All-Endoscopic Treatment of Acromioclavicular Joint Dislocation: Coracoclavicular Ligament Suture and Acromioclavicular Ligament Desincarceration

Abstract

Acute acromioclavicular (AC) joint dislocations are common and difficult to manage. The physiopathologic pattern begins with the rupture of the AC ligaments, then the coracoclavicular (CC) ligaments, and with an invasion of the clavicle through the deltotrapezial fascia. Therefore, we tend to perform a true suture of the CC ligaments, along with a release of the AC ligaments from the joint. We thus propose an all-endoscopic CC ligament suture and AC joint release. It starts with glenohumeral exploration enabling a repair of concomitant lesions when necessary. Dissection of the coracoid process is made, along with the lateral border of the conjoint tendon, medially the pectoralis minor tenotomy, and plexus brachial exposition and protection. Superiorly the CC ligaments are tagged and exposed. A major difference with others procedure then arises. We dissect the inferior and superior surfaces of the clavicle and the AC joint, although we maintain the continuity between the deltotrapezoid fascia and the AC ligaments. The AC dislocation is reduced under endoscopic control performing a true suture of the CC ligaments by the mean of 2 suture tapes and dog bones. After surgery, a shoulder brace is used for 6 weeks. Physiotherapy then begins.

© 2020 by the Arthroscopy Association of North America. Published by Elsevier.

Figures

Fig 1

Endoscopic portals, left shoulder. (A, posterior soft point; D, lateral portal; E, anterolateral portal; I, anteroinferior portal; J, between I and E; LSC, lateral supraclavicular; M, medial approach; MSC, medial supraclavicular.)

Fig 2

Coracoid and conjoint tendon dissection (left shoulder; a, b: posterior view; c, d: anterior view). (A) Posterior view (scope in soft point) of the rotator interval in the glenohumeral joint. (B) Lateral view (scope in D) of the coracoid process and conjoint tendon. (C) Anterior view (scope in I, instrument in M) of the coracoid process with pectoralis minor tenotomy. (D) Medial dissection of the coracoid process with musculocutaneous nerve dissection (scope in I, instrument in M) (C, coracoid process; MC, musculocutaneous nerve; Pm, pectoralis minor.).

Fig 3

Preparation of the CC space with CC ligaments along with clavicle exposition and acromioclavicular ligament dissection (left shoulder, anterior view). (A) Superior and lateral exposition of the coracoid, dissection of the lateral border of the coracoclavicular ligaments (scope in I, instrument in M). (B) Inferior dissection of the clavicle medially to the CC ligaments. (scope in I, instrument in M). (C) Superficial dissection of the clavicle (scope in I, instrument in M). (D) Dissection of the lateral part of the clavicle with desincarceration of the acromioclavicular ligaments (scope in I, instrument in J). (CC, coracoclavicular ligaments; Cl, clavicle; DTm, deltotrapezius muscle.)

Fig 4

Lateral clavicle tunnel drilling (left shoulder, anterior view, scope in I, K wire in lateral supraclavicular). Posterior tracking (A), anterior tracking (B), and lateral tracking (C) of the lateral drill hole position. Lateral drill position in the clavicle (D). (ACJ, acromioclavicular joint; CC, coracoclavicular ligament; Cl, clavicle; DTm, deltotrapezius muscle; lCl, lateral clavicle.)

Fig 5

Medial clavicle tunnel drilling (left shoulder, anterior view). (A-D) Drilling of the medial clavicle with protection of the neurovascular structures, using a curette. Scope in I, K wire is introduced in MSC (medial supra clavicular portal). (CC, coracoclavicular ligament; Cl, clavicle; mCl, medial 2/3 of clavicle; Tz, trapezius.)

Fig 6

Conoid ligament suture (left shoulder, anterior view, scope in I, suture grasper and dog bone in MSC). (A) Passage of the suture under the coracoid process behind conjoint tendon from lateral to medial. (B) Passage of the medial strand of the shuttle relay through the medial clavicle tunnel. (C) Passage of the lateral strand of the shuttle relay through the conoid ligament. (D) Retrieving the lateral strand of the shuttle relay through the medial clavicle Tunnel. (E) Dog Bone application on the medial clavicle tunnel. (F) Suture of the conoid ligament: shuttle relay has been replaced by tape sutures. (C, coracoid process; CC, coracoclavicular ligaments; Cl, clavicle; CT, conjoint tendon; MSC, medial supra clavicular; Pm, pectoralis minor; Tz, trapezius.)

Fig 7

Suture of the trapezoid ligament (left shoulder, anterior view, scope in I, suture grasper alternatively in lateral supraclavicular and M, switching stick in J). (A) Passage of the shuttle relay under the coracoid process behind conjoint tendon, from lateral to medial. (B) Passage of the medial strand of the shuttle relay through the trapezoid ligament. (C) Retrieving the medial strand of the shuttle relay after passing though the trapezoid ligament. (D) Passage of the medial strand of the shuttle relay through the lateral clavicle tunnel. (E) Suture of the trapezoid ligament under the lateral part of the clavicle after the lateral strand of the shuttle relay was passed in the lateral clavicle tunnel, and replaced by a suture tape. (F) Dog Bone application on the lateral clavicle tunnel and reduction with the switching stick. (ACJ, acromioclavicular joint; C, coracoid process; CC, coracoclavicular ligament; Cl, clavicle; CT, conjoint tendon; lCl, lateral clavicle.)

Fig 8

Control of the reduction of the ACJ with no incarceration of ACJ ligaments (left shoulder, anterior view, scope in I, switching stick in J). (Ac, acromion; ACJ, acromioclavicular joint; Cl, clavicle.)