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Coracoclavicular ligament reconstruction using the lateral

half of the conjoined tendon


Sonya M. Sloan, MD,a Jeffrey E. Budoff, MD,a,b John A. Hipp, PhD,a and Lyndon Nguyen, MS,a
Houston, TX

To preserve the coracoacromial (CA) ligament, we relying on the dynamic function of the distally at-
have used the lateral half of the conjoined tendon as tached conjoined tendon to stabilize the distal clavi-
an autograft source to replace the coracoclavicular cle, has also been reported.4,10,12,16
(CC) ligament. The purpose of this study is to compare Today, one of the most widely used surgical pro-
the ultimate tensile strength of the lateral 12 mm of the cedures for the reconstruction of a high-grade AC
conjoined tendon with that of the CA ligament and the joint separation is the Weaver-Dunn technique.34 Re-
ported in 1972, the Weaver-Dunn procedure uses the
CC ligament. Eight paired cadaveric male shoulders
CA ligament as a proximally based transfer to recon-
were tested to tensile failure with a custom pneumatic struct the CC ligament complex. Though often effec-
testing apparatus. Although the lateral 12 mm of the tive, this procedure involves the sacrifice of the CA
conjoined tendon was stronger than the CA ligament, ligament.
this difference was not statistically significant (P ⫽ The CA ligament functions as a secondary, static
.37). However, the intact CC ligament (621 ⫾ 209 N) stabilizer against anterior-superior humeral head mi-
was approximately 250% stronger than either the lat- gration.* Recent literature documents complications
eral 12 mm of the conjoined tendon (265 ⫾ 79 N, P associated with CA ligament resection in patients with
⬍ .001) or the CA ligament (246 ⫾ 69 N, P ⬍ .001). irreparable rotator cuff tears. Consequently, in that
We believe that the lateral half of the conjoined ten- situation, its preservation has been noted to be desir-
don is a viable alternative autograft source for recon- able.†
To avoid complications associated with resection
struction of the CC ligament in cases of symptomatic
of the CA ligament, we have used the lateral half of
acromioclavicular joint dislocation. Though not as the conjoined tendon as a proximally based transfer
strong as the native CC ligaments, the conjoined ten- for CC ligament reconstruction, especially in cases of
don is slightly stronger than the commonly used CA concomitant rotator cuff injury and/or surgery in
ligament. (J Shoulder Elbow Surg 2004;13:186-90.) paraplegics. It is also an advantageous autograft
source in revision situations in which the CA ligament
A cromioclavicular (AC) dislocations, initially de- has already been harvested or in cases in which an
fined by Allman1 as a grade III AC joint separation, excessive amount of distal clavicle has been resected
occur in conjunction with disruption of the coracocla- and a longer length of graft tissue is required. A
vicular (CC) ligament complex. The first surgical treat- similar technique was originally reported by Var-
ment of an AC joint dislocation was an arthrodesis gas32 in 1942, who credited de Carvalho with the
performed by Cooper8 in 1861. Since then, surgical idea.
reconstruction of the CC ligament complex has been The conjoined tendon takes origin from the cora-
accomplished by a number of different techniques coid immediately anterior to the CA ligament. As the
including the use of hardware fixation from the clav- musculocutaneous nerve enters the conjoined tendon
icle to the acromion,26,28 hardware fixation from the in its muscular medial side, the lateral half, which is
clavicle to the coracoid,5,17 and reconstruction with entirely tendinous, can be easily harvested without
autologous semitendinosus tendon15 or the cora- putting this nerve at risk. Moreover, a conjoined
coacromial (CA) ligament.34 Transfer of the coracoid, tendon graft can be harvested to be significantly
longer than the CA ligament.
From the Department of Orthopaedic Surgery, Baylor College of
Medicine,a and Houston VAMC.b
A literature search failed to note any study exam-
Reprint requests: Jeffrey E. Budoff, MD, 6550 Fannin St, Suite
ining the properties of the conjoined tendon as a graft
2525, Houston, TX 77030 (E-mail: jbudoff@bcm.tmc.edu). source. The purpose of this study was to compare the
Copyright © 2004 by Journal of Shoulder and Elbow Surgery ultimate tensile strength (UTS) of the intact CC liga-
Board of Trustees.
1058-2746/2004/$35.00 ⫹ 0 *References 2, 3, 6, 7, 9, 11, 13, 20, 24, 27, 33, 35, 36.
doi:10.1016/j.jse.2003.12.002 †References 3, 7, 13, 18, 20, 27, 29, 33, 35, 36.

186
J Shoulder Elbow Surg Sloan et al 187
Volume 13, Number 2

Experimental procedure
Intact CC ligament testing. Each embedded specimen
was secured, and the load cell was applied in the direction
of the conoid ligament. The UTS was recorded for each
intact CC ligament complex. Testing then followed for CA
ligament reconstruction and then conjoined tendon recon-
struction.
CA ligament transfer. The entire CA ligament was taken
off its insertion on the undersurface of the acromion. Its
length was measured to the nearest millimeter so that the
conjoined tendon could be cut to the same length. The CA
ligament was prepared as a proximally based transfer
attached to the coracoid as performed during the Weaver-
Dunn technique.34 No. 5 Ethibond sutures (Ethicon, Inc,
Figure 1 Biomechanical testing apparatus.
Somerville, NJ) were placed in a Bunnell-type weave with
two large Keith needles simultaneously passed through the
ligament to ensure that the needle tips did not cut the
sutures. In all reconstructions, great care was taken to start
all sutures 10 mm from the tip of the coracoid, thereby
ment, the CA ligament, and the lateral half of the leaving a 10-mm “free length” of unreinforced soft tissue.
The sutures were tied through drill holes in the distal clavi-
conjoined tendon. cle. The apparatus was then secured and tested as above.
Conjoined tendon transfer. Twelve millimeters or ap-
MATERIALS AND METHODS proximately half of the lateral conjoined tendon was cut to
the same length as the CA ligament and sutured with No. 5
Eight fresh-frozen male cadaveric shoulders (four right
Ethibond in an identical fashion to the CA ligament recon-
and four left) were used. The mean age of the specimens
struction. The 10-mm “free length” was observed in all
was 65 years, with a range from 64 to 68 years. Each specimens. The sutures were tied through drill holes in the
specimen was free from injury and disease, with no known distal clavicle, and the apparatus was secured and tested in
musculoskeletal disorders. The specimens were fresh-fro- the same manner as for the CA ligament reconstruction.
zen, stored at 0°C, and thawed for 24 hours at room The UTS of all specimens was noted, as was the mode of
temperature before testing. Dissection of each shoulder was failure (avulsion of the tendon from the coracoid substance,
completed with careful attention to preserving the conjoined avulsion fracture of the coracoid process, or intrasubstance
tendon, the CA ligament, and the CC ligament. After the soft-tissue failure).
aforementioned structures were identified, the skin, subcu-
taneous tissue, and surrounding muscles were removed.
Data analysis
Each specimen was embedded in an open rectangular
mold by use of Smooth Cast 320 (Smooth On Inc, Easton, The data were statistically analyzed by use of paired t
Pa), a liquid polymer. The proximal clavicles were similarly tests and 1-way analysis of variance tests.
potted, by use of 2-inch tubular polyvinyl chloride pipe. A
ferrous angle iron was secured to the potted clavicle with a RESULTS
threaded screw directly over the CC ligament. The distal
clavicle was then secured by an angle iron and clamp for The UTS for the intact CC ligament complex aver-
mounting purposes. The specimens were continuously hy- aged 621 ⫾ 209 N. The UTS of the CA ligament
drated by use of 0.9% normal saline solution at room averaged 246 ⫾ 69 N. The UTS of the conjoined
temperature. The AC ligament was sharply transected be- tendon averaged 265 ⫾ 79 N.
fore each experimental procedure to simulate damage The intact CC ligament complex had a greater
caused by an AC joint dislocation. The biomechanical ultimate tensile load to failure than both the CA liga-
testing apparatus was modified from that used by Mota- ment and the lateral 12 mm of the conjoined tendon
medi et al22 and Harris et al14 (Figure 1). Biomechanical (P ⬍ .001). The lateral 12 mm of the conjoined
testing was conducted with a custom pneumatic testing tendon tended to be stronger than the CA ligament,
apparatus. Each specimen was fixed to an x-y floating
but this difference was not statistically significant (P ⬎
platform to allow self-alignment to the load that was placed
.37) (Table I, Figure 2). There was no statistically
at a right angle to the x-y plane. A pneumatic cylinder
(Parker Hannifin Corporation, Cleveland, Ohio) and load significant difference in mode of failure between any
call (MUSE Measurements Corporation, Sandmas, Calif), of the structures tested (P ⫽ .12) (Table II).
centered directly above the graft, applied a uniaxial load CA ligament length varied from 34 to 41 mm, with
perpendicular to the anatomic position of the clavicle at a a mean of 38 mm. CA ligament width ranged from
constant rate of 31.15 N/s (7 lb/s). To ensure that all slack 24 to 33 mm and averaged 27.6 mm. The length of
was removed from the graft, a preload of 5 N was applied the lateral side of the conjoined tendon devoid of any
before testing. All specimens were loaded until failure. and all muscle fibers, proximal to its separation into
188 Sloan et al J Shoulder Elbow Surg
March/April 2004

gration, a greater length of graft source, and the


strength of the lateral 12 mm of the conjoined tendon
is at least equivalent to that of the CA ligament. No
donor-site morbidity, weakness, fatigue, cramping, or
musculocutaneous nerve injury has been experienced
in association with this technique. Although it is ac-
knowledged that violation of the CA ligament can
also be avoided by using allograft, the purpose of this
report is to present an alternative autograft for recon-
struction of the CC ligaments. Use of the lateral half of
the conjoined tendon may be considered when an
allograft is not desired.
The ultimate failure load for the intact CC ligament
(621 ⫾ 209 N) was comparable to that noted in
studies by Harris et al14 (500 ⫾ 134 N) and Mota-
medi et al22 (725 ⫾ 231 N). However, we found the
UTS of the CA ligament to be somewhat higher (246
Figure 2 Comparison of ultimate tensile failures. ⫾ 69 N) than that measured by Harris et al14 (145 ⫾
107 N).
The ultimate failure load for the conjoined tendon
Table I UTS reconstruction (265 ⫾ 79 N) was equivalent to the
strength of a CC screw measured by Harris et al14
UTS (N)
(229 ⫾ 99 N) but was less than that measured by
Structure (mean ⴞ SD)
Motamedi et al22 (390 ⫾ 254 N). It was also lower
Intact CC ligament 590.4 ⫾ 191.8 than augmentations performed with braided poly-
Conjoined tendon 265.3 ⫾ 78.9 dioxanone (677 N ⫾ 115 N) or with polydioxanone
CA Ligament 246.3 ⫾ 69.4 placed through (986 ⫾ 391 N) or around (763 ⫾
218 N) the clavicle.22
The recent trend has been toward preservation of
Table II Mode of failure the CA ligament, because of its function as a second-
ary, static stabilizer of the humeral head against
Structure Midsubstance Bone Insertional superior migration in the presence of rotator cuff
CC ligament 3 1 4
deficiency.‡ Should a patient later have a large rota-
CA ligament 3 0* 4 tor cuff tear develop, this loss of the CA ligament may
Conjoined tendon 2 2 4 predispose to anterosuperior instability and a de-
creased ability to actively elevate the arm, especially
*CA ligament was not tested because of prior bone fracture at clavicle. in those who undergo arthroplasty.3,13,20,27,33,35,36
As the prevalence of rotator cuff tears increases with
its two muscles (the long head of the biceps and age— up to approximately 51% in individuals aged
coracobrachialis), ranged from 55 to 67 mm and greater than 80 years19,21,23,25,30,31—rotator cuff
averaged 61 mm. However, the overall conjoined dysfunction is common enough that it may be antici-
tendon length proximal to the myotendinous junction pated to occur in a significant percentage of our
measured approximately 5 to 7 inches. surgical population.
When the CA ligament is being used as a graft
DISCUSSION source, obtaining adequate graft length for CC liga-
ment reconstruction can occasionally be problematic.
In this study two potential autograft sources for CC A more than ample length of graft can routinely be
ligament reconstruction were compared with regard harvested from the conjoined tendon, even in cases of
to UTS as well as length and failure type. We found prior excessive distal clavicle resection.
the lateral 12 mm of the conjoined tendon to be From a biomechanical testing standpoint, where
slightly stronger than the entire CA ligament, although one places suture into soft-tissue reconstructions is
this difference did not reach statistical significance significant, as sutures artificially reinforce the length
with the numbers tested. Clinical advantages of using of tissue in which they lie. As the free interval (the
the conjoined tendon instead of the CA ligament as a tissue length devoid of suture) becomes shorter, there
proximally based transfer for CC ligament reconstruc- is less unreinforced tissue length available to fail, and
tion include retention of the CA ligament as a passive
stabilizer against anterior-superior humeral head mi- ‡References 2, 3, 6, 7, 9, 11, 13, 20, 24, 27, 33, 35, 36.
J Shoulder Elbow Surg Sloan et al 189
Volume 13, Number 2

the structure’s UTS increases. It may be possible to patients with a coexisting rotator cuff tear, or in
manipulate soft-tissue strength by varying the length of patients who depend on their upper extremities for
the free interval. In this study the starting point for the transferring and ambulation (ie, paraplegics).
suture was kept a constant 10 mm from the coracoid
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