The implants
The Clavicular Clip and Sub-Coracoid Clip are made of medical titanium. The Clavicular Clip is designed to sit flush on the clavicular surface without leaving a protruding knot while the Sub-Coracoid Clip serves as the sub-coracoid counter-part. The Clavicular Clip allows a tendon graft to be used and the implant does not sink into the bone. The implants are connected to each other with a double-folded No. 5 braided non-resorbable suture. Subsequent implant removal is not needed at a later date.
Surgical Technique
1. The patient is placed in the beach chair position. The operation is initiated through the posterior portal. standard 30-degree arthroscope is used. The technique includes 4–5 portals (posterior, lateral, anterolateral, clavicular, and possibly an additional one). The lateral portal is marked with a needle right in front of the LHB and above the subscapularis tendon aiming at the coracoid neck. The exposure of the coracoid is initiated by opening the interval. The posterior side and the coracoid neck area are debrided.
2. The arthroscope is moved to the lateral portal with the use of a switching stick. The arthroscope stays there for the rest of the arthroscopy. The anterolateral portal is opened with the help of a needle aiming at the coracoid neck. The coracoid is debrided superiorly. In chronic cases, the pectoralis minor insertion may be detached from the coracoid
3. With the help of a needle, the place for the clavicular opening is determined. The clavicular superior cortex is cleared. A 2.4-mm guide pin is drilled through the clavicle and coracoid. The clavicular cortex is then pierced using a 5.0-mm stop-drill.
4. The Curved Lasso Guide is inserted through the clavicular opening. The Curved Lasso Guide is positioned in front of the clavicle and medial to the coracoid. The nitinol wire is pushed through the guide and to the anterolateral portal with the welded end first. The passing suture for the tendon graft is then guided under the coracoid.
5. The Curved Lasso Guide is then positioned posteriorly to the clavicle. The nitinol wire is pushed through the guide with the loop end first. The nitinol lasso wire and the passing suture are brought out together through the anterolateral portal.
6. The passing suture is threaded through the lasso loop and pulled around the clavicle. The tendon graft is then looped around the clavicle and coracoid.
7. The Straight Lasso Guide is passed through the clavicular and coracoid drill holes. The nitinol lasso wire is brought out with the welded end first, through the anterolateral portal and as a result, pulls the No. 5 interconnecting suture loop out.
8. The Sub-coracoid Clip is fastened to the interconnecting suture loop and positioned beneath the coracoid.
9. The arthroscopic part stops here
10. The other end of the interconnecting suture is threaded through the Clavicular Clip eyelet. The dorsal graft limb is intentionally left longer than the anterior limb.
11. After completing the arthroscopic CC reconstruction, the clavicular incision is extended over the AC joint. A separate wound over the AC joint can be used as well. The overstretched AC joint capsule is then dissected along its fibers. To facilitate repositioning, the distal end of the clavicle is resected using an oscillating saw. Soft tissue attachments and scar tissue surrounding the distal clavicle are released. With the entire reconstruction in place, the clavicle is repositioned and visually assessed for proper reduction. The interconnecting suture is tensioned and tied using a knot pusher. The repositioning conducted, the graft limbs are tensioned, tied, and secured to each other using No. 2 non-resorbable sutures.
9. Finally, the superior AC ligament is reconstructed using the longer end of the tendon graft. The graft is sutured on both sides of the AC joint, and the AC capsule is tightly plicated over it using strong interrupted sutures. The arthroscopic portals are closed using interrupted sutures, while the clavicular wound is closed in layers.
Postoperative Treatment
The patients are discharged the same day and each wear an arm sling for six weeks. They are allowed light rotatory movements and passive arm lifting within their limits of pain. The sling is removed after six weeks, but active rehabilitation does not begin until eight weeks after surgery at the earliest to provide enough time for graft integration. The patients are allowed to resume heavy labor at 3–4 months post-surgery, while overhead activity and sports can be resumed at six months.
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