Arthroscopic Distal Clavical Resection Using “Vis-à-Vis” Portal Kevin Kruse II, M.D., Matthew Yalizis, M.B.B.S., F.R.A.C.S., and Lionel Neyton, M.D.
Abstract: Arthroscopic distal clavicle resection has become an increasingly popular procedure in orthopaedics, and various techniques have been published. Many of the arthroscopic distal clavicle resection techniques that have been reported require visualization from the lateral portal with an anterior working portal to perform the resection. While these techniques have reported high success rates, there is often difficulty in viewing the entire acromioclavicular joint from the 2 standard arthroscopic portals (lateral and anterior). This is due to the medial edge of the acromion blocking the ability to visualize the most superior and posterior portions of the distal clavicle. We propose a technique for arthroscopic distal clavicle resection using an accessory anterior portal.
A
rthroscopic resection of the acromioclavicular joint (ACJ) has become a widely used procedure in shoulder arthroscopy. The proposed benefits of arthroscopic versus open distal clavicle resection are maintenance of anterior/superior ACJ ligaments/ deltotrapezial fascia, improved cosmesis, and less pain postoperatively. Gartsman et al. first showed in a cadaveric study that the distal clavicle could be resected arthroscopically in 1991.1 Since that first report, various techniques have been published.2-4 Commonly, the midlateral portal is used in order to visualize the ACJ during resection. Often it can be difficult to visualize the superior portion of the clavicle with this portal. We propose a technique that uses an accessory anterior portal for visualization while the distal clavicle resection is carried out via the standard anterior portal. This technique allows for complete visualization of the superior portion of the clavicle during the resection.
From the Texas Orthopaedic Associates (K.K.), Dallas, Texas, U.S.A.; Sydney Shoulder and Elbow Specialists (M.Y.), Sydney, Australia; and Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy (L.N.), Lyon, France. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 25, 2015; accepted February 8, 2016. Address correspondence to Lionel Neyton, M.D., Générale de Santé, Hôpital Privé Jean Mermoz; Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008 Lyon, France. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151095/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.023
Surgical Technique Patient Positioning The patient is positioned in the beach-chair position using 3 kg of suspended traction on a regular electric surgical table with the shoulder in approximately 30 of forward flexion. In order to perform the procedure, it is vital to ensure adequate clearance of the posterior shoulder during positioning. General anesthesia is routinely used with an interscalene block. For shoulder arthroscopy, we do not use any commercially available limb positioners. The acromion, clavicle, ACJ, coracoacromial ligament, coracoid, and all 4 portals (posterior, lateral, anterolateral, and anterior) are marked with marking pen (Fig 1). Diagnostic Arthroscopy To begin the procedure, 2 cm inferior and 2 cm medial to the posterolateral border of the acromion a standard posterior viewing portal is created. A diagnostic arthroscopy is performed after the arthroscope is atraumatically introduced into the glenohumeral joint, and a standard anterior portal is created with spinal needle localization just lateral to the tip of the coracoid. The arthroscope is then moved to the subacromial space, and a midlateral portal is made with a spinal needle. A subacromial bursectomy is performed, and the undersurface of the ACJ is debrided of soft tissue. The coracoacromial ligament is resected off the anterior aspect of the acromion. The ACJ is viewed from both the posterior and lateral portals (Figs 2 and 3).
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Fig 1. Standard portals used for the arthroscopic acromioclavicular joint resection via the vis-à-vis portal (posterior, lateral, anterolateral, and anterior).
Distal Clavicle Resection A portal that is 2 cm anterior to the anterolateral aspect of the acromion is made using a spinal needle to localize. We call this portal the “vis-a-vis” portal, because it allows for the face-to-face visualization of the ACJ (Video 1). The arthroscope is then inserted into the vis-à-vis portal, and the anterior portal is used as the working portal. The ACJ is debrided of all soft tissue with the combination of an electrocautery
Fig 2. View of the acromioclavicular joint from the posterior portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). It is evident that the superior and posterior portions of the distal clavicle are blocked by the medial aspect of the acromion. When performing a distal clavicle resection from this view, it is often necessary to resect the medial aspect of the acromion in order to visualize the entire end of the distal clavicle.
Fig 3. View of the acromioclavicular joint from the lateral portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). It is evident that the superior and posterior portions of the distal clavicle are blocked by the medial aspect of the acromion. When performing a distal clavicle resection from this view, it is often necessary to resect the medial aspect of the acromion in order to visualize the entire end of the distal clavicle.
and shaver (Mitek Vapr, Raynham, MA, and Stryker shaver/burr Kalamazoo, MI). Working from inferior to superior, an arthroscopic burr is then used to resect approximately 1-2 mm of the most medial aspect of the acromion and 5-7 mm of the most distal aspect of the clavicle (Figs 4-8). Care is taken to not disrupt the superior ligaments of the ACJ. The athroscope is then inserted directly into the ACJ via the anterior portal to ensure a complete resection of the distal clavicle.
Fig 4. View of the acromioclavicular joint from the vis-à-vis portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). When using this portal the entire superior as well as posterior aspect of the distal clavicle can be visualized, without having to resect any of the medial acromion. This is due to the “on face” angle of the portal.
CLAVICAL RESECTION USING “VIS-À-VIS” PORTAL
Fig 5. The first step of the resection is to remove the anterior ligament of the acromioclavicular joint as well as all the soft tissue around the joint with an electrocautery (acromion marked with arrow and clavicle with asterisk).
Postoperative Rehabilitation The patient is allowed to range the shoulder as tolerated immediately after surgery and resume daily activities when he or she is comfortable. The typical period of time it takes the patient to become completely pain free and resume all activities is 3 months.
Discussion The first descriptions of the arthroscopic distal clavicle dissection were described using the lateral portal for viewing and the anterior portal as the working portal for the resection.1,2 This technique requires the resection of the medial aspect of the acromion in order to visualize the superior aspect of the clavicle. In cases of a very hypertrophic distal clavicle seen with severe osteoarthritis, it can still be difficult to visualize the superior and posterior aspects of the distal clavicle from the lateral portal. In addition, relative to the acromion, the direction of the ACJ is anteromedial to posterolateral. This angle of the joint
Fig 6. The next step is to burr the medial side of the acromion moving inferior to superior (acromion marked with arrow and clavicle with asterisk).
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Fig 7. The last step of the procedure is burring down the lateral end of the distal clavicle moving inferior to superior (acromion marked with arrow and clavicle with asterisk).
also can contribute to the difficulty in performing the procedure. Several techniques have been described to combat this problem. A 70 arthroscope has been used from the lateral portal in order to better visualize the superior and posterior aspects of the clavicle. The direct approach described by Levine et al. requires that an arthroscope be inserted into the posterior aspect of the ACJ and that the arthroscope be inserted in a portal directly anterior the ACJ.4 This technique often requires the initial use of a 2.7-mm arthroscope if the ACJ is narrowed significantly. It has also been associated with disruption of the superior ligaments and postoperative instability of the ACJ. Elhassan et al. described a “windshield wiper” technique that uses a direct portal into the ACJ localized with a spinal needle and visualized from the lateral portal.3
Fig 8. Final acromioclavicular joint (ACJ) resection as viewed from the “vis-à-vis” portal. There is an adequate resection of the ACJ with no residual bone left in the posterior or superior portion of the clavicle. The superior ligaments of the ACJ remain intact (acromion marked with arrow and clavicle with asterisk).
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Table 1. Surgical Pearls and Pitfalls Pearls
Pitfalls
The location of the vis-à-vis portal is approximately 2 cm anterior to the anterolateral edge of the acromion. The vis-à-vis portal is often already made prior to undergoing the distal clavicle resection, as this is the same portal that we use for our arthroscopic biceps tenodesis. The anterior portal that is used as the working portal for the resection is typically made through the rotator interval while in the glenohumeral joint. Begin the resection of the distal clavicle by using electrocautery to remove all soft tissue around the joint. When performing the resection of the distal clavicle, be sure to resect the most superior and posterior portions, as this is the area that is most often inadequately resected. When performing the resection of the distal clavicle, be careful to preserve the superior and posterior ACJ ligaments.
Be sure to not make the portal too distal as the cephalic vein could be damaged. If performing a biceps tenodesis with acromioclavicular joint (ACJ) resection, perform the tenodesis first. The bleeding from the ACJ resection can obscure visualization during biceps tenodesis. Make sure to make this portal slightly lateral within the rotator interval as it will improve the angle of the burr during resection Failure to remove all soft tissue will impede visualization and increase the difficulty of the procedure. Failure to resect the posterior/superior portion of the clavicle is a common mistake and can cause continue ACJ pain postoperatively. Disruption of the posterior and superior ACJ ligaments can cause postoperative instability and pain.
Table 2. Advantages and Risks/Limitations Advantages
Risks/Limitations
The vis-à-vis portal allows for a more on face view of the acromioclavicular joint (ACJ) during arthroscopic resection. The view from this portal does not require resection of the medial acromion, which shortens the time of the procedure. The vis-à-vis allows for a more complete view of the posterior/ superior distal clavicle, ensuring a more complete resection of the ACJ. The vis-à-vis portal is the same portal that is used for arthroscopic biceps tendodesis,
The addition of the anterolateral portal could potentially damage the cephalic vein and make it too distal.
The main advantage of our technique is that it allows for the direct visualization of the ACJ without the resection of the medial acromion or the use of a different angled or sized arthroscope. Due to the direct face-on view of this portal, we are able to completely visualize the superior and posterior aspect of the clavicle throughout the procedure. When looking from the lateral portal, often there is an optical illusion created by the angle of the arthroscope that makes the distal clavicle resection appear flat when in fact there is a significant amount of posterior and superior bone that has not been resected. Our portal allows for the visualization of the most superior and posterior aspect of the distal clavicle even in the setting of a hypertrophic distal clavicle seen in severe osteoarthritis. Another advantage of this technique, is that it can be used to perform a concomitant biceps tenodesis in the bicipital groove when indicated (Table 1). A risk specific to this technique is that if the anterolateral portal were made too low, the cephalic vein could be damaged; however, we have never had this occur. Another risk to this technique is resection of the
One must be careful not to disrupt the superior ligaments of the ACJ when resectioning the superior portion of the distal clavicle. This can cause instability and pain.
superior ACJ that could potentially cause instability of the ACJ (Table 2). We feel that the vis-a-vis portal for arthroscopic resection of the ACJ allows for an efficient and complete resection of the distal clavicle. It can be a valuable tool to keep in the arthroscopic armamentarium, especially in the setting of significant distal clavicle hypertrophy.
References 1. Gartsman GM, Combs AH, Davis PF, Tullos HS. Arthroscopic acromioclavicular joint resection. An anatomical study. Am J Sports Med 1991;19:2-5. 2. Tolin BS, Snyder SJ. Our technique for the arthroscopic Mumford procedure. Orthop Clin North Am 1993;24: 143-151. 3. Elhassan B, Ozbaydar M, Diller D, Massimini D, Higgins LD, Warner JJP. Open versus arthroscopic acromioclavicular joint resection: A retrospective comparison study. Arthroscopy 2009;25:1224-1232. 4. Levine WN, Soong M, Ahmad CS, Blaine TA, Bigliani LU. Arthroscopic distal clavicle resection: A comparison of bursal and direct approaches. Arthroscopy 2006;22:516-520.
Abstract: Arthroscopic distal clavicle resection has become an increasingly popular procedure in orthopaedics, and various techniques have been published. Many of the arthroscopic distal clavicle resection techniques that have been reported require visualization from the lateral portal with an anterior working portal to perform the resection. While these techniques have reported high success rates, there is often difficulty in viewing the entire acromioclavicular joint from the 2 standard arthroscopic portals (lateral and anterior). This is due to the medial edge of the acromion blocking the ability to visualize the most superior and posterior portions of the distal clavicle. We propose a technique for arthroscopic distal clavicle resection using an accessory anterior portal.
A
rthroscopic resection of the acromioclavicular joint (ACJ) has become a widely used procedure in shoulder arthroscopy. The proposed benefits of arthroscopic versus open distal clavicle resection are maintenance of anterior/superior ACJ ligaments/ deltotrapezial fascia, improved cosmesis, and less pain postoperatively. Gartsman et al. first showed in a cadaveric study that the distal clavicle could be resected arthroscopically in 1991.1 Since that first report, various techniques have been published.2-4 Commonly, the midlateral portal is used in order to visualize the ACJ during resection. Often it can be difficult to visualize the superior portion of the clavicle with this portal. We propose a technique that uses an accessory anterior portal for visualization while the distal clavicle resection is carried out via the standard anterior portal. This technique allows for complete visualization of the superior portion of the clavicle during the resection.
From the Texas Orthopaedic Associates (K.K.), Dallas, Texas, U.S.A.; Sydney Shoulder and Elbow Specialists (M.Y.), Sydney, Australia; and Générale de Santé, Hôpital privé Jean Mermoz; Centre Orthopédique Santy (L.N.), Lyon, France. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 25, 2015; accepted February 8, 2016. Address correspondence to Lionel Neyton, M.D., Générale de Santé, Hôpital Privé Jean Mermoz; Centre Orthopédique Santy, 24 Avenue Paul Santy, 69008 Lyon, France. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/151095/$36.00 http://dx.doi.org/10.1016/j.eats.2016.02.023
Surgical Technique Patient Positioning The patient is positioned in the beach-chair position using 3 kg of suspended traction on a regular electric surgical table with the shoulder in approximately 30 of forward flexion. In order to perform the procedure, it is vital to ensure adequate clearance of the posterior shoulder during positioning. General anesthesia is routinely used with an interscalene block. For shoulder arthroscopy, we do not use any commercially available limb positioners. The acromion, clavicle, ACJ, coracoacromial ligament, coracoid, and all 4 portals (posterior, lateral, anterolateral, and anterior) are marked with marking pen (Fig 1). Diagnostic Arthroscopy To begin the procedure, 2 cm inferior and 2 cm medial to the posterolateral border of the acromion a standard posterior viewing portal is created. A diagnostic arthroscopy is performed after the arthroscope is atraumatically introduced into the glenohumeral joint, and a standard anterior portal is created with spinal needle localization just lateral to the tip of the coracoid. The arthroscope is then moved to the subacromial space, and a midlateral portal is made with a spinal needle. A subacromial bursectomy is performed, and the undersurface of the ACJ is debrided of soft tissue. The coracoacromial ligament is resected off the anterior aspect of the acromion. The ACJ is viewed from both the posterior and lateral portals (Figs 2 and 3).
Arthroscopy Techniques, Vol 5, No 3 (June), 2016: pp e667-e670
e667
e668
K. KRUSE ET AL.
Fig 1. Standard portals used for the arthroscopic acromioclavicular joint resection via the vis-à-vis portal (posterior, lateral, anterolateral, and anterior).
Distal Clavicle Resection A portal that is 2 cm anterior to the anterolateral aspect of the acromion is made using a spinal needle to localize. We call this portal the “vis-a-vis” portal, because it allows for the face-to-face visualization of the ACJ (Video 1). The arthroscope is then inserted into the vis-à-vis portal, and the anterior portal is used as the working portal. The ACJ is debrided of all soft tissue with the combination of an electrocautery
Fig 2. View of the acromioclavicular joint from the posterior portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). It is evident that the superior and posterior portions of the distal clavicle are blocked by the medial aspect of the acromion. When performing a distal clavicle resection from this view, it is often necessary to resect the medial aspect of the acromion in order to visualize the entire end of the distal clavicle.
Fig 3. View of the acromioclavicular joint from the lateral portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). It is evident that the superior and posterior portions of the distal clavicle are blocked by the medial aspect of the acromion. When performing a distal clavicle resection from this view, it is often necessary to resect the medial aspect of the acromion in order to visualize the entire end of the distal clavicle.
and shaver (Mitek Vapr, Raynham, MA, and Stryker shaver/burr Kalamazoo, MI). Working from inferior to superior, an arthroscopic burr is then used to resect approximately 1-2 mm of the most medial aspect of the acromion and 5-7 mm of the most distal aspect of the clavicle (Figs 4-8). Care is taken to not disrupt the superior ligaments of the ACJ. The athroscope is then inserted directly into the ACJ via the anterior portal to ensure a complete resection of the distal clavicle.
Fig 4. View of the acromioclavicular joint from the vis-à-vis portal in a right shoulder in the beach chair position (acromion marked with arrow and clavicle with asterisk). When using this portal the entire superior as well as posterior aspect of the distal clavicle can be visualized, without having to resect any of the medial acromion. This is due to the “on face” angle of the portal.
CLAVICAL RESECTION USING “VIS-À-VIS” PORTAL
Fig 5. The first step of the resection is to remove the anterior ligament of the acromioclavicular joint as well as all the soft tissue around the joint with an electrocautery (acromion marked with arrow and clavicle with asterisk).
Postoperative Rehabilitation The patient is allowed to range the shoulder as tolerated immediately after surgery and resume daily activities when he or she is comfortable. The typical period of time it takes the patient to become completely pain free and resume all activities is 3 months.
Discussion The first descriptions of the arthroscopic distal clavicle dissection were described using the lateral portal for viewing and the anterior portal as the working portal for the resection.1,2 This technique requires the resection of the medial aspect of the acromion in order to visualize the superior aspect of the clavicle. In cases of a very hypertrophic distal clavicle seen with severe osteoarthritis, it can still be difficult to visualize the superior and posterior aspects of the distal clavicle from the lateral portal. In addition, relative to the acromion, the direction of the ACJ is anteromedial to posterolateral. This angle of the joint
Fig 6. The next step is to burr the medial side of the acromion moving inferior to superior (acromion marked with arrow and clavicle with asterisk).
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Fig 7. The last step of the procedure is burring down the lateral end of the distal clavicle moving inferior to superior (acromion marked with arrow and clavicle with asterisk).
also can contribute to the difficulty in performing the procedure. Several techniques have been described to combat this problem. A 70 arthroscope has been used from the lateral portal in order to better visualize the superior and posterior aspects of the clavicle. The direct approach described by Levine et al. requires that an arthroscope be inserted into the posterior aspect of the ACJ and that the arthroscope be inserted in a portal directly anterior the ACJ.4 This technique often requires the initial use of a 2.7-mm arthroscope if the ACJ is narrowed significantly. It has also been associated with disruption of the superior ligaments and postoperative instability of the ACJ. Elhassan et al. described a “windshield wiper” technique that uses a direct portal into the ACJ localized with a spinal needle and visualized from the lateral portal.3
Fig 8. Final acromioclavicular joint (ACJ) resection as viewed from the “vis-à-vis” portal. There is an adequate resection of the ACJ with no residual bone left in the posterior or superior portion of the clavicle. The superior ligaments of the ACJ remain intact (acromion marked with arrow and clavicle with asterisk).
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K. KRUSE ET AL.
Table 1. Surgical Pearls and Pitfalls Pearls
Pitfalls
The location of the vis-à-vis portal is approximately 2 cm anterior to the anterolateral edge of the acromion. The vis-à-vis portal is often already made prior to undergoing the distal clavicle resection, as this is the same portal that we use for our arthroscopic biceps tenodesis. The anterior portal that is used as the working portal for the resection is typically made through the rotator interval while in the glenohumeral joint. Begin the resection of the distal clavicle by using electrocautery to remove all soft tissue around the joint. When performing the resection of the distal clavicle, be sure to resect the most superior and posterior portions, as this is the area that is most often inadequately resected. When performing the resection of the distal clavicle, be careful to preserve the superior and posterior ACJ ligaments.
Be sure to not make the portal too distal as the cephalic vein could be damaged. If performing a biceps tenodesis with acromioclavicular joint (ACJ) resection, perform the tenodesis first. The bleeding from the ACJ resection can obscure visualization during biceps tenodesis. Make sure to make this portal slightly lateral within the rotator interval as it will improve the angle of the burr during resection Failure to remove all soft tissue will impede visualization and increase the difficulty of the procedure. Failure to resect the posterior/superior portion of the clavicle is a common mistake and can cause continue ACJ pain postoperatively. Disruption of the posterior and superior ACJ ligaments can cause postoperative instability and pain.
Table 2. Advantages and Risks/Limitations Advantages
Risks/Limitations
The vis-à-vis portal allows for a more on face view of the acromioclavicular joint (ACJ) during arthroscopic resection. The view from this portal does not require resection of the medial acromion, which shortens the time of the procedure. The vis-à-vis allows for a more complete view of the posterior/ superior distal clavicle, ensuring a more complete resection of the ACJ. The vis-à-vis portal is the same portal that is used for arthroscopic biceps tendodesis,
The addition of the anterolateral portal could potentially damage the cephalic vein and make it too distal.
The main advantage of our technique is that it allows for the direct visualization of the ACJ without the resection of the medial acromion or the use of a different angled or sized arthroscope. Due to the direct face-on view of this portal, we are able to completely visualize the superior and posterior aspect of the clavicle throughout the procedure. When looking from the lateral portal, often there is an optical illusion created by the angle of the arthroscope that makes the distal clavicle resection appear flat when in fact there is a significant amount of posterior and superior bone that has not been resected. Our portal allows for the visualization of the most superior and posterior aspect of the distal clavicle even in the setting of a hypertrophic distal clavicle seen in severe osteoarthritis. Another advantage of this technique, is that it can be used to perform a concomitant biceps tenodesis in the bicipital groove when indicated (Table 1). A risk specific to this technique is that if the anterolateral portal were made too low, the cephalic vein could be damaged; however, we have never had this occur. Another risk to this technique is resection of the
One must be careful not to disrupt the superior ligaments of the ACJ when resectioning the superior portion of the distal clavicle. This can cause instability and pain.
superior ACJ that could potentially cause instability of the ACJ (Table 2). We feel that the vis-a-vis portal for arthroscopic resection of the ACJ allows for an efficient and complete resection of the distal clavicle. It can be a valuable tool to keep in the arthroscopic armamentarium, especially in the setting of significant distal clavicle hypertrophy.
References 1. Gartsman GM, Combs AH, Davis PF, Tullos HS. Arthroscopic acromioclavicular joint resection. An anatomical study. Am J Sports Med 1991;19:2-5. 2. Tolin BS, Snyder SJ. Our technique for the arthroscopic Mumford procedure. Orthop Clin North Am 1993;24: 143-151. 3. Elhassan B, Ozbaydar M, Diller D, Massimini D, Higgins LD, Warner JJP. Open versus arthroscopic acromioclavicular joint resection: A retrospective comparison study. Arthroscopy 2009;25:1224-1232. 4. Levine WN, Soong M, Ahmad CS, Blaine TA, Bigliani LU. Arthroscopic distal clavicle resection: A comparison of bursal and direct approaches. Arthroscopy 2006;22:516-520.
