fig1 to 6 illustrate a surgical procedure for treatment of an ac joint dislocation , using a first embodiment of a fastener system according to the invention . in fig1 , a 2 - inch incision is made from the palpable base of the tip of the coracoid 12 , to the anterior edge of the distal clavicle 14 . medial and lateral skin flaps are developed . the deltoid is split in line with its fibers , and the coracoid 12 is identified and cleared off all the way to the base . the medial and the lateral edges of the coracoid 12 at the base are clearly identified . the clavicle 14 is manually reduced , and while the reduction is being held , a drill tip guide wire 16 is drilled into the top of the clavicle 14 approximately 3 cm medial to the ac joint 18 , and midway between the anterior and the posterior border of the clavicle . the drill hole should be directly over the base of the coracoid 12 , and the drill wire 16 should be aimed slightly anteriorly . after drilling through the clavicle 14 , the wire 16 should be easily visualized in between the clavicle and the coracoid 16 . once the tip of the wire 16 is confirmed to be entering the coracoid 12 well centered between the medial and the lateral edges , it is then drilled all the way through and out of the base . a 4 . 5 mm dia . drill 22 is guided over the drill guide wire 16 to bore a first hole 24 through the clavicle 14 , and another hole 26 ( see fig3 ) through the coracoid 12 in alignment with the clavicle hole 24 . with the clavicle 14 well reduced , a depth gauge ( not shown ) is used to measure the length of a passage from the top opening of the bore hole 24 in the clavicle , to the bottom opening of the bore hole 26 in the coracoid . a 2 . 5 millimeter dia . drill hole 28 is bored in the clavicle 14 , one cm lateral to the top of hole 24 . a fastener 50 arranged according to the invention is shown in fig2 . the fastener 50 includes a sturdy elongate body 52 formed of surgical steel or an equivalent medically safe material . the fastener body 52 may measure , e . g ., approx . 4 mm wide by 12 mm long . an outer pair of openings 54 a , 54 b are formed near the opposite short side ends of the fastener body 52 , and an inner pair of openings 56 a , 56 b are centered on the long axis of the body 52 between the outer pair of openings 54 a , 54 b . an endless or closed loop stitch 58 engages the fastener 50 by passing through inner openings 56 a , 56 b in the fastener body 52 . the stitch 58 may be formed , for example , by tying the ends of a suture strand together to form a loop whose length corresponds to that measured by the depth gauge noted above . the fastener body 52 with the closed loop stitch 58 may also be obtained from smith & amp ; nephew , inc ., of memphis , tenn . under the mark endobutton ®, or from conmed of largo , fla . under the mark “ xo button ”. as seen in fig2 , two number 5 ethibond ( or similar ) sutures 60 , 62 are placed through the outer pair of openings 54 a , 54 b in the body 52 of the fastener 50 . a third suture 64 is passed through the apex of the loop suture 58 of the fastener 50 . the suture 64 is preferably well marked so it can be used to identify the loop suture 58 through which it passes . the fastener 50 with its associated sutures 60 , 62 , 64 are vertically oriented and urged through the top of the clavicle 14 through the hole 24 , using a 3 . 2 - mm smooth cylindrical plunger 70 . the fastener 50 is visualized in the space between clavicle 14 and coracoid 12 , and it is pushed further to enter the coracoid hole 26 until the fastener “ pops ” out from the underside of the coracoid 12 as seen in fig4 . then , by pulling the loop stitch 58 upward via the suture 64 , the fastener 50 assumes the horizontal position in fig4 to lock onto the underside of the coracoid 12 . a pair of tails of one of the remaining sutures , e . g ., suture 62 , are pulled out of the interval between the coracoid 12 and the clavicle 14 . this leaves the tails of one suture , e . g ., suture 60 that is looped to the fastener body 52 , available to exit from the top of the hole 24 in the clavicle 14 as shown in fig3 . with firm downward pressure on the clavicle 14 to maintain maximum reduction , the loop stitch 58 is pulled up through the hole 24 . with a very firm upward pull on the loop stitch 58 , the upper tip of the loop stitch will then protrude from the top of the clavicular hole 24 . in fig4 , a second button fastener body 152 which may be similar or identical in form to the fastener body 52 in fig2 , is held with a suture holder 70 and slid horizontally through the protruding loop of the stitch 58 until the body 152 is centered under the loop . it is preferred that the fastener body 152 be held with its long edge facing the clavicle 14 , rather than lie flat against the bone . the suture tails 60 exiting the hole 24 at the top of the clavicle , are passed through a pair of openings formed near the opposite ends of the body 152 . if the body 152 is formed with inner and outer pairs of openings like the fastener body 52 , it is preferred to pass the suture tails 60 through the outer pair of openings as shown in fig4 . the button fastener body 152 is turned with the suture holder 70 so it lies flat on the clavicle 14 , so that the suture tails 60 exit upward from the openings in the body 152 as shown in fig5 . suture 64 is withdrawn , and the suture tails 60 are tied across the top of the loop stitch 58 as shown in fig6 . this locks the stitch 58 in place and completes the reconstruction of the conoid portion of the coracoclavicular ligament . the suture tails 62 that were brought out of the coracoclavicular space are retrieved . one of the tails 62 is passed through the 2 . 5 mm drill hole 28 from beneath the clavicle 14 , and the ends of the suture tails are tied at or near the top of the hole 28 . this recreates the trapezoid portion of the coracoclavicular ligament . a fastener device 200 according to the invention is shown in fig7 . the device 200 includes two fastener bodies 252 a , 252 b each of which may be similar or identical in form to the fastener body 52 in fig2 . the fastener bodies 252 a , 252 b are linked by one endless or continuous loop 258 which passes through pairs of openings 256 a , 256 b formed in each of the bodies . like the fastener body 52 in the first embodiment , at least the body 252 b at the top of fig7 also has an outer pair of openings 254 a , 254 b formed near the opposite ends of the body . using the fastener device 200 of fig7 , the surgical procedure described above can be modified by threading two sutures 210 , 212 through the outer openings 254 a , 254 b at opposite ends of the fastener body 252 b at the top of fig7 . as depicted in fig8 and 9 the two fastener bodies 252 a , 252 b are oriented vertically in line with one another , and body 252 a at the bottom of the loop 258 is fully inserted into the top of the hole 24 in the clavicle 14 . fastener body 252 b is then inserted into the top of the hole 24 and urged downward with a plunger or other suitable tool so that the leading end of the body 252 b advances the body 252 a downward through the hole 24 to enter the top of the opening 26 at the top of the coracoid 12 . the body 252 a is then advanced further through the opening 26 until it fully exits the opening at the underside of the coracoid 12 . then , by pulling the sutures 210 , 212 on the fastener body 252 b upward , the fastener body 252 a assumes a horizontal position in fig1 to lock onto the underside of the coracoid 12 . when the joint is fully reduced as depicted in fig1 the sutures 210 , 212 are pulled upward until the fastener body 252 b exits the clavicular hole 24 as shown in the figure . then by pulling upward on the suture 212 as represented in fig1 , the fastener body 252 b is swivelled horizontally to lie flat on the surface of the clavicle 14 and thereby lock the joint reduction in place . the fastener device 200 of fig7 has an advantage over the fastener 50 of fig2 , by eliminating those steps in fig4 , 5 and 6 wherein a second , free fastener body 152 is needed to be inserted through the top of the loop 58 , and the suture 60 is tied so as to lock the fastener body 152 in place on the surface of the clavicle 14 . fasteners as disclosed herein have been used successfully in cases of chronic type 3 or 4 ac separations . the fasteners are set in an anatomically correct fashion to reproduce the course of the conoid portion of the coracoclavicular ligament . the strength and stiffness of the fasteners have been proven to exceed the native ligament complex by approximately 40 %. deforming forces due to the weight of the arm are distributed along the surfaces of the fasteners rather than the suture material itself which passes through the openings in the fasteners , thereby minimizing the chance of a soft tissue reaction to the suture material . the sutures 62 , which may be threaded through openings in the fastener bodies , can be used to recreate the course of the trapezoid component of the coracoclavicular ligament and add stability in the anteroposterior plane . in addition , the required drill holes are relatively small ( e . g ., approx . 4 mm or less ), allowing the implant to be used either as a stand - alone device or in conjunction with other biologic implants to improve long - term stability . forming the suture material in a continuous loop eliminates problems of knot slippage associated with other types of suture fixation . the procedure is straightforward and requires only a small incision with minimal soft tissue dissection . the inventive fasteners 50 , 200 allow a knotless fixation to be obtained for repair and / or reconstruction of the shoulder coracoclavicular ligament , with reliable and predictable results . the fasteners are inserted through holes bored in the clavicle and the coracoid to reproduce the normal course of the conoid portion of the coracoclavicular ligament . the fasteners may be used alone or in conjunction with a variety of biologic materials depending on whether surgery is being performed in an acute or a chronic setting . while the foregoing represents preferred embodiments of the invention , it will be understood by those skilled in the art that various modifications and changes may be made without departing from the spirit and scope of the invention , and that the invention includes all such modifications and changes as come within the bounds of the following claims .
a surgical fastener system for acromioclavicular joint dislocations , includes a first fastener having an elongate body , and an inner pair of openings centered on the long axis of the body . a closed loop stitch passes through the openings , and the length of the stitch corresponds to the depth of a passage defined between the top of a first hole bored through a patient &# 39 ; s clavicle , and the bottom of a second hole bored through the coracoid in axial alignment with the first hole . a second fastener has an elongate body arranged to slide under a portion of the loop stitch that protrudes from the top of the hole in the clavicle , after the first fastener is set beneath the coracoid and the stitch is pulled upward through the passage . in an alternate embodiment , the second fastener also has an inner pair of openings for passing and engaging the loop stitch .