Technical NoteFrom the
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Orthopaedics
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Elsevier. Thi
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https://doiArthroscopic Coracoclavicular Ligament
Reconstruction Using Graft Augmentation and
Titanium Implants
Juha O. Ranne, M.D., Terho U. Kainonen, M.D., Jussi A. Kosola, M.D.,
Lasse L. Lempainen, M.D., Kari J. Kanto, M.D., and Janne T. Lehtinen, M.D.Abstract: Several techniques have been introduced to treat acromioclavicular separation with coracoclavicular ligament
reconstruction using graft augmentation. A modified arthroscopic technique for coracoclavicular ligament reconstruction
was used based on a previous technique where the supportive device and tendon graft share the clavicular and coracoid
drill holes. A notable problem with the previous technique was large protruding suture knots on the washer and clavicle,
which could predispose to wound infection. In this modified technique, titanium implants were introduced. The implants
hid the suture knot on the clavicle, and less foreign material was needed between the clavicular and coracoid implants.ew skeletal traumas are associated with as manyFoperative techniques as acromioclavicular (AC)
joint separation. Controversy exists regarding the in-
dications for surgery, but a common consensus is that
grade I-II AC separations should be treated conser-
vatively, whereas grade III-V dislocations may need
surgery. Many recent techniques include cor-
acoclavicular (CC) tendon reconstruction using
tendon grafts and are either arthroscopic or arthros-
copy-assisted.1-6
A modified version of the arthroscopic CC reconstruc-
tion technique described by Ranne et al.7 was used in this
study where the anterior tendon graft limb was fixed toSports Trauma Research Unit, Neo Hospital (J.O.R., T.U.K.,
aavo Nurmi Centre, Department of Physical Activity and Health,
ty of Turku (J.O.R., L.L.L.), Turku; Department of Orthopedics,
aa City Hospital (K.J.K., J.T.L.), Tampere; and Department of
and Traumatology, Helsinki University Hospital (J.A.K.), Hel-
d.
rs report the following potential conflicts of interest or sources of
.R. is a shareholder of the CC-Clip company, which has the rights
rk and the US patent. Full ICMJE author disclosure forms are
this article online, as supplementary material.
ctober 15, 2017; accepted November 27, 2017.
orrespondence to Juha O. Ranne, M.D., Neo Hospital, Jouka-
, 20520 Turku, Finland. E-mail: juha.ranne@sairaalaneo.fi or
gmail.com
y the Arthroscopy Association of North America. Published by
s is an open access article under the CC BY-NC-ND license (http://
ons.org/licenses/by-nc-nd/4.0/).
/171283
.org/10.1016/j.eats.2017.11.005
Arthroscopy Techniques, Vol 7, Nothe middle of the clavicle, recreating the trapezoid liga-
ment. The posterior graft limb was wrapped around the
posterior edge of the clavicle, recreating the conoid liga-
ment (Fig1A). Furthermore, theposterior limbprevented
posterior instability of the distal clavicle. Reconstruction
of both ligaments stabilized the distal clavicle and was
anatomically accurate. The technique specifies one6-mm
and one 4.5-mm drill hole in the clavicle and coracoid,
respectively. Essentially, in this technique, the graft and
the interconnecting sutures share the same drill holes to
minimize clavicular fracture risk.
Although practical, the washer on the clavicle in the
previous technique had significant problems: the fixa-
tion sutures left large protruding knots on the washer
and clavicle. In several cases, irritation or infection of
the clavicular wound was noted. Large palpable knots
also remained underneath the healed skin wound oc-
casionally, making the patients uncomfortable. An
interference screw was used to fix the graft limbs in the
clavicular drill holes, which increased the amount of
foreign material underneath the clavicular skin wound.
The washer also spread the interconnecting sutures into
a funnel shape, gradually up to 8 mm 
 10 mm, inside
the clavicular drill hole. These led to increased tunnel
widening of the clavicular drill hole.8
The Technical Note aims to introduce the modified CC
reconstruction technique using knot hiding clavicular
and subcoracoid titanium implants. The implants hide
the protruding knots on the clavicle and allow less
foreign material in the reconstruction, especially
focusing on early-phase wound healing.5 (May), 2018: pp e465-e471 e465
Fig 1. (A) In this technique, the anterior tendon graft limb is fixed to the middle of the clavicle, recreating the trapezoid ligament.
The posterior graft limb is wrapped around the posterior edge of the clavicle, recreating the conoid ligament (arrows). Left
shoulder, anteromedial view. (B) The Clavicular Clip (a) and Subcoracoid Clip (b). The length of the Clavicular Clip is 14 mm,
16 mm, or 20 mm.
e466 J. O. RANNE ET AL.The Technique
The Implants
The Clavicular Clip (CC-Clip, Turku, Finland), made
of medical titanium, is designed to sit flush on theFig 2. (A) Using the conventional drill guide technique, a 4.5-m
shoulder, anterolateral view. (B) The clavicular drill hole is wideclavicular surface without leaving a protruding knot.
The loop of the clip hides the connecting suture knot in
the clavicular drill hole. The 5-mm Clavicular Clip loop
and the knot located in the 6-mm drill hole, at the same
time, squeeze the tendon graft limbs against them drill hole is made through the clavicle and coracoid. Left
ned to 6 mm (arrow). Left shoulder, anterolateral view.
Fig 3. (A) The passing sutures are pulled through the drill holes using the Blunt Lasso Guide. In this technique, it is important
that the welded end of the lasso loop always come first (arrow). Otherwise the welding easily splits leaving the passing suture
loose. Left shoulder, anterior view. (B) The No. 2 passing suture (a) for the interconnecting No. 5 suture (arrow). It is important
that the tendon graft (b) is always pulled first through the drill holes to avoid entanglement. Left shoulder, anterior view.
Fig 4. The Subcoracoid Clip in its place underneath the
coracoid. Note the loop fixation (arrow). Left shoulder, medial
view.
ARTHROSCOPIC CC RECONSTRUCTION TECHNIQUE e467clavicular drill-hole wall. Hence an interference screw is
unnecessary decreasing the amount of foreign material
required. The Subcoracoid Clip (CC-Clip) is designed to
be a simple ring with a smooth crossbar (Fig 1B). The
interconnecting suture is attached to the Subcoracoid
Clip with a loop knot, which reduces friction on the
suture. The clips allow the use of a single double-folded
No. 5 braided nonresorbable suture. The line between
the Clavicular Clip loop and the Subcoracoid Clip is
straight through the drill holes; therefore, a No. 5
braided nonresorbable interconnecting suture is suffi-
ciently strong. In cyclical load stress tests, forces up to
400 N per >100 cycles can be applied to suture knots
without their snapping depending on the suture ma-
terial (Mectalent, Oulu, Finland; Design Verification
Report 2017; No. MEC-157). The implants are to be left
in place and subsequent implant removal is unneeded.
The Operative Technique
The patient is placed in the beach chair position. A
semitendinosus autograft or allograft, as well as artifi-
cial tendon grafts, may be used as the tendon graft,
which is prepared by fixing a No. 2 passing suture at
one end of the graft. A No. 2 passing suture is also
attached to a double-folded No. 5 braided non-
resorbable interconnecting suture. Four portals (poste-
rior, lateral, anterolateral, and clavicular) are made. A
standard 30 arthroscope is used. A longitudinal
clavicular incision (2.5 cm in length) is made over the
clavicle, 2.5 cm medially from the AC joint.
Fig 5. (A) The anterior graft limb (a). The Blunt Lasso Guide is used once again to pull the passing suture for the dorsal graft limb
(b) through the clavicular drill hole. Again, it is important that the welded end of the lasso loop comes first (arrow). Left shoulder,
posterosuperior view. (B) The anterior graft limb (a) runs through the clavicular and coracoid drill holes. The end of the dorsal
graft limb (b) is wrapped around the dorsal edge of the clavicle and dorsal rim of the Clavicular Clip. Then it is pulled through the
clavicular drill hole adjacent to the anterior graft limb (a). Left shoulder, posterosuperior view.
Fig 6. (A) The Clavicular Clip on the edge of the clavicular drill hole. Note the No. 5 suture knot (arrow). Left shoulder, anterior
view. (B) The Clavicular Clip loop is slipped into the clavicular drill hole hiding the knot (arrow). The 5-mm Clavicular Clip loop
and the knot compress the graft limbs against the 6-mm drill-hole walls. Therefore, there is no need for an interference screw.
Left shoulder, anterior view.
e468 J. O. RANNE ET AL.
Fig 7. The arthroscopic photograph showing the complete
double-bundle reconstruction. The anterior graft limb (a),
dorsal graft limb (b), and interconnecting suture (arrow).
Fig 8. The complete coracoclavicular reconstruction (a). Note
the optional plication of the acromioclavicular joint capsule
(b). Left shoulder, anterior view.
ARTHROSCOPIC CC RECONSTRUCTION TECHNIQUE e469Using the conventional drill guide technique, a 4.5-
mm drill hole is made through the clavicle and cora-
coid (Fig 2A). The clavicular drill hole is centrally
located on the clavicle, approximately 2.5 cm proximal
to the AC joint. The coracoid drill hole is located cen-
trally and as proximally as possible. The clavicular drill
hole is then widened to 6 mm (Fig 2B). The passing
sutures are passed through the drill holes using the
Blunt Lasso Guide (CC-Clip) (Fig 3A). The tendon graft
is pulled first through the clavicular and coracoid drill
holes (Fig 3B). The distal limb end is then pulled to the
clavicular portal behind the clavicle. Thereafter, the
interconnecting sutures are passed through the drill
holes and pulled out through the anterolateral portal.
The Subcoracoid Clip is attached to the No. 5 suture
loop and then pulled back into its position underneath
the coracoid (Fig 4). The end of the dorsal graft limb is
taken over the dorsal edge of the clavicle, slipped
through the Clavicular Clip, and then pulled through
the clavicular drill hole beside the anterior graft limb
using the Blunt Lasso Guide (Fig 5A). With the entire
reconstruction in place, the clavicle is repositioned (Fig
5B). The repositioning is checked arthroscopically un-
der visual control. The interconnecting suture and
tendon graft are tensioned, and the sutures are tied
using a knot pusher (Fig 6A). Once the sutures are tied,
the Clavicular Clip loop is allowed to sink into the
clavicular drill hole hiding the suture knot (Fig 6B).
Finally, the anterior graft limb end is fixed onto the
dorsal limb behind the clavicle with No. 2 non-
resorbable sutures (Fig 7, Video 1).
In chronic cases, once the CC ligament reconstruction
is completed, the clavicular wound may be extendedlaterally to expose the AC joint. If the AC joint capsule
is addressed, it is done openly making the operation
arthroscopy-assisted. The AC joint may be debrided and
the clavicular end may be resected if necessary.
Thereafter, the AC joint capsule can be sutured and
plicated with interrupted sutures to enhance the
anterior-posterior stability of the distal clavicle (Figs 8
and 9).
Postoperative Treatment
A padded dressing is applied with a sling. The patients
are discharged from the hospital on the same day and
each wears a sling for 4 weeks. They are allowed light
rotatory movements and passive lifting of the arm
within the limits of pain. The sling is removed after
4 weeks, and active rehabilitation is initiated 8 weeks
after surgery. The patients are allowed to resume heavy
labor and sports at postoperative 3 and 4-6 months,
respectively.
Discussion
The strong interconnecting suture applied between
the CC Clip and Subcoracoid Clip is considered sem-
itemporary; the authors believe that it will eventually
snap. Therefore, a tendon graft is necessary for the
reconstruction, especially in chronic cases.
The Clavicular Clip was particularly designed for the
2-tunnel solution and to address the problems related to
earlier techniques. The Clavicular Clip has a simple
design; it worked as expected and was easy to handle.
The Subcoracoid Clip was equally practical and the
amount of wire or suture needed was minimal due to
the straight direction of the suture material between the
implants. The loop attachment of the Subcoracoid Clip is
strong with minimal movement in the loop knot, thus,
reducing friction. The first 2 months postoperatively
Fig 9. (A) The postoperative radiograph of a reduced clavicle. The superior part of the Clavicular Clip (16 mm) lies flush on the
clavicular surface (a). The Subcoracoid Clip is in its position underneath the coracoid process (b). Left shoulder. (B) The skin
wounds after 2 weeks from surgery. The lateral portal (a), anterolateral portal (b), and clavicular skin wound (c). Note that the
clavicular opening is extended laterally to address also the acromioclavicular joint capsule (arrow). The initial dorsal portal is not
visible in this projection. Left shoulder, anterolateral view.
Table 1. Tips and Tricks
Pearls Pitfalls Risks
Portals It is essential to have the portals in the
right placesdalways use needles
A displaced portalda notable problem Mishandling the arthroscopic
procedure
Posterior portal P The surgery is initiated through the
standard posterior portal
Check additional trauma: labrum,
supraspinatus tendon
Missing the whole picture
Lateral portal L Place a needle in front of the biceps
tendon and place the L portal there
Make sure the needle reaches the
proximal coracoid
Missing the whole picture
Anterolateral portal AL LþAL portals: good access to the
proximal coracoid
Missing the whole picture
Clavicular portal C Clavicular portal behind the clavicle.
Direct the needle to the coracoid neck
Make sure the needle reaches the
proximal coracoid
Missing the whole picture
Clavicular portal C Create a soft-tissue channel underneath
the clavicle to the coracoid neck
bluntly, with scissors
Otherwise it is difficult to get the suture
passer into the right position
Operative technique Meticulous hemostasis using
electrocautery throughout the surgery
Bleeding may hamper vision Mishandling the arthroscopic
procedure
Passing the graft Always pull the graft before the
supportive suture
The sutures and graft may tangle The graft gets stuck
Passing the graft Pull the passing suture of the graft first to
the clavicular portal and then pull the
graft
The graft does not usually slide well in
the suture passer eyelet
The graft gets stuck
Passing the graft When pulling the graft through the drill
holes assist with a suture passer placed
underneath the coracoid
To avoid the dead man angle The graft gets stuck
Passing the graft All of the graft must be in its place before
snapping the coracoid clip into the
clavicular drill hole
The clip fits tightly, and it is difficult to
pass anything through it once it is in
place
Problems, repeating it is time
consuming
Tensioning the graft and
the supportive device
Before the sutures are tied the assistant
presses the clavicular head down
It helps to tension the interconnecting
suture sufficiently
The interconnecting suture
remains too loose
Knot tying Use the knot pusher. It fits into the clip
loop
It is easier to make the knots sufficiently
tight enough
The interconnecting suture
knots remain too loose
e470 J. O. RANNE ET AL.
ARTHROSCOPIC CC RECONSTRUCTION TECHNIQUE e471are critical. The tendon graft must heal properly before
physiotherapy is initiated. Subsequently, it is very un-
likely for the reconstruction to fail excluding new
external trauma. The technique is simple enough for
any experienced shoulder surgeon to perform. Howev-
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