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Postoperative coracoid fracture after transcoracoid acromioclavicular joint reconstruction
J Shoulder Elbow Surg (2011) 20, e6-e10
www.elsevier.com/locate/ymse
Postoperative coracoid fracture after transcoracoid acromioclavicular joint reconstruction David C. Gerhardt, MDa, Joshua D. VanDerWerf, BSb, Lucas S. Rylander, MDa,*, Eric C. McCarty, MDa a b
Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA School of Medicine, Creighton University, Omaha, NE, USA
The acromioclavicular (AC) joint is a frequent site of shoulder injury and may represent up to 50% of athletic shoulder injuries in some sports.6,11 Treatment options include numerous nonsurgical and surgical approaches, and treatment is often tailored to the severity of injury. Rockwood’s expanded classification includes 6 grades of AC joint injury.11 For grades IV to VI, surgical management is generally recommended. More than 60 procedures have been described, and no strong consensus regarding the optimal fixation method exists.11,15 Recent trends towards anatomic coracoclavicular ligament reconstructions using arthroscopic methods have been documented; however, few reports exist regarding complications associated with these techniques. We report a postoperative coracoid fracture after AC joint reconstruction using a transcoracoid fixation technique.
and passive range of motion of the shoulder. She had already started 2 weeks of physical therapy, which had helped improve her range of motion. Her right shoulder demonstrated active forward flexion to 180 , external rotation to 60 , and internal rotation to T12. She had a positive cross-body adduction test. She had motor and sensory function intact distal to the elbow. She had isolated tenderness over the AC joint, and the distal clavicle displayed significant prominence. Radiographs demonstrated a Rockwood grade V AC joint separation (Fig. 1). After initial discussion of potential treatment options, including surgical reconstruction, the patient declined surgery in favor of nonoperative management. Approximately 2 months later, the patient returned to our office expressing interest in surgical reconstruction for her now chronic AC joint separation. Physical examination demonstrated similar findings to the initial visit. She was treated with arthroscopic AC joint reconstruction using a 6-mm posterior tibialis allograft tendon and open distal clavicle resection, as described below.
Case report
Surgical technique
A 57-year-old right hand-dominant woman sustained a high-speed direct blow to her right shoulder after a fall from her bicycle. She was initially treated in the emergency department, where radiographs demonstrated an AC joint separation. She was placed in a sling and told to arrange follow-up as an outpatient. Four weeks after this incident, she presented to our office for treatment recommendations. At the time of her initial presentation to our office she had minimal pain at rest; however, she had significant pain with active
Various all-arthroscopic or arthroscopically assisted techniques have been described for stabilization of the AC joint. The technique chosen for this patient is a modification of the arthroscopic subacromial technique described by Baumgarten et al2 and the transclavicular-transcoracoid technique augmented with a GraftRope (Arthrex, Naples, FL, USA) described by Scheibel et al.10 An arthroscopic reconstruction of the coracoclavicular ligaments using an allograft with a GraftRope augmentation was used in conjunction with an open distal clavicle resection. General anesthesia was initiated, and the patient was placed in the beach chair position. An initial diagnostic arthroscopy was followed by the arthroscope being placed in the subacromial space where the coracoacromial ligament was traced from the acromion down to the coracoid. The coracoid base was debrided and
No Investigational Review Board approval was necessary for this manuscript. *Reprint requests: Lucas S. Rylander, MD, 311 Mapleton Ave, Boulder, CO 80304. E-mail address: [email protected] (L.S. Rylander).
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.01.017
Coracoid fracture after transcoracoid acromioclavicular reconstruction
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Figure 1 Preoperative image of the right shoulder demonstrates a grade V acromioclavicular joint injury.
visualized arthroscopically. An incision was made directly over the clavicle, and a sagittal saw was then used to resect 0.5 cm of the distal clavicle. At approximately 35 mm from the end of the original distal clavicle, a guide pin was placed using the Arthrex Constant Guide. The guide pin was centered on the clavicle with respect to anterior and posterior, and midway between the ligamentous attachments of the conoid and trapezoid ligaments. The exit point for the guide pin was centered on the base of the coracoid, using the coracoid targeting portion of the Constant Guide. A 6-mm reamer sized for the allograft and GraftRope construct was drilled through the clavicle and the base of the coracoid. No blowout was noted of the medial or lateral walls of the coracoid base, and the tunnel appeared well centered. The coracoid flip button and graft construct were then passed through the clavicle and coracoid, and the button was optimally flipped under the coracoid with arthroscopic visualization. The clavicle was then reduced, and the allograft limbs were tensioned and fixated using a 5.5-mm polyetheretherketone interference screw passed over a nitinol wire through the clavicle washer and into the clavicle (Fig. 2). Excess graft was trimmed, and the deltotrapezial fascia was meticulously repaired during closure. Postoperative radiographs showed reduction of the AC joint (Fig. 3).
Figure 2 Sketch shows the reconstruction construct after passage of a cortical button under the coracoid and graft passage through the clavicle, just before insertion of the interference screw.
Postoperative course At her 1-week follow-up visit, the deformity was noted to have recurred. The patient had been compliant with full-time sling use during this period, and no motion or other physical therapy had begun yet at this point. Plain radiographs demonstrated that the graft construct had migrated superiorly through the coracoid, allowing the AC joint to resume its preoperative position (Fig. 4, A). A computed tomography scan confirmed a postoperative coracoid fracture that was not well visualized on plain radiographs (Fig. 4, B). The patient denied any postoperative trauma and reported compliance with postoperative restrictions. A revision of her AC joint reconstruction along with a coracoid fixation was performed. The revision surgery was done using an arthroscopic-assisted cannulated screw for fixation of the coracoid fracture. Using arthroscopic visualization, a semitendinosus
Figure 3 Postoperative image of the right shoulder demonstrates a well-reduced acromioclavicular joint and stable hardware. allograft was looped under the coracoid for the ligamentous reconstruction and tied over the top of the clavicle with #2 heavyduty suture. Specifically, the graft was looped over the clavicle, not taken through drill holes, and then sewn to itself. No screw fixation was used as part of the revision process except to fixate the coracoid fracture. The reconstruction was protected using a 3.5-mm LCP Clavicle Hook Plate (Synthes, West Chester, PA, USA; Fig. 5).
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Figure 4 A follow-up (A) radiograph and (B) computed tomography scan approximately 1 week after surgery demonstrate failure of fixation and recurrent dislocation of the acromioclavicular joint with associated coracoid fracture. At the 2-year follow-up, there has been no recurrence of AC separation or fracture to date. There are no symptoms. The patient is active, works out regularly, and cycles 100 to 200 miles a week. Physical examination reveals no deformity. The patient has minimal tenderness at the AC joint and clavicle. There is normal motion and full strength at the shoulder. Additionally, no signs of impingement are present. The hook plate has not been removed secondary to patient preference and lack of symptoms. The risk of future acromial fracture has been discussed.
Discussion AC injuries are among the most common shoulder injuries in sporting activities. Although there is consensus that Rockwood grade IV to VI AC joint separations typically warrant surgical intervention, there is disagreement on which technique to use.11 Recently, a focus has been placed on arthroscopic tendon graft reconstructions of the coracoclavicular ligaments. Most of our current literature regarding highgrade AC joint injuries emphasizes surgical reconstruction techniques and little emphasis is placed on the potential for substantial complications. To our knowledge, the complication of a coracoid fracture through a bone tunnel used for fixation has not been described in the literature. In addition, the salvage of such a fracture with AC joint instability can be complex and has not been described previously. Transfer of a patient’s coracoacromial ligament to the distal clavicle for reduction of an AC separation was described first by Weaver and Dunn in 1972.11,16 Because use of the native coracoacromial ligament for surgical reconstruction leads to a weaker, more pliable construct that results in a high failure rate, other techniques have gained favor.13,16,17 One modification of the Weaver-Dunn technique involves augmenting the stabilization with a suture loop around the base of the coracoid up to the clavicle.11 Techniques for accomplishing this type of
Weaver-Dunn procedure have also since been performed arthroscopically.12 Alternative techniques to the nonanatomic, WeaverDunn type reconstructions include the use of sutures and metallic buttons to achieve anatomic stabilization.7,17,18 Wei et al17 report good results using the triple endobutton technique, which involves passing sutures anchored by end buttons through drill holes in both coracoid and clavicle to achieve anatomic AC stabilization. Similarly, Wellmann et al18 report good results passing a flip button/polydioxanone construct through a coracoid bone tunnel and clavicle drill holes. However, use of metallic buttons and FiberWire suture (Arthex) anchored against the clavicle and coracoid has been reported by Lim et al7 as having a 50% failure rate. Similar fixation devices have been used arthroscopically with good results.3,14 Another option for AC reconstruction involves an anatomic reconstruction using tendon grafts, which has been shown in biomechanical studies to have good stability.11,13 The two predominant ways to accomplish anatomic reconstruction of the coracoclavicular ligaments are by looping the tendon graft around the coracoid and anchoring it to the clavicle or by passing the graft through a coracoid bone tunnel and anchoring it to, or passing it around, the clavicle.2,9,11,13 Various arthroscopic techniques for coracoclavicular reconstruction using tendon grafts have been described with good results.2,9,13 Because of the minimally invasive nature of the surgery combined with results comparable with open techniques described previously, arthroscopic-assisted stabilization of the AC joint with reconstruction of the coracoclavicular ligaments using a tibialis allograft was used in this case. Complications from surgical AC joint reconstruction vary, depending on which technique is used. For arthroscopic reconstruction, complications mostly include loss of reduction, persistent pain, instability, hardware complications,
Coracoid fracture after transcoracoid acromioclavicular reconstruction
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Figure 5 Final (A) anteroposterior, (B) outlet, and (C) axillary views of the right shoulder after fixation of the coracoid and placement of hook plate to maintain acromioclavicular joint reduction.
foreign-body reactions, and infection.11-13 Loss of reduction still remains the most common complication.12 Rarely, a postoperative coracoid fracture has been reported from the suture or graft passed around the coracoid. Baldwin et al1 suggest that techniques involving drilling or tunneling into the base of the coracoid theoretically increases the risk of fracture and recommend using a technique in which the graft is looped around the coracoid base instead.1 Gonzalez et al4 suggest using a smaller peroneus brevis graft, which requires a smaller coracoid bone tunnel than the larger and more common semitendinosus graft, thereby theoretically reducing fracture risk. In our review of the literature, postoperative coracoid fractures have been reported when the graft is looped around the coracoid base, but none have been reported from passing a graft through a bone tunnel.5,8,13 The cause of fracture in the looped graft/suture cases was bone erosion around the base of the coracoid. In addition, compounding factors were present that led to fracture in each report. Moneim and Balduini8 report a coracoid fracture in the presence of postoperative infection and bony erosion between drill holes in the clavicle. Tomlinson et al13 reported a fracture in a high-level baseball pitcher from throwing a ball 7 months after surgery. Jeon et al5 reported a fracture due to noncompliant heavy lifting by the patient in the early postoperative period. Salvage of AC joint fixation after coracoid fracture represents a complex problem in its own right. As discussed, this injury is rare and therefore has not been discussed in the literature except in case reports. In the setting of
transcoracoid fixation, it has not been discussed previously at all; therefore, all treatment recommendations represent level V evidence. Each case must be tailored to the needs of the current patient. If enough intact coracoid is present to loop graft under the coracoid base, revision AC reconstruction can occur in this manner, accompanied by coracoid fixation with internal hardware. If there is not enough coracoid base left to loop the graft under the coracoid and still maintain stability of AC fixation after coracoid fixation, several options exist. One can reconstruct the coracoclavicular ligaments with a graft under the fixated coracoid and protect the repair with a hook plate, as was done in our patient. Alternatively, the repair can be protected by spanning the AC joint with conventional or locked plating, working much like the Hook Plate. Either option requires subsequent surgery for removal of hardware. Another option to protect the revision reconstruction would be to use suture directly into the body of the scapula through transosseous tunnels or suture anchors. Alternatively, the graft can be placed through bony tunnels in the body of the scapula, bypassing the need to protect the coracoid repair site, although this can be technically demanding. Nothing in the current literature exists to guide the treating surgeon on which technique is superior at this time. Most surgical techniques for treatment of AC joint separations focus on reconstruction of the coracoclavicular ligaments and rely on secondary processes to address the AC ligaments. We chose to perform a distal clavicle resection as a concomitant procedure, which may have led
e10 to an additional insult to the already compromised soft tissue envelope surrounding the AC joint and higher force transmission across the coracoclavicular reconstruction. In our case, however, no noncompliance by the patient or other compounding postoperative complications were identified. Although our patient was a 57-year-old woman and likely had a bone density inferior to that of the younger man who typically undergoes this surgery, we can identify few other specific risk factors predisposing our patient to postoperative fracture. To our knowledge, this is the first reported case of postoperative coracoid fracture in this setting of a transcoracoid-type procedure. Although the transosseous bone tunnel in the coracoid used by our surgical technique has been theoretically implicated in increased fracture risk, this has not been reported in the literature. More investigation into the degree to which bone tunneling alters the integrity of the coracoid process is necessary. Different techniques involving use of smaller bone tunnels and smaller tendon grafts, or alternative graft docking techniques, may lead to a reduction in fracture risk when the transcoracoid technique is used. In conclusion, to our knowledge, the current report is the first to describe a patient with coracoid fracture after AC joint reconstruction using a transcoracoid fixation technique. As this method of fixation becomes more commonplace, we believe that it is important to understand its risks so that they can be appropriately weighed by treating surgeons and their patients. Further, it is important to consider how one may be able to salvage this complication if it does happen during a patient’s treatment. Much information is still needed, such as what risk factors place a patient at the highest risk for postoperative coracoid fracture or fixation pull-out. Bone density, tunnel size, number of tunnels, and fixation type are all potential risk factors. Hopefully, future complications using this technique can be avoided through further scientific work.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Baldwin K, Namdari S, Andersen J, Lee B, Itamura JM, Huffman GR. Luggage tag technique of anatomic fixation of displaced acromioclavicular joint separations. Clin Orthop Relat Res 2010;468:259-65. doi: 10.1007/s11999-009-0877-8
D.C. Gerhardt et al. 2. Baumgarten KM, Altchek DW, Cordasco FA. Arthroscopically assisted acromioclavicular joint reconstruction. Arthroscopy 2006;22. 228. e1-228.e6. doi:10.1016/j.arthro.2005.12.026 3. Chernchujit B, Tischer T, Imhoff A. Arthroscopic reconstruction of the acromioclavicular joint disruption: surgical technique and preliminary results. Arch Orthop Trauma Surg 2006;126:575-81. doi:10.1007/ s00402-005-0073-6 4. Gonzalez R, Damacen H, Nyland J, Caborn D. Acromioclavicular joint reconstruction using peroneus brevis tendon allograft. Arthroscopy 2007;23. 788.e1-4. doi:10.1016/j.arthro.2006.09.006 5. Jeon IH, Dewnany G, Hartley R, Neumann L, Wallace WA. Chronic acromioclavicular separation: the medium term results of coracoclavicular ligament reconstruction using braided polyester prosthetic ligament. Injury 2007;38:1247-53. doi:10.1016/j.injury.2007.05. 019 6. Kaplan L, Flanigan D, Norwig J, Jost P. Bradley. Prevalence and variance of shoulder injuries in elite collegiate football players. Am J Sports Med 2005;33:1142-6. doi:10.1177/03635 46505274718 7. Lim YW, Sood A, van Riet RP. Acromioclavicular joint reduction, repair and reconstruction using metallic buttons-early results and complications. Tech Shoulder Elbow Surg 2007;8:213-21. doi:10. 1097/BTE.0b013e3181578965 8. Moneim MS, Balduini FC. Coracoid fracture as a complication of surgical treatment by coracoclavicular tape fixation. A case report. Clin Orthop Relat Res 1982:133-5. doi:10.1097/00003086-19820800000026 9. Pennington W, Hergan D, Bartz B. Arthroscopic coracoclavicular ligament reconstruction using biologic and suture fixation. Arthroscopy 2007;23. 785.e1-7. doi:10.1016/j.arthro.2006.10.005 10. Scheibel M, Ifesanya A, Pauly S, Haas N. Arthroscopically assisted coracoclavicular ligament reconstruction for chronic acromioclavicular joint instability. Arch Orthop Trauma Surg 2008;128:1327-33. doi:10.1007/s00402-007-0547-9 11. Simovitch R, Sanders B, Ozbaydar M, Lavery K, Warner JJ. Acromioclavicular joint injuries: diagnosis and management. J Am Acad Orthop Surg 2009;17:207-19. 12. Snow M, Funk L. Technique of arthroscopic Weaver-Dunn in chronic acromioclavicular joint dislocation. Tech Shoulder Elbow Surg 2006; 7:155-9. doi:10.1097/00132589-200609000-00007 13. Tomlinson D, Altchek D, Davila J, Cordasco F. A modified technique of arthroscopically assisted AC joint reconstruction and preliminary results. Clin Orthop Relat Res 2008;466:639-45. doi:10.1007/s11999007-0085-3 14. Trikha SP, Acton D, Wilson AJ, Curtis MJ. A new method of arthroscopic reconstruction of the dislocated acromio-clavicular joint. Ann R Coll Surg Engl 2004;86:161-4. doi:10.1308/0035884043 23043265 15. Turman K, Miller C, Miller D. Clavicular fractures following coracoclavicular ligament reconstruction with tendon graft. A report of three cases. J Bone Joint Surg Am 2010;92:1526-32. doi:10.2106/ JBJS.I.00410 16. Weaver JK, Dunn HK. Treatment of acromioclavicular injuries, especially complete acromioclavicular separation. J Bone Joint Surg Am 1972;54:1187-94. 17. Wei HF, Chen YF, Zeng BF, Zhang CQ, Chai YM, Wang HM, Lu Y. Triple endobutton technique for the treatment of acute complete acromioclavicular joint dislocations: preliminary results. International Orthopaedics (SICOT) 2010 (online first). doi:10.1007/s00264-0101057-x 18. Wellmann M, Zantop T, Petersen W. Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation. Arthroscopy 2007;23. 1132.e1-5. doi:10.1016/j.arthro. 2006.12.015
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Postoperative coracoid fracture after transcoracoid acromioclavicular joint reconstruction David C. Gerhardt, MDa, Joshua D. VanDerWerf, BSb, Lucas S. Rylander, MDa,*, Eric C. McCarty, MDa a b
Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA School of Medicine, Creighton University, Omaha, NE, USA
The acromioclavicular (AC) joint is a frequent site of shoulder injury and may represent up to 50% of athletic shoulder injuries in some sports.6,11 Treatment options include numerous nonsurgical and surgical approaches, and treatment is often tailored to the severity of injury. Rockwood’s expanded classification includes 6 grades of AC joint injury.11 For grades IV to VI, surgical management is generally recommended. More than 60 procedures have been described, and no strong consensus regarding the optimal fixation method exists.11,15 Recent trends towards anatomic coracoclavicular ligament reconstructions using arthroscopic methods have been documented; however, few reports exist regarding complications associated with these techniques. We report a postoperative coracoid fracture after AC joint reconstruction using a transcoracoid fixation technique.
and passive range of motion of the shoulder. She had already started 2 weeks of physical therapy, which had helped improve her range of motion. Her right shoulder demonstrated active forward flexion to 180 , external rotation to 60 , and internal rotation to T12. She had a positive cross-body adduction test. She had motor and sensory function intact distal to the elbow. She had isolated tenderness over the AC joint, and the distal clavicle displayed significant prominence. Radiographs demonstrated a Rockwood grade V AC joint separation (Fig. 1). After initial discussion of potential treatment options, including surgical reconstruction, the patient declined surgery in favor of nonoperative management. Approximately 2 months later, the patient returned to our office expressing interest in surgical reconstruction for her now chronic AC joint separation. Physical examination demonstrated similar findings to the initial visit. She was treated with arthroscopic AC joint reconstruction using a 6-mm posterior tibialis allograft tendon and open distal clavicle resection, as described below.
Case report
Surgical technique
A 57-year-old right hand-dominant woman sustained a high-speed direct blow to her right shoulder after a fall from her bicycle. She was initially treated in the emergency department, where radiographs demonstrated an AC joint separation. She was placed in a sling and told to arrange follow-up as an outpatient. Four weeks after this incident, she presented to our office for treatment recommendations. At the time of her initial presentation to our office she had minimal pain at rest; however, she had significant pain with active
Various all-arthroscopic or arthroscopically assisted techniques have been described for stabilization of the AC joint. The technique chosen for this patient is a modification of the arthroscopic subacromial technique described by Baumgarten et al2 and the transclavicular-transcoracoid technique augmented with a GraftRope (Arthrex, Naples, FL, USA) described by Scheibel et al.10 An arthroscopic reconstruction of the coracoclavicular ligaments using an allograft with a GraftRope augmentation was used in conjunction with an open distal clavicle resection. General anesthesia was initiated, and the patient was placed in the beach chair position. An initial diagnostic arthroscopy was followed by the arthroscope being placed in the subacromial space where the coracoacromial ligament was traced from the acromion down to the coracoid. The coracoid base was debrided and
No Investigational Review Board approval was necessary for this manuscript. *Reprint requests: Lucas S. Rylander, MD, 311 Mapleton Ave, Boulder, CO 80304. E-mail address: [email protected] (L.S. Rylander).
1058-2746/$ - see front matter Ó 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.01.017
Coracoid fracture after transcoracoid acromioclavicular reconstruction
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Figure 1 Preoperative image of the right shoulder demonstrates a grade V acromioclavicular joint injury.
visualized arthroscopically. An incision was made directly over the clavicle, and a sagittal saw was then used to resect 0.5 cm of the distal clavicle. At approximately 35 mm from the end of the original distal clavicle, a guide pin was placed using the Arthrex Constant Guide. The guide pin was centered on the clavicle with respect to anterior and posterior, and midway between the ligamentous attachments of the conoid and trapezoid ligaments. The exit point for the guide pin was centered on the base of the coracoid, using the coracoid targeting portion of the Constant Guide. A 6-mm reamer sized for the allograft and GraftRope construct was drilled through the clavicle and the base of the coracoid. No blowout was noted of the medial or lateral walls of the coracoid base, and the tunnel appeared well centered. The coracoid flip button and graft construct were then passed through the clavicle and coracoid, and the button was optimally flipped under the coracoid with arthroscopic visualization. The clavicle was then reduced, and the allograft limbs were tensioned and fixated using a 5.5-mm polyetheretherketone interference screw passed over a nitinol wire through the clavicle washer and into the clavicle (Fig. 2). Excess graft was trimmed, and the deltotrapezial fascia was meticulously repaired during closure. Postoperative radiographs showed reduction of the AC joint (Fig. 3).
Figure 2 Sketch shows the reconstruction construct after passage of a cortical button under the coracoid and graft passage through the clavicle, just before insertion of the interference screw.
Postoperative course At her 1-week follow-up visit, the deformity was noted to have recurred. The patient had been compliant with full-time sling use during this period, and no motion or other physical therapy had begun yet at this point. Plain radiographs demonstrated that the graft construct had migrated superiorly through the coracoid, allowing the AC joint to resume its preoperative position (Fig. 4, A). A computed tomography scan confirmed a postoperative coracoid fracture that was not well visualized on plain radiographs (Fig. 4, B). The patient denied any postoperative trauma and reported compliance with postoperative restrictions. A revision of her AC joint reconstruction along with a coracoid fixation was performed. The revision surgery was done using an arthroscopic-assisted cannulated screw for fixation of the coracoid fracture. Using arthroscopic visualization, a semitendinosus
Figure 3 Postoperative image of the right shoulder demonstrates a well-reduced acromioclavicular joint and stable hardware. allograft was looped under the coracoid for the ligamentous reconstruction and tied over the top of the clavicle with #2 heavyduty suture. Specifically, the graft was looped over the clavicle, not taken through drill holes, and then sewn to itself. No screw fixation was used as part of the revision process except to fixate the coracoid fracture. The reconstruction was protected using a 3.5-mm LCP Clavicle Hook Plate (Synthes, West Chester, PA, USA; Fig. 5).
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Figure 4 A follow-up (A) radiograph and (B) computed tomography scan approximately 1 week after surgery demonstrate failure of fixation and recurrent dislocation of the acromioclavicular joint with associated coracoid fracture. At the 2-year follow-up, there has been no recurrence of AC separation or fracture to date. There are no symptoms. The patient is active, works out regularly, and cycles 100 to 200 miles a week. Physical examination reveals no deformity. The patient has minimal tenderness at the AC joint and clavicle. There is normal motion and full strength at the shoulder. Additionally, no signs of impingement are present. The hook plate has not been removed secondary to patient preference and lack of symptoms. The risk of future acromial fracture has been discussed.
Discussion AC injuries are among the most common shoulder injuries in sporting activities. Although there is consensus that Rockwood grade IV to VI AC joint separations typically warrant surgical intervention, there is disagreement on which technique to use.11 Recently, a focus has been placed on arthroscopic tendon graft reconstructions of the coracoclavicular ligaments. Most of our current literature regarding highgrade AC joint injuries emphasizes surgical reconstruction techniques and little emphasis is placed on the potential for substantial complications. To our knowledge, the complication of a coracoid fracture through a bone tunnel used for fixation has not been described in the literature. In addition, the salvage of such a fracture with AC joint instability can be complex and has not been described previously. Transfer of a patient’s coracoacromial ligament to the distal clavicle for reduction of an AC separation was described first by Weaver and Dunn in 1972.11,16 Because use of the native coracoacromial ligament for surgical reconstruction leads to a weaker, more pliable construct that results in a high failure rate, other techniques have gained favor.13,16,17 One modification of the Weaver-Dunn technique involves augmenting the stabilization with a suture loop around the base of the coracoid up to the clavicle.11 Techniques for accomplishing this type of
Weaver-Dunn procedure have also since been performed arthroscopically.12 Alternative techniques to the nonanatomic, WeaverDunn type reconstructions include the use of sutures and metallic buttons to achieve anatomic stabilization.7,17,18 Wei et al17 report good results using the triple endobutton technique, which involves passing sutures anchored by end buttons through drill holes in both coracoid and clavicle to achieve anatomic AC stabilization. Similarly, Wellmann et al18 report good results passing a flip button/polydioxanone construct through a coracoid bone tunnel and clavicle drill holes. However, use of metallic buttons and FiberWire suture (Arthex) anchored against the clavicle and coracoid has been reported by Lim et al7 as having a 50% failure rate. Similar fixation devices have been used arthroscopically with good results.3,14 Another option for AC reconstruction involves an anatomic reconstruction using tendon grafts, which has been shown in biomechanical studies to have good stability.11,13 The two predominant ways to accomplish anatomic reconstruction of the coracoclavicular ligaments are by looping the tendon graft around the coracoid and anchoring it to the clavicle or by passing the graft through a coracoid bone tunnel and anchoring it to, or passing it around, the clavicle.2,9,11,13 Various arthroscopic techniques for coracoclavicular reconstruction using tendon grafts have been described with good results.2,9,13 Because of the minimally invasive nature of the surgery combined with results comparable with open techniques described previously, arthroscopic-assisted stabilization of the AC joint with reconstruction of the coracoclavicular ligaments using a tibialis allograft was used in this case. Complications from surgical AC joint reconstruction vary, depending on which technique is used. For arthroscopic reconstruction, complications mostly include loss of reduction, persistent pain, instability, hardware complications,
Coracoid fracture after transcoracoid acromioclavicular reconstruction
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Figure 5 Final (A) anteroposterior, (B) outlet, and (C) axillary views of the right shoulder after fixation of the coracoid and placement of hook plate to maintain acromioclavicular joint reduction.
foreign-body reactions, and infection.11-13 Loss of reduction still remains the most common complication.12 Rarely, a postoperative coracoid fracture has been reported from the suture or graft passed around the coracoid. Baldwin et al1 suggest that techniques involving drilling or tunneling into the base of the coracoid theoretically increases the risk of fracture and recommend using a technique in which the graft is looped around the coracoid base instead.1 Gonzalez et al4 suggest using a smaller peroneus brevis graft, which requires a smaller coracoid bone tunnel than the larger and more common semitendinosus graft, thereby theoretically reducing fracture risk. In our review of the literature, postoperative coracoid fractures have been reported when the graft is looped around the coracoid base, but none have been reported from passing a graft through a bone tunnel.5,8,13 The cause of fracture in the looped graft/suture cases was bone erosion around the base of the coracoid. In addition, compounding factors were present that led to fracture in each report. Moneim and Balduini8 report a coracoid fracture in the presence of postoperative infection and bony erosion between drill holes in the clavicle. Tomlinson et al13 reported a fracture in a high-level baseball pitcher from throwing a ball 7 months after surgery. Jeon et al5 reported a fracture due to noncompliant heavy lifting by the patient in the early postoperative period. Salvage of AC joint fixation after coracoid fracture represents a complex problem in its own right. As discussed, this injury is rare and therefore has not been discussed in the literature except in case reports. In the setting of
transcoracoid fixation, it has not been discussed previously at all; therefore, all treatment recommendations represent level V evidence. Each case must be tailored to the needs of the current patient. If enough intact coracoid is present to loop graft under the coracoid base, revision AC reconstruction can occur in this manner, accompanied by coracoid fixation with internal hardware. If there is not enough coracoid base left to loop the graft under the coracoid and still maintain stability of AC fixation after coracoid fixation, several options exist. One can reconstruct the coracoclavicular ligaments with a graft under the fixated coracoid and protect the repair with a hook plate, as was done in our patient. Alternatively, the repair can be protected by spanning the AC joint with conventional or locked plating, working much like the Hook Plate. Either option requires subsequent surgery for removal of hardware. Another option to protect the revision reconstruction would be to use suture directly into the body of the scapula through transosseous tunnels or suture anchors. Alternatively, the graft can be placed through bony tunnels in the body of the scapula, bypassing the need to protect the coracoid repair site, although this can be technically demanding. Nothing in the current literature exists to guide the treating surgeon on which technique is superior at this time. Most surgical techniques for treatment of AC joint separations focus on reconstruction of the coracoclavicular ligaments and rely on secondary processes to address the AC ligaments. We chose to perform a distal clavicle resection as a concomitant procedure, which may have led
e10 to an additional insult to the already compromised soft tissue envelope surrounding the AC joint and higher force transmission across the coracoclavicular reconstruction. In our case, however, no noncompliance by the patient or other compounding postoperative complications were identified. Although our patient was a 57-year-old woman and likely had a bone density inferior to that of the younger man who typically undergoes this surgery, we can identify few other specific risk factors predisposing our patient to postoperative fracture. To our knowledge, this is the first reported case of postoperative coracoid fracture in this setting of a transcoracoid-type procedure. Although the transosseous bone tunnel in the coracoid used by our surgical technique has been theoretically implicated in increased fracture risk, this has not been reported in the literature. More investigation into the degree to which bone tunneling alters the integrity of the coracoid process is necessary. Different techniques involving use of smaller bone tunnels and smaller tendon grafts, or alternative graft docking techniques, may lead to a reduction in fracture risk when the transcoracoid technique is used. In conclusion, to our knowledge, the current report is the first to describe a patient with coracoid fracture after AC joint reconstruction using a transcoracoid fixation technique. As this method of fixation becomes more commonplace, we believe that it is important to understand its risks so that they can be appropriately weighed by treating surgeons and their patients. Further, it is important to consider how one may be able to salvage this complication if it does happen during a patient’s treatment. Much information is still needed, such as what risk factors place a patient at the highest risk for postoperative coracoid fracture or fixation pull-out. Bone density, tunnel size, number of tunnels, and fixation type are all potential risk factors. Hopefully, future complications using this technique can be avoided through further scientific work.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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