Surgical Technique for Arthroscopy-Assisted Anatomical Reconstruction of Acromioclavicular and Coracoclavicular Ligaments Using Autologous Hamstring Graft in Chronic Acromioclavicular Joint Dislocations  Bancha Chernchujit, M.D., Prashant Parate, D.N.B.  Arthroscopy Techniques  Volume 6, Issue 3, Pages e641-e648 (June 2017) DOI: 10.1016/j.eats.2017.01.009 Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 1 The left shoulder is being operated on, with the patient in the beach chair position. The ipsilateral leg is also draped for graft harvest. The table is kept as low as possible, and the head is stabilized properly with supports. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 2 The left shoulder is being operated on, with the patient in the beach chair position. Standard skin markings are done using bony landmarks (tip of coracoid, anterior and posterior border of clavicle, AC joint, lateral border of acromion, posterolateral corner of acromion, and spine of scapula). Kim's portal is a used for arthroscopy, which is placed 2 cm on a line extended from the posterolateral corner of the clavicle towards the posterolateral corner of the acromion. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 3 The left shoulder is being operated on, with the patient in the beach chair position. Kim's portal is used for visualization, and a rotator interval portal is made just lateral to the acromion and used for instrumentation. The undersurface of the coracoid is roughened using a shaver blade, which helps in healing of the graft. Using a shaver blade ensures the bone is not damaged and the strength of the coracoid is maintained. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 4 The left shoulder is being operated on, with the patient in the beach chair position. An approximately 4 to 5 cm incision is made on the superior surface of the clavicle closer to the anterior border of the clavicle. Soft tissues are cleared from the posterior, lateral, and anterior border of clavicle. This helps in reduction of AC joint and does not cause any obstruction to graft passage. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 5 The left shoulder is being operated on, with the patient in the beach chair position. Kim's portal is used for visualization, and a rotator interval portal is made just lateral to the acromion and used for instrumentation. A loop of ethibond is passed under the coracoid under vision from the medial to the lateral as close to the bone as possible. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 6 The left shoulder is being operated on, with the patient in the beach chair position. A loop of ethibond is passed under the coracoid under vision from the medial to the lateral as close to the bone as possible. A gauze piece is shuttled using this loop, which helps to dilate passage for the graft. After the passage is created, the graft is shuttled using this gauze piece. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 7 (A) The left shoulder is being operated on, with the patient in the beach chair position. Kim's portal is used for visualization. The graft along with 2 strong Ultrabraid threads is shuttled with a gauze piece, which was used to create a passage for the graft. The graft sits well under the coracoid. (B) The graft is pulled out in such a way that the stronger end of the graft is longer than the other end, which can be used to reconstruct the AC joint. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 8 (A) The left shoulder is being operated on, with the patient in the beach chair position. The clavicle is exposed properly, and lateral 6 mm is marked with cautery. (B) The marked portion is cut using a saw, and the bone piece is removed. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 9 (A) Diagram showing marking of the lateral end of the clavicle for placement of tunnels. Points for making a tunnel are selected according to the width of the coracoid base. These points can be marked by holding the graft vertically with both limbs parallel to each other. This is a more individualized approach than using fixed distance marking. The tunnel in the acromion is made around 1 cm lateral from the AC joint. Tunnels are made in the center of the clavicle and acromion so that after fixation, both bones are aligned well. (B) The left shoulder is being operated on, with the patient in the beach chair position. Tunnels of appropriate size are made as per markings. Tunnels are made in the center of the clavicle and acromion so that after fixation, both bones are aligned well. (CC, coracoclavicular.) Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 10 (A) The left shoulder is being operated on, with the patient in the beach chair position. Both limbs of the graft are crossed so that the graft close to the medial border of the coracoid comes out through the lateral tunnel and vice versa along with Ultrabraid sutures. (B) The graft is tied to itself in such a way that the stronger and longer end of the graft comes laterally for reconstruction of the AC joint. (C) A blunt ended device is used to maintain overreduction by applying force medial to both tunnels. This ensures that the clavicle does not fracture at the tunnels and that the surgeon has adequate space to operate. An endobutton is used as a cortical augmentation device, and Ultrabraid is tied on the button. (D) After primary stabilization with Ultrabraid over endobutton, the graft is tightened again and the knot is sutured using vicryl No. 1. The blunt device still maintains an overreduced position. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 11 (A) The left shoulder is being operated on, with the patient in the beach chair position. A loop of ethibond is passed in the acromial tunnel. It can be done using a wire passer spectrum device for shuttling threads. (B) The graft is pulled in such a way that it goes from the upper surface of the clavicle to the undersurface of the acromion and through the bone tunnel; it comes out on the superior surface of the acromion. This helps in further pulling the clavicle downwards, and soft tissue comes between the 2 bones and acts as an articular disc. (C) A blunt ended device is still used to maintain overreduction by applying force medial to both tunnels. The graft coming out from the acromion is pulled medially and tied with itself medially. After healing, this makes a strong support. (D) Diagrammatic representation of final construct. The graft crosses above the coracoid before passing through the clavicular tunnels. It is tied with itself, and then a longer and stronger graft is passed in such a way that it goes from the upper surface of the clavicle to the undersurface of the acromion and through the bone tunnel; it comes out on the superior surface of the acromion. Soft-tissue interposition can be seen between the 2 bones, which avoids pain from bone-to-bone contact. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 12 The left shoulder is being operated on, with the patient in the beach chair position. The graft stitched with itself using vicryl can be seen as a strong cord on the clavicle. Tight closure of the deltotrapezeal fascia provides additional support. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Fig 13 (A) Preoperative x-ray of the patient showing AC dislocation. (B) Postoperative x-ray of patient showing well-reduced AC dislocation. Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

Appendix Figure 1 Arthroscopy Techniques 2017 6, e641-e648DOI: (10.1016/j.eats.2017.01.009) Copyright © 2017 Arthroscopy Association of North America Terms and Conditions