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Technical Note
Coracoclavicular Stabilization With Two Loops of
Equal Tension Using a Double O Loops Technique in
the Distal Clavicle Fracture
Chaiwat Chuaychoosakoon, M.D., Yada Duangnumsawang, D.V.M., M.Sc.,
Prapakorn Klabklay, M.D., Tanarat Boonriong, M.D., and Adinun Apivatgaroon, M.D.
Abstract: The distal clavicle fracture is one of the most common injuries around the shoulder joint. There is no consensus
regarding a gold standard treatment. Each technique has advantages and disadvantages. Currently, coracoclavicular (CC)
stabilization is one of the most popular techniques because this operative procedure provides good stability of the fracture
and has few complications. The CC stabilization is a suspensory fixation that consists of many two-CC-loop arrangements.
It is, however, difficult to gain equal tension in both CC loops because one loop is always tighter and has greater action in
maintaining bone alignment than the other loop. To solve this problem, we propose a double O loops technique to achieve
two equal tension loops.
The clavicle fracture is one of the most common
injuries around the shoulder joint, involving 44%
to 66% of all shoulder fractures. Clavicle fractures are
divided into proximal, middle and distal fracture areas.
Twenty percent of clavicle fractures are distal third
fractures that are usually classified using the Neer
classification. This classification is based on the
configuration of the fracture and the status of the
coracoclavicular (CC) ligaments. Neer types I and III
are quite stable because the fractures are nondisplaced
or minimally displaced. The other types of distal
clavicle fracture are less stable. The treatment is based
on type of injury. There is a consensus that the
treatment of choice in distal clavicle fracture type V is
operative management. There is a wide choice of
fixations. The surgical techniques are plate and screw
fixation, hook plating, k-wire fixation, tension band
wiring, CC screws, and CC stabilization. Currently,
most surgeons prefer to perform CC stabilization to
maintain the reduction and achieve the healing pro-
cess in the distal clavicle fracture. The mode of CC
stabilization is suspensory fixation. There are open
procedures and arthroscopic-assisted procedures in CC
stabilization. The advantage of the open procedure is
that it is simple, but the intraarticular pathology
cannot be evaluated.
1
There are many surgical tech-
niques in CC stabilization, normally including two
loops between the coracoid process and the clavicle.
The most problematic aspect of this method is that it is
almost impossible to achieve equal tension in the two
loops; for ideal reduction outcome, both loops should
have equal tension, but the tighter loop will have
greater influence. The looser loop will act to maintain
the reduction if the tighter loop fails or becomes loose.
The surgeon can, however, set the tension equally by
using a double O loops technique as described in this
article.
Surgical Technique
The patient is placed in the supine position on the
operating table. Next, regional anesthesia (inter-
scalene block) combined with general anesthesia is
performed. After anesthesia is induced, the patient is
From the Department of Orthopaedic Surgery and Physical Medicine,
Faculty of Medicine, Prince of Songkla University, (C.C., P.K., T.B.), and the
Faculty of Veterinary Science, Prince of Songkla University (Y.D.), Songkla,
and the Department of Orthopaedic, Faculty of Medicine, Thammasat Uni-
versity (A.A.), Prathumthani, Thailand.
The authors report that they have no conflicts of interest in the authorship
and publication of this article. Full ICMJE author disclosure forms are
available for this article online, as supplementary material.
Received September 20, 2019; accepted November 16, 2019.
Address correspondence to Chaiwat Chuaychoosakoon, M.D., Faculty of
Medicine, Prince of Songkla University, Department of Orthopaedic Surgery
and Physical Medicine, 15 Karnjanavanich Road, Hat Yai, Songkla 90112,
Thailand. E-mail: psu.chaiwat@gmail.com
Ó2019 by the Arthroscopy Association of North America. Published by
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2212-6287/191144
https://doi.org/10.1016/j.eats.2019.11.010
Arthroscopy Techniques, Vol -,No-(Month), 2019: pp e1-e5 e1
set in a modified semilateral decubitus position (Fig 1
AandB).
2
The patient is prepped and draped in a
sterile fashion.
A sterile marker is used to outline the surface
anatomy of the shoulder (Fig 2). A saber incision is
made 5 cm over the shoulder from the distal clavicle
to the tip of the coracoid (Fig 3A). The incision land-
mark is 2 cm medial to the fracture site. The deltoid
fibers are separated to expose the coracoid process
(Fig 3B). A certain kind of suture material such as
Ethibond No. 2 (Ethibond, Somerville, NJ) is looped
around the base of the coracoid process and behind
the coracoacromial ligament from the medial aspect to
the lateral aspect of the coracoid base using a 90right
angle clamp. In this step, the surgeon must continually
keep in mind the neurovascular structures (subclavian
artery, subclavian vein and brachial plexus) located
medially and close to the coracoid process.
3
The
Ethibond No. 2 is replaced with a shuttle loop using
the shuttle relay technique (Fig 3C). The next step is at
theclaviclearea.Thefullthicknessofthedelto-
trapezial fascia of the clavicle is incised in longitudinal
plane over the clavicle and the fascia is peeled off from
theboneusingaperiosteumelevator(Fig 3D). A
double length of Ethibond No. 5 is formed. The loop
end of the Ethibond No. 5 is passed underneath the
coracoid process by using a shuttle suture then pulled
upward and passed anterior to the anterior border of
the clavicle. The other end of the double loop is passed
posterior to the posterior border of the clavicle
(Fig 4A). The fracture is then reduced by lifting the
arm up. The Ethibond No. 5 is tightened to maintain
the reduction (Fig 4B). The alignment is checked un-
der a fluoroscope (Fig 5). For CC stabilization, the first
tunnel (lateral tunnel) is created at the center of the
clavicle and approximately 5 mm medial to the medial
fragment of the fracture. The lateral limb of the shuttle
suture is passed through the first tunnel of the clavicle
using a stainless wire. The second tunnel (medial
tunnel) is created at the center of the clavicle and
medial to the first tunnel about 15 mm. The medial
limb of the shuttle suture is passed through the second
tunnel of the clavicle by a stainless wire. The 4-holes
of a small plate are applied at the superior border of
theclavicle.Theshuttleisalsopassedthroughthe
holes of the clavicular plate. One limb of fiber wire No.
5 (Arthrex, Naples, FL) is passed through the lateral
hole of the plate, the lateral tunnel of the clavicle,
looped around the coracoid base and passed through
the medial tunnel of the clavicle and the medial hole
of the plate (Fig 6A). The other limb of the fiber wire
No. 5 is passed through the medial hole of the plate
(Fig 6B), the medial tunnel of the clavicle and looped
around the coracoid base a second time (Fig 6C) then
passed through the lateral tunnel of the clavicle and
the lateral hole of the plate using the shuttle loop
technique (Fig 6D). The fiber wire is tightened over
theplatebyasimplesuture.Withthistechnique,
there is equal tension in both loops. The alignment is
Fig 1. Modified semilateral de-
cubitus position for cor-
acoclavicular stabilization in right
shoulder. (A) Frontal and (B)
lateral view.
Fig 2. Overview of operating site in right shoulder. (A,
acromion process; C, clavicle; CA, coracoclavicular ligament;
CP, coracoid process.)
e2 C. CHUAYCHOOSAKOON ET AL.
checked under a fluoroscope (Fig 7 A and B). The
deltoid fiberisthenrepairedbyVicryl3-0.Theskinis
closed layer by layer. The entire surgical technique is
shown in Video 1, with audio narration. Tables 1 and
2present tips, pitfalls, key points, advantages, and
disadvantages of using this technique.
Postoperative Care
A shoulder abduction sling is used for 6 weeks.
Controlled passive mobilization of the shoulder is
allowed on the second day after surgery. Active assisted
exercise of the shoulder is allowed in the sixth week
after surgery. At 3 months’follow-up, the patient
achieves the full range of motion of the shoulder, and
the radiographic finding shows good alignment.
Discussion
The distal clavicle fracture is one of the most common
fractures around the shoulder joint. It is mainly divided
into stable and unstable fractures. The patient with an
unstable distal clavicle fracture usually requires opera-
tive treatment. There are several surgical techniques to
treat this fracture, including CC stabilization with syn-
thetic sutures, tendon augmentation or screw systems,
Fig 3. The surgical exposure of
right shoulder. (A) A saber inci-
sion is made 5 cm over the
shoulder, (B) The coracoid base
is exposed, (C) The Ethibond No.
2 is replaced with a shuttle loop
using the shuttle relay technique,
(D) The full thickness of the
deltotrapezial fascia is peeled off
from the bone using a perios-
teum elevator. (A, acromion
process; C, clavicle; CA, cor-
acoclavicular ligament; CB,
coracoid base.)
Fig 4. The steps of maintain the
reduction. (A) The loop end of
the Ethibond No. 5 is passed
underneath the coracoid process
by using a shuttle suture then
pulled upward and passed ante-
rior to the anterior border of the
clavicle. The other end of the
double loop is passed posterior to
the posterior border of the clav-
icle. (B) The Ethibond No. 5 is
tightened to maintain the
reduction.
CORACOCLAVICULAR STABILIZATION IN THE DISTAL CLAVICLE FRACTURE e3
fracture fixation methods using a plate and screw sys-
tem, hook plating, tension band wiring, or K-wire
fixation.
The two most popular techniques of fixation are CC
stabilization with synthetic sutures and Hook plating.
In CC stabilization, two areas are involved. The first
area is the base of the coracoid process. The surgeon
candointhisareaintwoways.Thefirst way is to pass
a loop underneath the coracoid base. The second way
is to make either one or two tunnels at this area. With
this technique of making tunnels through the coracoid
base, there is a risk of coracoid base fracture, especially
in Asian patients who generally have a smaller cora-
coid base than other races, but the fixation is more
rigid than the looped-under-the-coracoid-base tech-
nique, which involves the risk of suture grinding. The
second area is the clavicular bone. Most surgeons
create the clavicular tunnel by using the anatomical
landmark of the native CC ligaments. In the technique
beginning with a loop underneath the coracoid base,
most surgeons use two loops for CC stabilization. It is,
however, difficult to gain equal tension in both loops,
and one loop is almost always tighter and has greater
action in maintaining bone alignment than the other
loop. In order to solve this problem, the surgeon can
use the modified tight loop technique as described
above. In hook plating fixation, the incision is longer
than the CC stabilization technique and the surgeon
must expose the acromion process in order to pass the
hook of the plate under the acromion and posterior to
the acromioclavicular joint. This fixation method is
reliable and has few complications; however, it can
lead to various adverse subacromial effects such as
Fig 5. The alignment is checked under a fluoroscope.
Fig 6. The steps of a double O loops technique. (A) One limb of fiber wire No. 5 is passed through the lateral hole of the plate, the
lateral tunnel of the clavicle, looped around the coracoid base and passed through the medial tunnel of the clavicle and the
medial hole of the plate. (B) The other limb of the fiber wire No. 5 is passed through the medial hole of the plate, the medial
tunnel of the clavicle and (C) looped around the coracoid base a second time then (D) passed through the lateral tunnel of the
clavicle and the lateral hole of the plate using the shuttle loop technique.
e4 C. CHUAYCHOOSAKOON ET AL.
acromial osteolysis, subacromial shoulder impinge-
ment, or even rotator cuff tear, requiring a second
operation to remove the implant.
The double-O-loops technique is a safe technique,
easy to apply to achieve two equal tension loops, which
overcomes the problem of unequal tension of the two
loops.
Acknowledgement
The authors sincerely thank Konchanok Jaipakdee
for allowing us to disclose the information, Konwarat
Ninlachart for assistance with drawing the illustra-
tions; and Dave Patterson for assistance in English
editing.
References
1. Beirer M, Zyskowski M, Crönlein M, et al. Concomitant
intra-articular glenohumeral injuries in displaced fractures
of the lateral clavicle. Knee Surg Sport Traumatol Arthrosc
2017;25:3237-3241.
2. Keyurapan E, Chuaychoosakoon C. Modified semilateral
decubitus position for shoulder arthroscopy and its
application for open surgery of the shoulder (one setting
for all shoulder procedures). Arthrosc Tech 2018;7:e307-
e312.
3. Chuaychoosakoon C, Suwanno P, Klabklay P, et al.
Proximity of the coracoid process to the neurovascular
structures in various patient and shoulder positions: A
cadaveric study. Arthrosc - J Arthrosc Relat Surg 2019;35:
372-379.
Fig 7. The alignment is finally
checked under a fluoroscope: (A)
anteroposterior and (B) lateral
transcapular views.
Table 1. Pearls and Pitfalls
Pearls
The fluoroscope is located on the side opposite to the injured
shoulder.
Reduce the clavicle by lifting the arm.
To preserve the blood supply at the fracture site, the surgeon
should not open the fracture site.
The surgeon should reduce the distal clavicle fracture before the
tunnel is created.
Beware of creating the tunnel too laterally because of the
poorer quality of the bone.
The tunnel is created using a 2.5-mm drill bit that creates a hole
through which the suture can be easily passed. Achieve equal
tension in both loops by pulling up both limbs of the sutures
before tightening.
Pitfalls
There can be a risk of neurovascular injury if the surgeon dis-
sects medially or inferiorly to the base of the coracoid process.
Key Points
The base of the coracoid process is looped from the medial
border to the lateral border.
The clavicular bone cut out by suture material is prevented
using 4 holes of a small plate.
Table 2. Advantages and Disadvantages
Advantages
This technique is suitable for distal clavicle fracture (Unstable
Neer type III, Neer type IV and type V).
The technique provides better healing conditions because the
fracture site is not exposed.
The surgeon can set the tension equally by using a double O
loops technique.
There is less risk of fracture of the coracoid process.
Disadvantages
The technique is not suitable for comminuted clavicle-coracoid
fracture.
CORACOCLAVICULAR STABILIZATION IN THE DISTAL CLAVICLE FRACTURE e5
