is also associated with the risk of infection, hardware failure, and fracture.
Banffy et al. proposed that the results of the single tunnel ac joint technique were similar to the dual tunnel technique. The strength offered was close to that of a native ligament. This technique has a lesser chance of inducing a fracture in the clavicle. Costic et al. biomechanical study showed that the clavicle strength was reduced by 40% after the dual tunnel technique.
Yoo et al.[26-27] and Nicholas et al have reported results in favour of single tunnel method over dual tunnel method. They reported that single tunnel is associated with less of fracture or recurrence of complaints compared to dual tunnel method. observed an incidence of 4.3% fractures of the lateral clavicle for procedures involving 6 mm tunnel for graft or 5.5 mm tunnels for screws. All of the patients in the current study, presented as acute and were treated with the procedure described above, with excellent functional outcomes in more than 90% of the cases. These results demonstrate that operational treatment is the treatment of choice in Type III and higher AC joint dislocations.
| Conclusion|| |
AC joint dislocation management should also include repair or reconstruction of the ligaments, which play a crucial role in preventing the translations of the joint. Isolated reduction of joints has a high propensity for failure, as do nonanatomical reconstructs, as proved in previous studies. Anatomical reconstruction with autogenous graft is a reliable approach to managing these dislocations. Native ligament strength can be simulated by the semitendinosus graft, and re-enforcement of the capsule by the residual graft used to enclose the ac joint and acromion is an added advantage of this technique. As suggested in recent literature on clavicle fractures, the only drawback in short clavicles is associated with a tunnel size of 6 mm with the eccentric placement of the tunnel. Operative treatment for type III Rockwood AC joint dislocations should be considered a standard treatment option. Anatomical reconstructs have superseded nonanatomical constructs and are the way ahead to the management of these injuries. They offer reliable, consistent, and good results with less propensity for fracture if tunnel sizes and placement are chosen carefully and avoid the need for a secondary procedure for implant removal.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]