| Acromioclavicular
Joint Reconstruction Using Gore-Tex Tape
Evaluation Of A New Surgical Technique
And Rehabilitation Protocol Kevin
R. Stone, M.D.
Angelo De Carli, M.D.
Robert Day, A.T.C.
Mike Mullin, A.T.C. N.B.
We no longer use GORE-TEX®; we now use allograft tendon. 
ABSTRACTSurgical
repair of the grade III acromioclavicular joint with Gore-Tex tape can lead to
a rapid recovery and early return to activity and sports. The new technique avoids
the placement of metal screws and anatomically repairs the disrupted joint. An
aggressive postoperative rehabilitation program is permitted and leads to an early
return of muscle strength. However the technique has specific pitfalls that may
lead to early failures. The surgical technique and rehabilitation program are
described and illustrated.
IntroductionInjuries
to the acromioclavicular (AC) joint are common. Although most of the injuries
are treated without surgical repair, surgical intervention is often preferred
for throwing athletes with severe dislocations. The surgical techniques have had
many complications and require significant recovery periods prior to return to
full sports. To diminish the complication rate and to speed the return to full
throwing sports a new technique of permanent tape fixation and rapid rehabilitation
is described with its own benefits and potential problems.
Mechanism of Injury and ClassificationThe
AC joint is formed by the lateral end of the clavicle and acromion process of
the scapula, and has a cartilaginous intraarticular disc. The joint provides a
connection between the trunk and upper extremity through the sternoclavicular
joint, clavicle and acromioclavicular joint. The AC joint is stabilized by two
separate ligamentous structures: the AC ligament and the scapuloclavicular ligaments.
The much stronger stabilizing system consists of the conoid and trapezoid ligaments,
which run obliquely from the coracoid to the clavicle in opposing directions and
are analogous to the cruciate ligaments of the knee, preventing anterior-posterior
and upward displacement of the clavicle and acting as a rotational guide. The
acromioclavicular capsule is relatively more lax and is reinforced by a superior
AC ligament. The most frequent mechanism of injury to the AC joint is a fall or
a sharp blow on the acromion process which forces the scapula and the arm downward
while the clavicle, locked by the ribs, is then pushed upward. According to Rockwood
(1) these lesions are classified in six different types: Type
I: partial tear of the acromioclavicular ligament without real change in position
of the distal clavicle in relation to the acromion.
Type
II: Rupture of the acromioclavicular ligament with a partial tear of the coracoclavicular
ligaments. The distal end of the clavicle is displaced in relation to the acromion
less than the full width of the clavicle itself.
Type
III: Rupture of the AC ligament and the coracoclavicular ligaments, with displacement
of the distal clavicle more than its full width (Figure 1).
Type
IV: posterior displacement of the distal clavicle through the muscle aponeuroses
of trapezius. Deltoid and trapezius muscles are detached from the distal clavicle.
Type V: The distal
clavicle is severely displaced upward toward the base of the neck, covered only
by skin and subcutaneous tissue, with a complete rupture of the deltoid- trapezius
musculature.
Type
VI: Inferior dislocation of the clavicle under either the acromion or the
coracoid process. Coracoclavicular ligaments and muscles are intact or disrupted. "The
multiplicity of procedures available is clear evidence that none is totally satisfactory;
thus the search for more satisfactory methods continues" (2). However almost all
authors note excellent or good results either with conservative or with surgical
treatment (references 3-20). More than fifty different bandaging techniques and
more than thirty different operations have been suggested for the treatment of
complete AC joint dislocation. Surgical repairs fall into two general categories:
those that attempt to restore the normal anatomy and those that alter the anatomy
in order to achieve reduction and stability. Today most surgeons use various combinations
of the techniques described as shown in Table I.
Surgical IndicationsThe
management for acute dislocations of the acromioclavicular joint is controversial.
Most of orthopaedists have agreed that Type I and II injuries require a conservative
treatment; however the debate in case of type II injury concerns which type of
non-surgical treatment to employ, either symptomatic only or bandaging in order
to attempt an external reduction of the AC joint dislocation. Grade III injuries
may be managed either with surgery or non-operatively. The trend in management
of AC type III dislocations in young active people is suggested by results of
a questionnaire sent by Cox (20) to the chairmen of all orthopaedic residency
training programs in North America and to a group of orthopaedic surgeons active
in sports medicine. Eighty-six per cent of physicians involved in care of collegiate
and professional athletes and seventy-two per cent of the chairmen preferred non-surgical
treatment. Among the physicians that were choosing a conservative treatment, 33%
and 28% respectively (team physicians and chairmen) were using manual reduction
of the dislocation and maintenance of that reduction by an acromioclavicular immobilizer.
However, the questionnaire failed to ask whether the athlete was male or female,
a thrower or not, or whether the dominant arm was injured (20). In our experience,
throwers and other overhead athletes playing tennis, volleyball, and squash are
significantly weakened by the grade III joint dislocation for up to a year after
injury. In these athletes, and with patients concerned about the cosmetic appearance
of the dislocation, we recommend prompt repair and rapid return to training.
Surgical ProcedureOur
preferred approach for all shoulder surgery, both arthroscopic and open, is with
the patient in the beach chair position. The arm is draped free and gravity provides
a safe level of traction. The AC joint is exposed through a vertical longitudinal
incision directly over the AC joint extending down just superior to the coracoid
in Langer's lines. A sharp dissection is carried down to the superior surface
of the clavicle. The
torn superior ligamentous connection between the clavicle and the acromion is
carefully identified and preserved. Using sharp dissection, the remaining fascial
fibers are dissected from the superior surface of the clavicle. Using blunt dissection,
the tip of the coracoid is identified. A 4.5 millimeter AO drill and guide is
brought into place. A Darrach retractor is placed inferior to the clavicle and
a vertical 4.5 millimeter drill hole is placed from superior to inferior, directly
in the mid body of the clavicle one centimeter from the distal clavicular end.
A second 4.5 millimeter drill hole is then placed from superior to inferior through
the distal tip of the coracoid process, taking care not to break through the distal
tip of the coracoid, again, one centimeter from the distal tip. Careful identification
of the coracoclavicular ligaments is then performed. If the ligaments are of sufficient
quality, a #1 Ethibond suture is woven into the remaining coracoclavicular ligaments
and passed through the periosteum of the clavicle, performing a primary repair
of the coracoclavicular ligaments. A flexible Richard's suture passer is then
passed through the clavicle, carrying a #1 Ethibond suture and through the distal
tip of the coracoid from superior to inferior. The suture is then passed with
a sharp needle through the end of a 4 millimeter Gore-Tex tape. The suture and
tape are then pulled through from superior to inferior of the clavicle and the
coracoid (Figure 2). The loop of
the Gore-Tex tape is left on the superior surface of the clavicle and the Gore-Tex
tape is looped over the distal tip of the coracoid back up to the loop on the
superior surface of the clavicle and folded down over itself in a belt loop fashion
(Figure 3). Using a large Kocher
clamp, the distal end of the Gore-Tex is clamped and tension applied, reducing
the clavicle to the level of the acromion (Figure
4). A #1 Ethibond suture is passed through the looped ends of the Gore-Tex
tape, securing the vertical strands to each other, effectively stopping any further
slippage of the Gore- Tex tape onto itself. The tape is then wound around itself
in a candy-stick fashion (Figure 5).
Two further #1 Ethibond sutures are passed through the vertical strands of the
Gore-Tex tape, effecting final locking of the tape onto itself (Figure
6). This step defines the ultimate failure strength of the procedure.
If the tape shreds or is weakened during needle passage, failure may occur by
early rupture of the suture-tape construct. Closure is then undertaken by primarily
repairing the superior ligamentous tissues overlying the clavicle and acromion.
Soft tissue closure is performed by using 0 and 2-0 absorbable suture with 3-0
nylon in the skin. Marcaine is instilled in the incision to afford postoperative
pain relief and a standard ABD dressing is applied to the superior aspect of the
shoulder with a shoulder sling. An Aircast Cryo Cuff is applied to the shoulder
and left in place until the dressing is changed on the first post operative day.
| Figure
2 | Figure
3 | Figure
4 | | | |
| Figure
5 | Figure
6 | | | | |
CASE REPORTS Case
Report 1: A
22 year old female was involved in a side impact auto accident where she hit her
right shoulder on the dash board. She suffered a grade 3 AC joint separation.
Shortly after the accident she was repaired surgically. Approximately 4 months
later she noticed that her clavicle was elevated although she does not recall
any post operative complications. She did not like the appearance of the shoulder
and requested a second reconstruction. On physical examination she had full range
of motion with equal strength bilaterally except for a slight loss of supraspinatus
strength on the involved side. The second surgery (AC joint reconstruction using
Gore-Tex Tape) was performed approximately 5 months after the first. The
day following the surgery she was started on icing and pendulum exercises. A sling
was used for comfort. Two weeks later shoulder pulley range of motion exercises
and biceps and triceps strengthening were started. Six weeks after surgery she
started active range of motion exercises for the shoulder in all planes. Strengthening
of the internal and external rotators of the shoulder and upper back as described
earlier were started, also. Eight weeks after surgery she had full range of motion
with only a slight loss of strength. She was allowed to begin returning to her
normal activities. Sixteen weeks following surgery she had no complaints about
her shoulder and she returned to work.
Case Report 2: A
32 year old highly active male suffered a third degree AC joint separation while
snowboarding. The patient fell face first onto the hard snow and tried to somersault
back to his feet. Upon rolling to his right shoulder he felt a pop in the shoulder.
On physical examination he had a Grade III AC joint separation. One week later
surgery was performed to reconstruct the AC joint using Gore-Tex tape. The day
following surgery the patient was started on icing, pendulum exercises and active
and isometric internal and external rotation exercises. Four days later the exercise
program continued and he was started on the AC joint taping program. One
month after surgery the patient was started on the rehabilitation program described
above. He progressed as he tolerated the exercises and additional weight. Five
months after surgery the patient had regained his full range of motion and strength
and resumed his full activity level which includes windsurfing, road and off road
bicycling, running and snowboarding. Case
Report 3: A
42 year old active female suffered a third degree AC joint separation and possible
shoulder subluxation when she landed on her right shoulder during a bicycle accident.
On physical examination she had a Grade III AC joint separation as well as a possible
anterior subluxation. One week later her AC joint was reconstructed using Gore-Tex
tape. The day following surgery she was started on icing, pendulum exercises and
isometric internal and external rotation shoulder strengthening. Two
weeks later she was started on biceps and triceps strengthening. Three weeks after
surgery she had full passive range of motion of the shoulder and active range
of motion to 90 degrees. Shoulder and scapular strengthening exercises as described
earlier were started one month after surgery. She regained full range of motion
eight weeks after surgery. Fourteen
weeks after surgery she felt a pop in the shoulder area and noticed that her clavicle
was slightly elevated. At the time she began to have mild pain with her normal
upper body exercise program. Upon physical examination a Grade I AC joint elevation
was found. She had full range of motion with decreased strength due to pain. She
also complained of left trapezius pain and left arm weakness. Her exercise program
was decreased to pain free levels for two weeks then progressed as tolerated.
Eleven
months after surgery she had increased elevation of the right AC joint. She complained
of aching in the AC joint as well as general upper body weakness. She contributed
most of the weakness to her decreased activity following a diagnosis of cervical
disc disease and spurring on the left side. However, prominence of the joint suggested
failure of the reconstruction. Case
Report 4: A
43 year old male was horseback riding when he fell from his horse and landed on
his right shoulder. Upon physical examination a Grade III AC joint separation
was found. This was repaired using Gore-Tex tape three weeks after the injury.
Icing and pendulum exercises were started the day following surgery. Three
weeks following surgery he was started in a formal physical therapy program. At
four weeks after surgery he had active and passive shoulder flexion to 145 degrees
and active and passive abduction to 135 degrees. At this time he was started on
the exercise program described earlier. Three
months after surgery he had full range of motion with mild tenderness at the surgical
site. He was continuing to increase his exercise program. Four months after surgery
he had full range of motion with near normal strength. His only complaint was
daily aching but this stopped with exercise. Five
months after surgery he had full range of motion, normal strength, no complaints
of pain or aching, and had returned to his normal activity level. Preferred
Post-Operative Protocol On day one post surgery, the dressing is changed, an ABD
pad is placed on the superior surface of the wound and cross taping performed
in order to reinforce the clavicular reduction. The patient is advised to use
the Cryo Cuff icing unit as much as possible over the next 2-3 weeks. An optional
sling is used for comfort and support. Isometric internal and external rotation
exercises in standing are started. Immediate range of motion exercises with pendulum
and biceps and triceps strengthening exercises are permitted. A nerf ball or hand
strengthening ball is used to strengthen the grip and forearm muscles. All of
the exercises are performed 2-3 times per day for the next two weeks. On
the fifth post operative day the patient returns to the office and the dressing
is removed. Supportive taping for the AC joint is applied using dressing retention
tape on the skin and rigid strapping tape for support (Figure 7). The patient
is taught how to change and apply the tape. Active internal and external rotation
exercises are started. The exercises are begun in standing and progressed to side
lying as pain and range of motion permit.
| Figure
7 |  |
After
four weeks the patient is started on a more aggressive home rehabilitation program.
The shoulder exercises performed are flexion to 90 degrees, abduction to 90 degrees,
bent over extension, bent over horizontal abduction, and side lying external rotation.
The patient performs 3 sets of 10-15 repetitions with 3 pounds for the first four
exercises. The patient is allowed to increase the weight when able to perform
3 sets of 15 repetitions. Side lying external rotation is started at 2 pounds
and the weight is increased in 1 pound increments as the patient is able to perform
3 sets of 25 repetitions. The primary emphasis of this phase is to concentrate
on the rotator cuff endurance without compromising the AC joint. These exercises
are done on a 5 times per week basis for two weeks. At
the sixth post operative week the range of motion of flexion and abduction are
increased to 180 degrees as tolerated by the patient. The patient continues to
increase the weight to 5 pounds as he is able to complete 3 sets of 15 with each
exercise. A maximum of 5 pounds is used for any of these exercises. Additionally
a scapular strengthening program is started with 3 sets of 10-15 repetitions using
the SPORT Cord system. The first exercise is seated rowing with the resistance
from overhead (Figure 8). The patient
is instructed to pull down and back to the belt line. The second exercise is seated
middle rowing with the resistance at the chest level (Figure
9). The patient is instructed to pull straight into the chest at a
level below the nipple line. Third, is standing rowing with the resistance from
below (Figure 10). The patient
is instructed to pull the cord under the chin but not to allow the upper arms
to abduct more than 90 degrees. The final exercise is the standing punch for the
serratus anterior. The patient is instructed to put the cord at shoulder level.
A straddled stance with the arm extended at the shoulder level perpendicular to
the trunk is used (Figure 11).
With the elbow extended the patient thrusts the arm forward while keeping the
trunk still and not bending the elbow.
The
exercise program is performed on a three times per week basis for each group.
The patient is given the option to do all of the exercises in one day or to alternate
days with each group. The goal for the patient is to be able to complete 3 sets
of 25 repetitions with side lying external rotation using 5 pounds, 3 sets of
15 repetitions using 5 pounds with the shoulder flexion, abduction, extension,
and horizontal abduction, and 3 sets of 15 repetitions with the SPORT Cord program.
Once the patient is able to achieve these goals a progressive return to sporting
activities is planned.
SUMMARYAC
joint dislocations can be safely and solidly repaired without the use of metal
or screws. The repair technique with the Gore-Tex tape has lead to a stable shoulder
that could be exercised promptly in three of the four patients described in this
report. Early return of muscle strength and sporting activities are achieved by
following a disciplined shoulder exercise program. Long term complications as
a result of Gore-Tex Tape use remain to be evaluated, however one patient appears
to have failed fourteen weeks after reconstruction. Most likely, weakness at the
suture Gore-Tex interface is the cause. To correct this weakness, a crimp mechanism,
securing the Gore-Tex without suture use is under development. At this time, Gore-Tex
reconstruction of Grade III AC joint reconstructions may be useful but would benefit
from an improved closure technique prior to widespread use.
References -
Rockwood C, Green D: Fractures in Adults, pp 870-2. Lippencott, 1984.
-
Kappakas G, McMaster J: Repair of acromioclavicular separation using a dacron
prosthesis graft. Clin Orthop, 131:247-251, 1978.
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O'Carroll P, Sheehan J: Open reduction and percutaneous kirschner wire fixation
in complete disruption of the acromioclavicular joint injury, Journal of Accident
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Copeland S, Kessel L: Disruption of the acromioclavicular joint: surgical anatomy
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Warren-Smith C, Ward M: Operation for acromioclavicular dislocation. J Bone Joint
Surg. 69B(5):715-718, 1987.
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Berson B, Gilbert M, Green S: Acromioclavicular dislocations; treatment by transfer
of the conjoined tendon and distal end of the coracoid process to the clavicle.
Clin Orthop, 135:157-164, 1978.
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Nelson C: Repair of acromio-clavicular separations with knitted dacron graft.
Clin Orthop, 143:289, 1979.
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Bosworth B: Acromioclavicular separation: new method of repair. Surg Gynecol Obstet,
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Vargus L: Repair of complete acromioclavicular dislocation, utilizing the short
head of the biceps. J Bone Joint Surg, 24(4):772-773, 1942.
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Tyler G: Acromioclavicular dislocation fixed by a vitallium screw through the
joint. Bosworth Surg Gynec Obst, 245, 1941.
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Roper B, Levack B: The surgical treatment of acromioclavicular dislocations. J
Bone Joint Surg, 64B(5):597-598, 1982.
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J, Erlanger S, Dick H: Biomechanics and comparison of two operative methods of
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T, Wilson F, Oglesby J: Dislocation of the acromioclavicular joint. J Bone Joint
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Imantani R, Hanlon J, Cady G: Acute complete acromioclavicular separation. J Bone
Joint Surg, 57A(3):328-332, 1975.
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Wojtys E, Nelson G: Conservative treatment of grade III acromioclavicular dislocations.
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Varney J, Coker J, Cawley J: Treatment of acromioclavicular dislocation by means
of a harness. J Bone Joint Surg, 34A(1):232-233, 1952.
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Moneim M, Balduini C: Coracoid fracture as a complication of surgical treatment
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TABLE 1 Sample of Acromioclavicular Joint Reconstruction Techniques
AUTHORS TECHNIQUE#
STAGE FOLLOW RESULTS COMPLICATIONS X-RAYS
O'CARROL P.F.A-C
JOINT REPAIR (PERCUTANEOUS KIRSCHNER WIRE) 35
35 ACUTE 30 MO 33 GOOD 2 SUBLUXATION 1 INFECTION
1 LOOSE OF FIXATION I BREAKAGE OF WIRE 19 OSSIFICATION AC JOINT
COPELAND
S.CORACOACROMIAL
LIG. + BONE TO THE CLAVICLE + BOSWSORTH SCREW
9
9 CHRONIC 9 MO 7 GOOD 2 SUBLUXATION 1 SEVERE CHANGES
TIP OF CLAVICLE WARREN-
SMITH C.D. EXCISION
OF THE DISTAL CLAVICLE + C.A. LIG. IN TO THE CUT END OF THE REMAINING CLAVICLE
29 9 ACUTE
20 CHRONIC 38 MO 17 EXCELLENT 11 GOOD 1 POOR 1 CALCIFICATION
C-A LIG. KAPPAKAS
G.S. C.A. LIG.
RECONSTRUCTION WITH A DACRON PROSTHESIS GRAFT 20 20
ACUTE 13 MO 18 SATISFACTORY 2 UNSATISFATORY 1 INFECTION
4 EROSION OF THE GRAFT 10 CALICIFICATIONS C.A. REGION BERSON
B.L. TRANSFER
OF CONJOINED TENDON AND DISTAL END OF CORACOID TO THE CLAVICLE 29 23
ACUTE 6 CHRONIC 47 MO 14 EXCELLENT 14 GOOD 1 FAIR
1 FRACTURE 2 INFECTIONS 1 TRANSIENT FROZEN S. 40% CALCIFICATIONS
NELSON CA.
RECONSTRUCTION WITH UNITED DACRON GRAFT 43
27 MO 98/100 POINTS MEAN 1 INFECTION 2 DEGENERATIVE CHANGES
AC JOINT BOSWORTH
A.B. CORACO-CLAVICULAR
FIXATION WITH BOSWORTH SCREW 4
ACUTE 2 EXCELLENT 2 POOR 1 PARTIAL REDISLOCATION 2 SCREW
BENDING 1 CALCIFICATION ZARICZNYJ
B. AC AND CA RECONSTRUCTION
WITH AUTOGENOUS TENDON (PALH. LONGUS OR EXT. 5TH TOE) 16
1-18 YRS 16 SATISFACTORY BARGEN
J.H. AC JOINT
REDUCTION + WITH FIXATION WITH WIRE OR DACRON / C-C LOOP 44
12 14/12 15/4 3/10 9/1 18 AC WIRES BROKE. BENT OR
BACKED 3 INFECTIONS IMATANI,
R.J. AJ JOINT
RED. + FIXATION WITH STEINMANN PINS OR BONSWORTH 15 ACUTE >10 INCREASING
OF THE AC JOINT IN FOLLOW UP LARSON
E. AC JOINT FIXATION (KIRSCHNER WIRES) 39 ACUTE 39
MO 36 EXCELLENT 2 GOOD 0 FAIR 1 POOR 6 INFECTIONS
2 K.W. MIGRATION 6 K.W. BREAKAGE UNDARAM
N. CORACO-CLAVICULAR FIXATION (MODIFIED BOSWORTH TECH.) 31
ACUTE 12 YRS 24 EXCELLENT OR GOOD 7 FAIR NO CORRELA- TION
BETWEEN X-RAY & CLIMCAL RESULTS STAM
L. CORACO CLAVICULAR
FIXATION WITH DACRON LIGAMENT 20
4 YRS 19 EXCELLENT OR GOOD 1 POOR BAKALIM
G. CORACO CLAVICULAR
REPAIR + AC JOINT FIXATION (KIRSCHNER) 19
ACUTE 4 YRS 14 GOOD 5 POOR 2 PARTIAL DISLOCATIONS 1 COMPLETE
DISLOCATION 13 OSSIFICATIONS C-A LIG. SAGE
F.P. A-C JOINT
FIXATION (K-WIRES, STEINMANN KNOWLES PINS...) 33
ACUTE/CHRONIC 17 MO 22 EXCELLENT 8 GOOD 3 POOR 4 EXTRUSION
OF PINS OR INFECTION 43 CALCIFICATIONS NEVIASER
J.S AC JOINT FIXATION
(KIRSCHNER) + CORACO ACROMIAL LIG. TRANSFERENCE 112
ACUTE/CHRONIC 10 YRS 103 EXCELLENT 5 FAIR 4 POOR 4 RECURRENCE
1 INFECTION 1 BROKEN KIRSCHNER 22 CALCIFICATIONS CORACO CLAVICLE
16 CALCIFICATIONS AC JOINT ENS
W.D. AC JOINT
FIXATION + DELTOID TRAREZIUS IMBRICATION 7
6-2 MO 7 EXCELLENT NONE | 
