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Shoulder & Elbow. ISSN 1758-5732

T O R I G I N A L A R T I C L E

Falling from the Tightrope: double versus single Tightropesin patients with acromioclavicular joint dislocations: techniqueand complicationsChrysi 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

ReceivedReceived 20 March 2010;accepted 5 January 2011

KeywordsAcromioclavicular, Tightrope, arthroscopic,lateral end clavicle fracture, acromioclaviculardislocationConflicts of InterestNone declared

CorrespondenceChrysi Tsiouri, Upper Limb Unit, Departmentof 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: [email protected]

DOI:10.1111/j.1758-5740.2011.00112.x

ABSTRACT

Background We welcomed the innovative arthroscopic stabilization of the acromioclavicular jointdislocations with the Tightrope as it seemed promising regarding results and rehabilitation howeverour results were not satisfactory.

Materials and Methods We clinically and radiographically reviewed the first thirty one consecutive patientstreated 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 itdoes not address the acromioclavicular ligament and the instability at the anteroposterior plane.

INTRODUCTIONOf the most recent advances in arthroscopic reduction and fixationof acromioclavicular joint (ACJ) injuries is the Tightrope (Arthrex,Inc., Naples, FL, USA) [1]. It leaves minimal scarring and dispenseswith secondary surgery to remove any implants. The early resultswere encouraging [1–6]. We started using the Tightrope in our unitin 2007. Initially, as a single implant as described in 2006 [2] and,later, with a modified technique to employ two Tightropes. Wepresent our technique and discuss our results and complications.

PATIENTSANDMETHODSBetween July 2007 and February 2010, forty consecutive patientswith ACJ dislocations or lateral end of clavicle fractures hadarthroscopic Tightrope fixation of their injury by the senior author.We reviewed the first 31 (30 male, one female) consecutive patients.Twenty-six had ACJ dislocations, three had lateral end of claviclefractures and two had both. The patients were followed up at6 weeks, 12 weeks and 52 weeks. At final follow-up, they wereassessed independently with the Constant score. Radiographicexamination of the ACJ was also undertaken.

Surgical techniqueThe standard technique of arthroscopic stabilization of the ACJ waswell described by Tennet in 2008 [1]. We modified the technique

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

Patient positioningAnatomical studies show that the conoid ligament originates fromthe posterior aspect of the clavicle 4.5 cm medial to its lateral endand inserts into the base of the medial aspect of the coracoid.The trapezoid ligament originates from 2.5 cm to 3.5 cm medialto the lateral end of the clavicle and inserts into the base of thecoracoid 10 mm anterior and 5 mm lateral to the conoid ligamentinsertion [7–9]. To prepare a drill hole in such a medial position inthe clavicle, we had to place the patient in a beach chair positionon a shoulder table with a small head rest rather than a head guard.

ACJ reductionTo avoid over correction or mal reduction of the dislocated ACJ,we provisionally stabilized the joint with a smooth 2 mm K-wire.Reduction was confirmed with an image intensifier. If reductionis performed later, at the time of Tightrope fixation, the secondTightrope may draw the lateral clavicle in an anterior and inferiordirection with over correction towards the coracoid and looseningof the first device.

© 2011 British Elbow and Shoulder Society130 Shoulder and Elbow © 2011 British Elbow and Shoulder Society. Shoulder and Elbow 2011 3, pp 130–135

T Falling from the Tightrope Tsiouri et al.

Concomitant injuriesStandard arthroscopy of the glenohumeral joint was performedin all cases through the posterior portal to identify and treat anyconcomitant intra-articular injuries. Superior labral tear from ante-rior to posterior [1] and anterior labral tear [1] were treated at thesame time. One pan labral tear had to be treated arthroscopically3 months later because of concern of excessive fluid distention inone seating.

PortalsThe anterolateral viewing portal was established in the subacromialspace just below the anterior corner of the acromium. The workingportal was established half way between this and the coracoidprocess anteriorly (Fig. 1). To minimize soft tissue distention, nooutflow cannulae was used. Debridement of the soft tissues lateralto the coraoid arch was undertaken with a 4 mm mechanicalshaver (Aggressor, FMS, Mitek, Raynham, MA, USA). We do not findthermal resection particularly helpful.

Placement of the two guide pins over the clavicleSoft tissue distension and swelling from the injury can makepalpation of the clavicle inaccurate. Placing spinal needles at theanterior and posterior borders of the clavicle, the drill sleeve of theguide (Arthrex) was then centered between them over the surfaceof the clavicle. The medial guide pin was inserted 5 cm from thelateral end of the clavicle, slightly towards the posterior aspect ofthe bone and aiming towards the base of the coracoid. The lateralguide pin should be at least 1 cm lateral and aiming to exit from theundersurface of the arch of the coracoid anterior to the previouspin. The position of the aiming device to receive the guide pin intothe coracoid was determined arthroscopically.

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

Fig. 1 Patient set-up.

Fig. 2 Guidewire insertion.

Fig. 3 Guidewires exiting at coracoids undersurface.

Fig. 4 Tightrope insertion.

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

© 2011 British Elbow and Shoulder SocietyShoulder and Elbow © 2011 British Elbow and Shoulder Society. Shoulder and Elbow 2011 3, pp 130–135 131


Fig. 5 Two Tightropes at coracoid undersurface.

The ACJ stabilizing K-wire was then removed and the reductionwas confirmed using the image intensifier. Before skin closure, wemade an attempt to cover the prominent knots of the fibrewiresunder a separate soft tissue layer.

Postoperative immobilization was limited to 4 weeks in a slingbut 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 fracture—dislocations had to be converted to mini-openreductions because reduction was not Possible because of softtissue interposition. These were excluded from the statistics of thestudy.

RESULTSClinical evaluationThere were 18 acute and 13 chronic cases. Mean delay to surgeryof the chronic cases was 13 weeks (6 weeks to 32 weeks). Table 1presents the diagnosis and type of fixation for the acute and chroniccases. The mean age was 40 years (range 19 years to 65 years) withan average follow-up of 14 months (range 4 months to 24 months).There were seven manual workers and nine patients were involvedin contact sports.

At final follow-up, the mean Constant score was 80.5 (range 50to 98). The average immobilization period of the shoulder was on

average only 3 weeks (range 0 weeks to 8 weeks) instead of therecommended 4 weeks.

We had six clinical failures (19%) Surprisingly, the two worstConstant 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 beentreated with double Tightrope fixation. Neither is involved in sports(one is a plumber and the second an office administrator). Both ofthem have regained a full range of movement but report dull ache.

Of the three single Tightrope fixations that failed, one developedinfection after treatment of an acute type V ACJ dislocation. Theother two were chronic injuries.

Three double Tightropes failed, all in acute type V injuries. Onewas secondary to superficial infection and this was attributed tohis immediate return to work as an army trainer. The other twodouble Tightrope lost the reduction after the endo-buttons erodedinto the clavicle.

Radiological evaluationSubluxation of the ACJ was observed in three patients after theirendo-buttons erodedinto theclavicle. Theyoccurredwithin thefirst8 weeks after stabilization. Interestingly, two of these were acuteinjuries fixed with double Tightrope. None were symptomatic. Ofmore concern were the four patients with endo-buttons that cutout, resulting in a loss of reduction. Two were single Tightrope,which cut out at 3 weeks and 10 weeks. The other was a patientwith a double Tightrope stabilization who was injured in a martialarts competition at 20 weeks after surgery. The last patient was acollege student and competitive motorcyclist but did not reportany injury prior to failure.

Details of failed stabilizations are listed in Table 2.

Statistical analysisUsing the SPSS package for Windows (SPSS, Inc., Chicago, IL, USA)considering p < 0.05 statistically significant, we attempted tocorrelate our results to several factors. We found no significantcorrelation (Spearman’s correlations, Fig. 6) between failure,subluxation or successful stabilization and type of injury, chronicity,operation duration, operation date, use of a single or doubleTightrope, return to work or sports, or duration of immobilization.Performing a one-way analysis of variance, we found no statistical

Table 1 Rockwood classification

Fixation Fixation

Acute Single TR Double TR Chronic Single TR Double TR

Type III∗ 4 1 3 6 2 4Type V∗ 10 1 9 6 1 5FDC + ACJ dislocation 2 1 1 0 0 0FDC 2 0 2 1 0 1Total 18 3 15 13 3 10

∗Classification according to Rockwood.ACJ, acromioclavicular joint; FDC, fracture distal end of clavicle; TR, Tightrope.



Table 2 Failures

Case Type Fixation Acute/chronicOperation duration

(minutes) FU Time of failure Return to physical Failure Mode of failure

5 III 2TR Chronic 105 20 4/52 Plumber-6/52 Subluxed One cut out8 III 1TR Acute 100 24 3/52 NA Failed Cut out

12 V 1TR Acute 98 12 6/52 Rugby-12/52 Subluxed Eroded13 V 1TR Chronic 90 18 10/52 NA Failed Cut out22 V 2TR Acute No data 10 8/52 NA Subluxed Eroded23 V 2TR Acute 90 23 20/52 Martial arts Failed Cut out26 V 2TR Acute 170 7 2/52 Army trainer-immediate Failed Infection27 V 2TR Chronic 120 5 6/52 NA Failed Cut out29 V 1TR Chronic 120 5 2/52 NA Failed 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).

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

operation date

failu

res

and

su

blu

xati

on

s

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

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

difference in failure rate when patients were separated accordingto fixation method (single or double Tightrope), chronicity of injuryor type of injury.

DISCUSSIONWe welcomed the innovative method of arthroscopic stabilizationoftheACJ using theTightropedevicesinceit was first announced [2]and adopted it as treatment choice for all our patients with ACJdislocations that needed surgery. The procedure is less invasiveand traumatic for the patient, patient morbidity is low because it isan arthroscopic procedure and no implant removal is required. Thesubstitute ‘ligament’ appears to reconstitute normal anatomy witha similar biomechanical strength [7]. Recently, a series of 19 patientswith acute grade 4 and 5 ACJ dislocations and 2-year follow-up wasreported with no failures or infections [10]. Good results have beenpublished in short series or cases of lateral end of clavicle fracturestabilizations with the Tightrope [11–14]. However, other studies

raise caution as a result of complications [15–18], prompting thesearch for more adequate biomechanically methods [18]. Initially,we used the Tightrope as a single device in accordance with themanufacturer’s instructions [19] but, later on, as a double device,aiming to reproduce both the conoid and trapezoid ligaments witha stronger anatomical reconstruction.

Imhoff et al. biomechanical studies [7] showed that the natu-ral coracoclavicular ligaments resisted a vertical load to failure of598 N, and a static anterior load of 338 N. With double Tightropereconstruction, the vertical load to failure was 982 N, whereas thestatic anterior load was 627 N, almost twice the native strength.

Loss of reduction secondary to button erosionWe encountered our first early failures within 4 weeks postoper-atively secondary to the clavicular endo-button cutting into theclavicle. Interestingly, button erosions and displacements werenoted by Tennent [1] when they reported the single techniquein 2008. Although ‘asymptomatic’, three out of their ten patients(30%) lost their ACJ reduction at follow-up. They attributed thisto the larger drill hole prepared for the Tightrope in their earlycases. We also had three such ‘asymptomatic’ subluxations. Wealso observed 10% endo-button erosion of the clavicle withoutsubluxation. Of more concern, we had four failures secondary tothe buttons cutting out of the bone altogether. We consider thesmall surface area of the 6 mm endo-button coupled with thegravitational traction on the coracoid by the upper limb exerts apressure above that which the clavicle cortex can withstand. Theendo-button then acts as a cheese grater and erodes into the bone.We reported this to the manufacturer and new endo-buttons witha wider 10 mm flat disc 10 mm were introduced at the end of 2008.Even though the present study did not include any patients treatedwith the new Tightrope buttons, it is worth noting that we observedthree failures subsequently, thus raising our total failure rate toalmost 22% (nine out of 41). One of them, a female patient withacute type 3 ACJ dislocation, was treated with a double Tightropethat actually failed within the 4 weeks of immobilization! She isasymptomatic, although there is redislocation and, on radiographic



control, one of the clavicle endo-buttons is lying 1 cm above theclavicle, suggesting Fibrewire failure. Fibrewire failure has beenreported in literature and was the main cause of a 50% failurerate [15].

Fractures of the lateral end of the clavicle with coracoclavicularligament ruptureAll three of our lateral end clavicle fractures with wide displace-ment united after arthroscopic Tightrope stabilization. Because theacromioclavicular ligaments were intact in these patients, reduc-tion of the superiorly displaced clavicle fragment to their lateralends with the Tightrope for 6 weeks appeared to lead to union.

InfectionThe second reason for failure in our series was infection. The knotstied with #5 Fiberwire tended to be bulky. When tied over theclavicle that lacks adequate soft tissue cover, the knots causedirritation to the overlying skin and resulted in wound breakdownand infection. This was particularly noted in our young patientswho returned to their sporting activities early before biologicalhealing of the ligaments. We now create a full thickness soft tissueflap to cover these knots, followed by separate skin closure, andwe have not had any more infections.

RehabilitationCompared with open reduction and internal fixation with metalwork across the ACJ, arthroscopic Tightrope stabilization was arelatively less painful procedure. In our series, patients discardedtheir slings early, with return to manual work and sporting activities.This did not give the soft tissues sufficient time to heal, resultingin wound irritation, breakdown and subsequent infection. Weconsider that the high incidence of button erosions was also relatedto the early shoulder movements that these patients enjoyed.

Technical exacting procedureThe difficult step in the procedure was to place the Tightrope ingood quality bone in the clavicle and coracoid. Because the patientwas inclined at 45◦ in a beach-chair position, the drill sleeve couldoften be placed too close to the anterior edge of the sloping clavicleresulting, in anterior cut out of the Tightrope. The task was madeeven more challenging with the placement of two 4.5 mm drillholes in a narrow coracoid with the double Tightrope technique.

Although the jig can provide sitting of a single Tightrope betweenthe coracoid and the clavicle comfortably, the same jig tends toplace the second endo-button close to the first in the undersurfaceof the coracoid. It does not allow easy lateral placement of the clav-icular drill hole in the same oblique direction as that of the trapezoidligament. By tilting the jig to place the second drill hole laterally, theguide pin often misses the lateral edge of the coracoids. However,even when this kind of device is implanted using open techniquesthat are easier and more straightforward, high complication rateshave been noted [15]. A recent series of 23 acute acromioclaviculardislocations stabilized with the double Tightrope using a fullyarthroscopic technique similar to ours reported good results withtwo failures that were attributed to the complexity of the technique

and a 30% loss of reduction [20]. The authors recommend that theTightrope is used only by experienced arthroscopists because thisis a procedure with a steep learning curve. In our experience, wecould not detect any correlation between our failures and ourlearning curve. There is a constant distribution of our failures overtime even though our technique was improving (Fig. 6).

Neither of the Tightropes can address the anteroposterior insta-bility at the lateral end of the clavicle in relation to the acromium.Indeed, no reconstruction of the acromioclavicular ligaments wasattempted in our series.

Biological healing and biomechanical advantagesIn our experience, the Tightrope was successful in stabilizing 81%of the ACJ after acute or chronic injuries. The reason is that itonly offers partial reconstruction of the torn conoid and trapezoidligaments, thus stabilizing the clavicle to the coracoid. There is noattempt to address the instability between the acromion and theclavicle. Anteroposterior instability is not dealt and this may be thereason for our failures.

Acromioclavicular joint injuries havealways been difficult to treat,which is the reason why there are more than 60 different methodsof stabilization described in the literature [21]. They vary betweenacromion-clavicle fixation methods, such as K-wires and tensionbanding, hook plates or recently specially designed anatomicalplates [22], or coracoclavicular stabilization with or without distalclavicle resection with screws, sutures, anchor sutures or ligamenttransfers, grafts or tapes, showing variable results [21,23–30].Further development of arthroscopic techniques is necessary toimprove results of ACJ stabilization. In addition, there is currentlyno evidence that biological healing with scar tissue formationoccurs between the clavicle and the coracoid in chronic ACJreconstructions with the Tightrope or any means of stabilizingthe ACJ [21]. To date, the results of biological reconstructionwith host or donor tendons have been disappointing [21,23–25]because the grafts may fail in their ‘anchoring’ point at the clavicleor their midsubstance, or loosen, and, with doubtful biologicalhealing of the coracoclavicular ligaments, either instability or thesymptoms (or both) recur [22,26]. There is no agreement as towhether they are as strong as the native ligaments [21,27–29]but improved results occur when the graft is supplemented bysutures or other nonbiological material. Most of these proceduresare performed open. Pure arthroscopic repairs are few in theliterature and involve mostly the Tightrope or alike implants untilthe very late application of all arthroscopic Modified–WeaverDunn procedure with a published technique but no reportedresults yet [30]. The latest studies combine the Tightrope devicewith tendon graft or transposition in an attempt to achievebiomechanical stability closer to the native stability and showpromising early results [28]. There is a controlled laboratory studythat compared the Weaver–Dunn combination with Tightropeor tape cerclage augmentation, which showed excellent stabilitywith the Tightrope in all planes [29]. It has been suggested thatthe Tightrope alone should only be used in the acute settingand, for chronic cases, augmentation with sutures or biologicalmaterial is necessary [20]. The Tightrope combined with other



means of anteroposterior stabilization of the ACJ may providesatisfactory results but research is still ongoing [30.31]. Based onour experience, we would recommend that the Tightrope only beused when the surgeon is prepared to treat instability between theacromion and the lateral end of the clavicle.

ConclusionsThe Tightrope, whether single or double, stabilized successfullythe clavicle in relation to the coracoid in only 81% of our patients.We consider our failure rate to be disappointingly high. We cannotidentify any specific factor that contributed to failure and thereforewe have ceased using it.

The current arthroscopic technique cannot successfully correct allACJ dislocations. The current jig requires modification and the tech-nique needs to include biological fixation of the lateral end of theclavicle to the acromion. We can only recommend this procedure toskilled arthroscopic shoulder surgeons who would be prepared toaddress stability across the acromioclavicular joint at the same time.

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