Shoulder & Elbow.

ISSN 1758-5732

ORIGINAL ARTICLE

Falling from the Tightrope: double versus single Tightropes in patients with acromioclavicular joint dislocations: technique and complications
Chrysi Tsiouri , Yong-wei Pan & Daniel Mok Upper Limb Unit, Department of Orthopaedics, Epsom General Hospital, Epsom, UK Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing, China

ABSTRACT
Received Received 20 March 2010; accepted 5 January 2011 Keywords Acromioclavicular, Tightrope, arthroscopic, lateral end clavicle fracture, acromioclavicular dislocation Conicts of Interest None declared Correspondence Chrysi Tsiouri, Upper Limb Unit, Department of Orthopaedics, Epsom General Hospital, Dorking Road, Epsom, Surrey KT18 7EG, UK. Tel.: +44 (0)1372 735 735. Fax: +44 (0)1372 735 310. E-mail: xpysa@doctors.org.uk DOI:10.1111/j.1758-5740.2011.00112.x

Background We welcomed the innovative arthroscopic stabilization of the acromioclavicular joint dislocations with the Tightrope as it seemed promising regarding results and rehabilitation however our results were not satisfactory. Materials and Methods We clinically and radiographically reviewed the rst thirty one consecutive patients treated with this method and analysed their scores in search of correlations between results and patient, injury or surgery factors. Results We had 19% failure rate that was not statistically correlated with any factors. Conclusion We believe the Tightrope alone is not adequate to stabilize the acromioclavicular joint as it does not address the acromioclavicular ligament and the instability at the anteroposterior plane.

INTRODUCTION Of the most recent advances in arthroscopic reduction and xation of acromioclavicular joint (ACJ) injuries is the Tightrope (Arthrex, Inc., Naples, FL, USA) [1]. It leaves minimal scarring and dispenses with secondary surgery to remove any implants. The early results were encouraging [16]. We started using the Tightrope in our unit in 2007. Initially, as a single implant as described in 2006 [2] and, later, with a modied technique to employ two Tightropes. We present our technique and discuss our results and complications. PATIENTS AND METHODS Between July 2007 and February 2010, forty consecutive patients with ACJ dislocations or lateral end of clavicle fractures had arthroscopic Tightrope xation of their injury by the senior author. We reviewed the rst 31 (30 male, one female) consecutive patients. Twenty-six had ACJ dislocations, three had lateral end of clavicle fractures and two had both. The patients were followed up at 6 weeks, 12 weeks and 52 weeks. At nal follow-up, they were assessed independently with the Constant score. Radiographic examination of the ACJ was also undertaken. Surgical technique The standard technique of arthroscopic stabilization of the ACJ was well described by Tennet in 2008 [1]. We modied the technique 130

to accommodate the insertion of two Tightropes between the coracoid and the clavicle.

Patient positioning Anatomical studies show that the conoid ligament originates from the posterior aspect of the clavicle 4.5 cm medial to its lateral end and inserts into the base of the medial aspect of the coracoid. The trapezoid ligament originates from 2.5 cm to 3.5 cm medial to the lateral end of the clavicle and inserts into the base of the coracoid 10 mm anterior and 5 mm lateral to the conoid ligament insertion [79]. To prepare a drill hole in such a medial position in the clavicle, we had to place the patient in a beach chair position on a shoulder table with a small head rest rather than a head guard.

ACJ reduction To avoid over correction or mal reduction of the dislocated ACJ, we provisionally stabilized the joint with a smooth 2 mm K-wire. Reduction was conrmed with an image intensier. If reduction is performed later, at the time of Tightrope xation, the second Tightrope may draw the lateral clavicle in an anterior and inferior direction with over correction towards the coracoid and loosening of the rst device.

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Concomitant injuries Standard arthroscopy of the glenohumeral joint was performed in all cases through the posterior portal to identify and treat any concomitant intra-articular injuries. Superior labral tear from anterior to posterior [1] and anterior labral tear [1] were treated at the same time. One pan labral tear had to be treated arthroscopically 3 months later because of concern of excessive uid distention in one seating. Portals The anterolateral viewing portal was established in the subacromial space just below the anterior corner of the acromium. The working portal was established half way between this and the coracoid process anteriorly (Fig. 1). To minimize soft tissue distention, no outow cannulae was used. Debridement of the soft tissues lateral to the coraoid arch was undertaken with a 4 mm mechanical shaver (Aggressor, FMS, Mitek, Raynham, MA, USA). We do not nd thermal resection particularly helpful. Placement of the two guide pins over the clavicle Soft tissue distension and swelling from the injury can make palpation of the clavicle inaccurate. Placing spinal needles at the anterior and posterior borders of the clavicle, the drill sleeve of the guide (Arthrex) was then centered between them over the surface of the clavicle. The medial guide pin was inserted 5 cm from the lateral end of the clavicle, slightly towards the posterior aspect of the bone and aiming towards the base of the coracoid. The lateral guide pin should be at least 1 cm lateral and aiming to exit from the undersurface of the arch of the coracoid anterior to the previous pin. The position of the aiming device to receive the guide pin into the coracoid was determined arthroscopically.
Fig. 3 Guidewires exiting at coracoids undersurface.

Fig. 2 Guidewire insertion.

Passage of endo-button Care was taken to orientate the endo-button in an anterior pointed diagonal fashion to facilitate its passage through the bone tunnels

Fig. 4 Tightrope insertion.

Fig. 1 Patient set-up.

by pulling one of the two leading sutures longer (Figs 2 and 3). Often stuck as it emerged from the coracoid, the button could easily be retrieved by placing a probe into it and pulling. A second Tightrope was inserted in a similar fashion (Figs 4 and 5). 131

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Fig. 5 Two Tightropes at coracoid undersurface.

average only 3 weeks (range 0 weeks to 8 weeks) instead of the recommended 4 weeks. We had six clinical failures (19%) Surprisingly, the two worst Constant scores (50 and 64) do not involve any of the failures. They are both male patients, aged 52 years and 54 years old, respectively, with chronic type V ACJ dislocations that had been treated with double Tightrope xation. Neither is involved in sports (one is a plumber and the second an ofce administrator). Both of them have regained a full range of movement but report dull ache. Of the three single Tightrope xations that failed, one developed infection after treatment of an acute type V ACJ dislocation. The other two were chronic injuries. Three double Tightropes failed, all in acute type V injuries. One was secondary to supercial infection and this was attributed to his immediate return to work as an army trainer. The other two double Tightrope lost the reduction after the endo-buttons eroded into the clavicle. Radiological evaluation Subluxation of the ACJ was observed in three patients after their endo-buttonserodedinto theclavicle.Theyoccurredwithin therst 8 weeks after stabilization. Interestingly, two of these were acute injuries xed with double Tightrope. None were symptomatic. Of more concern were the four patients with endo-buttons that cut out, resulting in a loss of reduction. Two were single Tightrope, which cut out at 3 weeks and 10 weeks. The other was a patient with a double Tightrope stabilization who was injured in a martial arts competition at 20 weeks after surgery. The last patient was a college student and competitive motorcyclist but did not report any injury prior to failure. Details of failed stabilizations are listed in Table 2. Statistical analysis Using the SPSS package for Windows (SPSS, Inc., Chicago, IL, USA) considering p < 0.05 statistically signicant, we attempted to correlate our results to several factors. We found no signicant correlation (Spearmans correlations, Fig. 6) between failure, subluxation or successful stabilization and type of injury, chronicity, operation duration, operation date, use of a single or double Tightrope, return to work or sports, or duration of immobilization. Performing a one-way analysis of variance, we found no statistical

The ACJ stabilizing K-wire was then removed and the reduction was conrmed using the image intensier. Before skin closure, we made an attempt to cover the prominent knots of the brewires under a separate soft tissue layer. Postoperative immobilization was limited to 4 weeks in a sling but return to sports and labour was discouraged for 3 months. The mean duration of the procedure was 105 minutes (60 minutes to 205 minutes). Two fracturedislocations had to be converted to mini-open reductions because reduction was not Possible because of soft tissue interposition. These were excluded from the statistics of the study. RESULTS Clinical evaluation There were 18 acute and 13 chronic cases. Mean delay to surgery of the chronic cases was 13 weeks (6 weeks to 32 weeks). Table 1 presents the diagnosis and type of xation for the acute and chronic cases. The mean age was 40 years (range 19 years to 65 years) with an average follow-up of 14 months (range 4 months to 24 months). There were seven manual workers and nine patients were involved in contact sports. At nal follow-up, the mean Constant score was 80.5 (range 50 to 98). The average immobilization period of the shoulder was on Table 1 Rockwood classication Fixation Acute Type V FDC + ACJ dislocation FDC Total

Fixation Double TR 3 9 1 2 15 Chronic 6 6 0 1 13 Single TR 2 1 0 0 3 Double TR 4 5 0 1 10

Single TR 1 1 1 0 3

Type III

4 10 2 2 18

Classication according to Rockwood. ACJ, acromioclavicular joint; FDC, fracture distal end of clavicle; TR, Tightrope.
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Table 2 Failures Operation duration (minutes) 105 100 98 90 No data 90 170 120 120

Case 5 8 12 13 22 23 26 27 29

Type III III V V V V V V V

Fixation 2TR 1TR 1TR 1TR 2TR 2TR 2TR 2TR 1TR

Acute/chronic Chronic Acute Acute Chronic Acute Acute Acute Chronic Chronic

FU 20 24 12 18 10 23 7 5 5

Time of failure 4/52 3/52 6/52 10/52 8/52 20/52 2/52 6/52 2/52

Return to physical Plumber-6/52 NA Rugby-12/52 NA NA Martial arts Army trainer-immediate NA NA

Failure Subluxed Failed Subluxed Failed Subluxed Failed Failed Failed Failed

Mode of failure One cut out Cut out Eroded Cut out Eroded Cut out Infection Cut out Infected

FU, months of follow-up. Time of failure in weeks postoperatively. Return to physical activity in weeks postoperatively (work or sport; NA, non-applicable). raise caution as a result of complications [1518], prompting the search for more adequate biomechanically methods [18]. Initially, we used the Tightrope as a single device in accordance with the manufacturers instructions [19] but, later on, as a double device, aiming to reproduce both the conoid and trapezoid ligaments with a stronger anatomical reconstruction. Imhoff et al. biomechanical studies [7] showed that the natural coracoclavicular ligaments resisted a vertical load to failure of 598 N, and a static anterior load of 338 N. With double Tightrope reconstruction, the vertical load to failure was 982 N, whereas the static anterior load was 627 N, almost twice the native strength. Loss of reduction secondary to button erosion We encountered our rst early failures within 4 weeks postoperatively secondary to the clavicular endo-button cutting into the clavicle. Interestingly, button erosions and displacements were noted by Tennent [1] when they reported the single technique in 2008. Although asymptomatic, three out of their ten patients (30%) lost their ACJ reduction at follow-up. They attributed this to the larger drill hole prepared for the Tightrope in their early cases. We also had three such asymptomatic subluxations. We also observed 10% endo-button erosion of the clavicle without subluxation. Of more concern, we had four failures secondary to the buttons cutting out of the bone altogether. We consider the small surface area of the 6 mm endo-button coupled with the gravitational traction on the coracoid by the upper limb exerts a pressure above that which the clavicle cortex can withstand. The endo-button then acts as a cheese grater and erodes into the bone. We reported this to the manufacturer and new endo-buttons with a wider 10 mm at disc 10 mm were introduced at the end of 2008. Even though the present study did not include any patients treated with the new Tightrope buttons, it is worth noting that we observed three failures subsequently, thus raising our total failure rate to almost 22% (nine out of 41). One of them, a female patient with acute type 3 ACJ dislocation, was treated with a double Tightrope that actually failed within the 4 weeks of immobilization! She is asymptomatic, although there is redislocation and, on radiographic 133

failures and subluxations

01/04/2007 01/07/2007 01/10/2007 01/01/2008 01/04/2008 01/07/2008 01/10/2008 01/01/2009

operation date

Fig. 6 Distribution of failures (blue dots) and subluxations (red dots) on learning curve (healed cases are void dots).

difference in failure rate when patients were separated according to xation method (single or double Tightrope), chronicity of injury or type of injury. DISCUSSION We welcomed the innovative method of arthroscopic stabilization oftheACJ using theTightropedevicesinceitwasrstannounced [2] and adopted it as treatment choice for all our patients with ACJ dislocations that needed surgery. The procedure is less invasive and traumatic for the patient, patient morbidity is low because it is an arthroscopic procedure and no implant removal is required. The substitute ligament appears to reconstitute normal anatomy with a similar biomechanical strength [7]. Recently, a series of 19 patients with acute grade 4 and 5 ACJ dislocations and 2-year follow-up was reported with no failures or infections [10]. Good results have been published in short series or cases of lateral end of clavicle fracture stabilizations with the Tightrope [1114]. However, other studies

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control, one of the clavicle endo-buttons is lying 1 cm above the clavicle, suggesting Fibrewire failure. Fibrewire failure has been reported in literature and was the main cause of a 50% failure rate [15]. Fractures of the lateral end of the clavicle with coracoclavicular ligament rupture All three of our lateral end clavicle fractures with wide displacement united after arthroscopic Tightrope stabilization. Because the acromioclavicular ligaments were intact in these patients, reduction of the superiorly displaced clavicle fragment to their lateral ends with the Tightrope for 6 weeks appeared to lead to union. Infection The second reason for failure in our series was infection. The knots tied with #5 Fiberwire tended to be bulky. When tied over the clavicle that lacks adequate soft tissue cover, the knots caused irritation to the overlying skin and resulted in wound breakdown and infection. This was particularly noted in our young patients who returned to their sporting activities early before biological healing of the ligaments. We now create a full thickness soft tissue ap to cover these knots, followed by separate skin closure, and we have not had any more infections. Rehabilitation Compared with open reduction and internal xation with metal work across the ACJ, arthroscopic Tightrope stabilization was a relatively less painful procedure. In our series, patients discarded their slings early, with return to manual work and sporting activities. This did not give the soft tissues sufcient time to heal, resulting in wound irritation, breakdown and subsequent infection. We consider that the high incidence of button erosions was also related to the early shoulder movements that these patients enjoyed. Technical exacting procedure The difcult step in the procedure was to place the Tightrope in good quality bone in the clavicle and coracoid. Because the patient was inclined at 45 in a beach-chair position, the drill sleeve could often be placed too close to the anterior edge of the sloping clavicle resulting, in anterior cut out of the Tightrope. The task was made even more challenging with the placement of two 4.5 mm drill holes in a narrow coracoid with the double Tightrope technique. Although the jig can provide sitting of a single Tightrope between the coracoid and the clavicle comfortably, the same jig tends to place the second endo-button close to the rst in the undersurface of the coracoid. It does not allow easy lateral placement of the clavicular drill hole in the same oblique direction as that of the trapezoid ligament. By tilting the jig to place the second drill hole laterally, the guide pin often misses the lateral edge of the coracoids. However, even when this kind of device is implanted using open techniques that are easier and more straightforward, high complication rates have been noted [15]. A recent series of 23 acute acromioclavicular dislocations stabilized with the double Tightrope using a fully arthroscopic technique similar to ours reported good results with two failures that were attributed to the complexity of the technique 134

and a 30% loss of reduction [20]. The authors recommend that the Tightrope is used only by experienced arthroscopists because this is a procedure with a steep learning curve. In our experience, we could not detect any correlation between our failures and our learning curve. There is a constant distribution of our failures over time even though our technique was improving (Fig. 6). Neither of the Tightropes can address the anteroposterior instability at the lateral end of the clavicle in relation to the acromium. Indeed, no reconstruction of the acromioclavicular ligaments was attempted in our series. Biological healing and biomechanical advantages In our experience, the Tightrope was successful in stabilizing 81% of the ACJ after acute or chronic injuries. The reason is that it only offers partial reconstruction of the torn conoid and trapezoid ligaments, thus stabilizing the clavicle to the coracoid. There is no attempt to address the instability between the acromion and the clavicle. Anteroposterior instability is not dealt and this may be the reason for our failures. Acromioclavicularjointinjurieshavealwaysbeen difcultto treat, which is the reason why there are more than 60 different methods of stabilization described in the literature [21]. They vary between acromion-clavicle xation methods, such as K-wires and tension banding, hook plates or recently specially designed anatomical plates [22], or coracoclavicular stabilization with or without distal clavicle resection with screws, sutures, anchor sutures or ligament transfers, grafts or tapes, showing variable results [21,2330]. Further development of arthroscopic techniques is necessary to improve results of ACJ stabilization. In addition, there is currently no evidence that biological healing with scar tissue formation occurs between the clavicle and the coracoid in chronic ACJ reconstructions with the Tightrope or any means of stabilizing the ACJ [21]. To date, the results of biological reconstruction with host or donor tendons have been disappointing [21,2325] because the grafts may fail in their anchoring point at the clavicle or their midsubstance, or loosen, and, with doubtful biological healing of the coracoclavicular ligaments, either instability or the symptoms (or both) recur [22,26]. There is no agreement as to whether they are as strong as the native ligaments [21,2729] but improved results occur when the graft is supplemented by sutures or other nonbiological material. Most of these procedures are performed open. Pure arthroscopic repairs are few in the literature and involve mostly the Tightrope or alike implants until the very late application of all arthroscopic ModiedWeaver Dunn procedure with a published technique but no reported results yet [30]. The latest studies combine the Tightrope device with tendon graft or transposition in an attempt to achieve biomechanical stability closer to the native stability and show promising early results [28]. There is a controlled laboratory study that compared the WeaverDunn combination with Tightrope or tape cerclage augmentation, which showed excellent stability with the Tightrope in all planes [29]. It has been suggested that the Tightrope alone should only be used in the acute setting and, for chronic cases, augmentation with sutures or biological material is necessary [20]. The Tightrope combined with other

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12. Qureshi F, Potter D. The use of the arthroscopic tightrope in shoulder injuries, 2005. http://www.opnews.com/articles/145/articles.php#3 (date last accessed 27 November 2008). 13. Khan LAK, Bradnock TJ, Scott C, Robinson CM. Fractures of the clavicle. J Bone Joint Surg Am 2009; 91:44760. 14. Nourissat G, Kakuda C, Dumontier C, Sautet A, Doursounian L. Arthroscopic stabilization of neer type 2 fracture ofthe distal part of the clavicle. Arthroscopy 2007; 23:674.e14. 15. Lim YW, Sood A, Riet RP, Bain GI. Acromioclavicular joint reduction, repair and reconstruction using metallic buttons early results and complications. Tech Shoulder Elbow Surg 2007; 8:21321. 16. Gangadharan R, Parker J, Harwood PJ, Venkateswaran B. Technical pitfalls in artrhoscopic reconstruction of acute acromioclavicular dislocations using TightRope. J Bone Joint Surg Br Proceedings, May 2009; 91-B: 261. 17. Ball S, Sankey A, Cobiella C. Clavicle fracture following Tight Rope xation of acromioclavicular joint dislocation. Inj Extra 2007; 38:4302. 18. Lim YW. Triple endobutton in AC joint reduction & reconstruction. Ann Acad Med Singapore 2008; 37:2949. 19. http://www.deviceinnovation.com/index.php?lay=show&ac=article& Id=301167&Ntype=6. 20. Salzmann GM, Walz L, Buchmann S, et al. Arthroscopically assisted 2-bundle anatomical reduction of acute acromioclavicular joint separations. Am J Sports Med 2010; 38:117987. 21. Nicholas SJ, Lee SJ, Mullaney MJ, Tyler TF, McHugh MP. Clinical outcomes of coracoclavicular ligament reconstructions using tendon grafts. Am J Sports Med 2007; 35:19127. 22. http://www.acumed.net/locking-superior-distal-clavicle-plates. 23. Mazzocca AD, Santangelo SA, Johnson ST, et al. A biomechanical evaluation of an anatomical coracoclavicular ligament reconstruction. Am J Sports Med 2006; 34:23646. 24. Costic RS, Labriola JE, Rodosky MW, Debski RE. Biomechanical rationale for development of anatomical reconstructions of coracoclavicular ligaments after complete acromioclavicular joint dislocations. Am J Sports Med 2004; 32:192936. 25. Lee SJ, Nicholas SJ, Akizuki KH, et al. Reconstruction of the coracoclavicular ligaments with tendon grafts: a comparative biomechanical study. Am J Sports Med 2003; 31:64855. 26. Choi SW, Lee TJ, Moon KH, Cho KJ, Lee SY. Minimally invasive coracoclavicular stabilization with suture anchors for acute acromioclavicular dislocation. Am J Sports Med 2008; 36:9615. 27. Harris RI, Wallace AL, Harper GD, et al. Structural properties of the intact and the reconstructed coracoclavicular ligament complex. Am J Sports Med 2000; 28:1038. 28. Tauber M, Gordon K, Koller H, Fox M, Resch H. Semitendinosus tendon graft versus a modied Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study. Am J Sports Med 2009; 37:18190. 29. Wellmann M, Lodde I, Schanz S, et al. Biomechanical evaluation of an augmented coracoacromial ligament transfer for acromioclavicular joint instability. Arthroscopy 2008; 24:1395401. 30. Laurent L, Baier GP, Leuzinger J. Arthroscopic treatment of acute and chronic acromioclavicular joint dislocation. Arthroscopy 2005; 21: 1017.e18. 31. Zooker CC, Parks BG, White KL, Hinton RY. TightRope versus ber mesh tape augmentation of acromioclavicular joint reconstruction: a biomechanical study. Am J Sports Med 2010; 38:12048.

means of anteroposterior stabilization of the ACJ may provide satisfactory results but research is still ongoing [30.31]. Based on our experience, we would recommend that the Tightrope only be used when the surgeon is prepared to treat instability between the acromion and the lateral end of the clavicle. Conclusions The Tightrope, whether single or double, stabilized successfully the clavicle in relation to the coracoid in only 81% of our patients. We consider our failure rate to be disappointingly high. We cannot identify any specic factor that contributed to failure and therefore we have ceased using it. The current arthroscopic technique cannot successfully correct all ACJ dislocations. The current jig requires modication and the technique needs to include biological xation of the lateral end of the clavicle to the acromion. We can only recommend this procedure to skilled arthroscopic shoulder surgeons who would be prepared to address stability across the acromioclavicular joint at the same time. References
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