Authors’ Reply

We thank Drs. Shyamalan and Tennent for their interesting comments and the interesting discussion about our recent “Technical Note” in the October 2007 issue of Arthroscopy.1Wellmann M. Zantop T. Petersen W. Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation.Arthroscopy. 2007; 23 (Available online at www.arthroscopyjournal.org): 1132.e1-1132.e5Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Our experience with coracoclavicular polydioxanone (PDS) cerclage for the treatment of acute acromioclavicular (AC) joint injuries date back to the 1990s. Several studies have shown excellent or good clinical results and good AC joint reduction after treatment of AC joint separation using a coracoclavicular PDS sling.2Rolf O. Hann von Weyhern A. Ewers A. Boehm T.D. Gohlke F. Acromioclavicular dislocation Rockwood III-V: results of early versus delayed surgical treatment.Arch Orthop Trauma Surg. 2007; (Nov 22 [Epub ahead of print])PubMed Google Scholar, 3Prokop A. Helling H.J. Andermahr J. Mönig S. Rehm K.E. Tossy III injuries of the acromioclavicular joint In what circumstances is surgery still justified? Personal results and literature review.Orthopade. 2003; 32 (in German): 432-436Crossref PubMed Scopus (18) Google Scholar, 4Fremerey R.W. Lobenhoffer P. Bosch U. Freudenberg E. Tscherne H. Surgical treatment of acute, complete acromioclavicular joint dislocation Indications, technique and results.Unfallchirurg. 1996; 99 (in German): 341-345PubMed Google Scholar, 5Probst A. Hegelmaier C. Stabilization of the injured shoulder joint with PDS cord.Aktuelle Traumatol. 1992; 22 (in German): 61-64PubMed Google Scholar None of these studies have shown that the PDS cerclage loses integrity and breaks before healing of the coracoclavicular ligaments. Therefore we have no concerns with the use of a PDS cord. In a biomechanical study with a cyclic loading protocol, we found that the flip button repair (646 N) and the conventional PDS banding (663 N) revealed significantly higher ultimate loads than the suture anchor repairs (Twinfix/Ultrabraid; Smith & Nephew Endoscopy, Andover, MA) (P < .001) whereas no significant differences were found for the elongation behavior under cyclic loading.6Wellmann M. Zantop T. Weimann A. Raschke M.J. Petersen W. Biomechanical evaluation of minimally invasive repairs for complete acromioclavicular joint dislocation.Am J Sports Med. 2007; 35: 955-961Crossref PubMed Scopus (55) Google Scholar Therefore we have no concerns about the use of a 1.3-mm PDS cord or two 0.7-mm PDS cords for the stabilization of AC joint separations. We found no published studies investigating No. 5 FiberWire (Arthrex, Naples, FL) for AC joint stabilization in the literature. We also have good clinical experience with the use of nonabsorbable 1-mm polyester cord (Ethibond; Ethicon, Somerville, NJ) for the stabilization of AC joint injuries. Our experience with the button technique dates back to the end of the 1990s after poor experience with anchor techniques. The senior author used the first button (EndoButton; Smith & Nephew Endoscopy) for fixation of a PDS cerclage below the coracoid in 1999. In 2003 we started to develop specific instruments to minimize the invasiveness of the procedure. Now, this system is called MINAR (minimally invasive AC joint repair) (Karl Storz, Tuttlingen, Germany). The drill hole in the coracoid is made with a specific aimer (Karl Storz). The aimer protects the neurovascular structures from injury by the drill. The button is placed below the coracoid with a specific button pusher (Karl Storz). This technique for application of the Flipptack (Karl Storz)1Wellmann M. Zantop T. Petersen W. Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation.Arthroscopy. 2007; 23 (Available online at www.arthroscopyjournal.org): 1132.e1-1132.e5Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar differs considerably from the TightRope technique (Arthrex) as it has been described.7Arthroscopic stabilization of acute acromioclavicular joint dislocation using the TightRope system: Surgical technique. Arthrex, Naples, FL2006Google Scholar With the MINAR technique, the application of the stabilizing suture cerclage is possible via a small incision of 3 cm. There is no need for an additional incision or for arthroscopy. For the arthroscopic AC joint repair with the TightRope system (Arthrex), it has been recommended to completely release the superior glenohumeral ligament and partially release the middle glenohumeral ligament,7Arthroscopic stabilization of acute acromioclavicular joint dislocation using the TightRope system: Surgical technique. Arthrex, Naples, FL2006Google Scholar which is not necessary with the MINAR system. The arthroscopic AC joint repair is a technique for an advanced shoulder surgeon to use. In Germany AC joint injuries are typically not treated in centers specializing in arthroscopy but are treated in general hospitals, where experience with shoulder arthroscopy might be limited. In addition, the use of arthroscopy is associated with additional costs that are not covered in our health care systems. The MINAR technique is easy to perform, and our surgical time is approximately 25 minutes. Indeed, in our “Technical Note” we presented no clinical results of the MINAR technique.1Wellmann M. Zantop T. Petersen W. Minimally invasive coracoclavicular ligament augmentation with a flip button/polydioxanone repair for treatment of total acromioclavicular joint dislocation.Arthroscopy. 2007; 23 (Available online at www.arthroscopyjournal.org): 1132.e1-1132.e5Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar An ongoing prospective study is being performed, and we hope to have the opportunity to present the 2-year results at an upcoming international meeting. The results look very promising. We thank Drs. Gunaratnam and Tennent for providing us with references regarding the TightRope technique. Unfortunately, we could not find the surgical description published by Arthrex7Arthroscopic stabilization of acute acromioclavicular joint dislocation using the TightRope system: Surgical technique. Arthrex, Naples, FL2006Google Scholar or the meeting abstracts8Richards A. Potter D. Learmonth D. Tennent D. Arthroscopic stabilisation of acute distal clavicle fractures and dislocations using the tightrope syndesmosis repair system.in: Presented at the Annual Meeting of the Arthroscopy Association of North America, Vancouver, BC2005Google Scholar in our Medline search. Again, we thank Drs. Gunaratnam and Tennent for this stimulating discussion. The TightRope SystemArthroscopyVol. 24Issue 4PreviewWe read with interest the article by Dr. Petersen and his colleagues1 in the October 2007 issue of Arthroscopy. We agree that treatment of injuries of grade IV and above to the acromioclavicular joint are typically treated surgically. However, we would like to raise a few issues relating to the article. Full-Text PDF

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