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Editorial Commentary: Arthroscopically Assisted Acromioclavicular Joint Reconstruction—Not Seeing Does Not Mean Do Not Worry
Editorial Commentary: Arthroscopically Assisted Acromioclavicular Joint ReconstructiondNot Seeing Does Not Mean Do Not Worry Andreas B. Imhoff, M.D., and Felix Dyrna, M.D.
Abstract: To minimize risks during arthroscopic-assisted reduction and internal fixation of acromioclavicular dislocation, drilling should only be performed with an anatomically reduced clavicle. This re-creates the important distances to the neurovascular structures because a posteriorly displaced clavicle reduces the distance to the suprascapular nerve. In addition, visualization is of high importance for the arthroscopic coracoid preparation, as are mini-open incisions, to create an accurate and well-placed tunnel for drilling. Last, because the highest potential risk of neurovascular injuries occurs with the drilling itself instead of the final construct, all possible assistance and supports guiding the surgeon should be used to avoid any pitfalls. Hence, radiography and arthroscopy are helpful tools to create and check precise tunnel placement. Still, there are risks, and surgeons must be aware of and mitigate against neurovascular complications.
See related article on page 75
T
he article “Anatomical Evaluation of the Proximity of Neurovascular Structures During Arthroscopically Assisted Acromioclavicular Joint Reconstruction: A Cadaveric Pilot Study” by Banaszek et al.1 investigates the clearance to important neurovascular structures when performing a minimally invasive acromioclavicular (AC) joint reconstruction by subsequent anatomic dissection. The subject of surgical intervention for high-grade AC joint injuries has become a topic of great interest, showing a variety of possible procedures without a recommended standard.2 The study by Banaszek et al. focused on the safety of a single procedure performed under perfect visualization (no bleeding) in a limited number of specimens (n ¼ 6, with 2 of them being paired), using a synthetic graft substitute and a coracoclavicular suspension device on an uninjured AC joint to measure the distance to the suprascapular nerve and artery. Those limitations should be considered when one reviews the results critically. The measurements were performed on the final construct, leaving out potential risk factors such as
Technical University Munich Ó 2016 by the Arthroscopy Association of North America 0749-8063/16972/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.10.009
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guiding pins, drills, and suture passers. In addition, the only included neurovascular structures were the suprascapular nerve and artery. Further structures such as the axillary nerve, musculocutaneous nerve, or plexus brachialis were not considered. Arthroscopic-assisted techniques using cortical button devices have become more popular as they have shown comparable biomechanical data on the one side and reproducible patient satisfaction and favorable cosmetic results on the other side compared with open procedures.2-4 However, possible complications should not be underestimated. Recent reviews of complication rates support the importance of caution and the existing learning curve when performing these reconstructions.5,6 Neurovascular complications are rare and only a few case reports have been published, but the results are devastating and such complications should be avoided by paying meticulous attention when performing the procedure.7,8 Individual anatomy can differ significantly between patients as shown by the different anatomic descriptions of the suprascapular nerve and its relation to surrounding structures.9 However, Banaszek et al.1 showed that an arthroscopic-assisted reconstruction with a coracoclavicular suspension device and a looped graft around the coracoid base can be performed safely and reproducibly. There are further aspects that are important and should be considered, in our opinion, when performing
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 1 (January), 2017: pp 82-83
EDITORIAL COMMENTARY
this procedure. First, as pointed out by the authors, drilling should only be performed with an anatomically reduced clavicle. This re-creates the important distances to the neurovascular structures because a posteriorly displaced clavicle reduces the distance to the suprascapular nerve. Second, visualization is of high importance for the arthroscopic coracoid preparation, as well as mini-open incisions, to create an accurate and wellplaced tunnel for drilling. Last, because we think that the highest potential risk of neurovascular injuries occurs with the drilling itself instead of the final construct, all possible assistance and supports guiding the surgeon should be used to avoid any pitfalls. Hence, radiography and arthroscopy are helpful tools to create and check precise tunnel placement.
4.
5.
6.
7.
References 1. Banaszek D, Pickell M, Wilson E, et al. Anatomical evaluation of the proximity of neurovascular structures during arthroscopically assisted acromioclavicular joint reconstruction: A cadaveric pilot study. Arthroscopy 2017;33:75-81. 2. Beitzel K, Cote MP, Apostolakos J, et al. Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy 2013;29:387-397. 3. Venjakob AJ, Salzmann GM, Gabel F, et al. Arthroscopically assisted 2-bundle anatomic reduction of acute
8.
9.
83
acromioclavicular joint separations: 58-Month findings. Am J Sports Med 2013;41:615-621. Beitzel K, Obopilwe E, Chowaniec DM, et al. Biomechanical comparison of arthroscopic repairs for acromioclavicular joint instability: Suture button systems without biological augmentation. Am J Sports Med 2011;39: 2218-2225. Woodmass JM, Esposito JG, Ono Y, et al. Complications following arthroscopic fixation of acromioclavicular separations: A systematic review of the literature. Open Access J Sports Med 2015;6:97-107. Martetschläger F, Horan MP, Warth RJ, Millett PJ. Complications after anatomic fixation and reconstruction of the coracoclavicular ligaments. Am J Sports Med 2013;41: 2896-2903. Theodorides AA, Watkins CEL, Venkateswaran B. Brachial plexus injury following the use of LARS suture passer during an open Weaver-Dunn procedure. J Shoulder Elbow Surg 2013;22:e1-e5. Tragord BS, Bui-Mansfield LT, Croy T, Shaffer SW. Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: A resident’s case problem. J Orthop Sports Phys Ther 2015;45: 299-305. Ebraheim NA, Whitehead JL, Alla SR, et al. The suprascapular nerve and its articular branch to the acromioclavicular joint: An anatomic study. J Shoulder Elbow Surg 2011;20:e13-e17.
Abstract: To minimize risks during arthroscopic-assisted reduction and internal fixation of acromioclavicular dislocation, drilling should only be performed with an anatomically reduced clavicle. This re-creates the important distances to the neurovascular structures because a posteriorly displaced clavicle reduces the distance to the suprascapular nerve. In addition, visualization is of high importance for the arthroscopic coracoid preparation, as are mini-open incisions, to create an accurate and well-placed tunnel for drilling. Last, because the highest potential risk of neurovascular injuries occurs with the drilling itself instead of the final construct, all possible assistance and supports guiding the surgeon should be used to avoid any pitfalls. Hence, radiography and arthroscopy are helpful tools to create and check precise tunnel placement. Still, there are risks, and surgeons must be aware of and mitigate against neurovascular complications.
See related article on page 75
T
he article “Anatomical Evaluation of the Proximity of Neurovascular Structures During Arthroscopically Assisted Acromioclavicular Joint Reconstruction: A Cadaveric Pilot Study” by Banaszek et al.1 investigates the clearance to important neurovascular structures when performing a minimally invasive acromioclavicular (AC) joint reconstruction by subsequent anatomic dissection. The subject of surgical intervention for high-grade AC joint injuries has become a topic of great interest, showing a variety of possible procedures without a recommended standard.2 The study by Banaszek et al. focused on the safety of a single procedure performed under perfect visualization (no bleeding) in a limited number of specimens (n ¼ 6, with 2 of them being paired), using a synthetic graft substitute and a coracoclavicular suspension device on an uninjured AC joint to measure the distance to the suprascapular nerve and artery. Those limitations should be considered when one reviews the results critically. The measurements were performed on the final construct, leaving out potential risk factors such as
Technical University Munich Ó 2016 by the Arthroscopy Association of North America 0749-8063/16972/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.10.009
82
guiding pins, drills, and suture passers. In addition, the only included neurovascular structures were the suprascapular nerve and artery. Further structures such as the axillary nerve, musculocutaneous nerve, or plexus brachialis were not considered. Arthroscopic-assisted techniques using cortical button devices have become more popular as they have shown comparable biomechanical data on the one side and reproducible patient satisfaction and favorable cosmetic results on the other side compared with open procedures.2-4 However, possible complications should not be underestimated. Recent reviews of complication rates support the importance of caution and the existing learning curve when performing these reconstructions.5,6 Neurovascular complications are rare and only a few case reports have been published, but the results are devastating and such complications should be avoided by paying meticulous attention when performing the procedure.7,8 Individual anatomy can differ significantly between patients as shown by the different anatomic descriptions of the suprascapular nerve and its relation to surrounding structures.9 However, Banaszek et al.1 showed that an arthroscopic-assisted reconstruction with a coracoclavicular suspension device and a looped graft around the coracoid base can be performed safely and reproducibly. There are further aspects that are important and should be considered, in our opinion, when performing
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 1 (January), 2017: pp 82-83
EDITORIAL COMMENTARY
this procedure. First, as pointed out by the authors, drilling should only be performed with an anatomically reduced clavicle. This re-creates the important distances to the neurovascular structures because a posteriorly displaced clavicle reduces the distance to the suprascapular nerve. Second, visualization is of high importance for the arthroscopic coracoid preparation, as well as mini-open incisions, to create an accurate and wellplaced tunnel for drilling. Last, because we think that the highest potential risk of neurovascular injuries occurs with the drilling itself instead of the final construct, all possible assistance and supports guiding the surgeon should be used to avoid any pitfalls. Hence, radiography and arthroscopy are helpful tools to create and check precise tunnel placement.
4.
5.
6.
7.
References 1. Banaszek D, Pickell M, Wilson E, et al. Anatomical evaluation of the proximity of neurovascular structures during arthroscopically assisted acromioclavicular joint reconstruction: A cadaveric pilot study. Arthroscopy 2017;33:75-81. 2. Beitzel K, Cote MP, Apostolakos J, et al. Current concepts in the treatment of acromioclavicular joint dislocations. Arthroscopy 2013;29:387-397. 3. Venjakob AJ, Salzmann GM, Gabel F, et al. Arthroscopically assisted 2-bundle anatomic reduction of acute
8.
9.
83
acromioclavicular joint separations: 58-Month findings. Am J Sports Med 2013;41:615-621. Beitzel K, Obopilwe E, Chowaniec DM, et al. Biomechanical comparison of arthroscopic repairs for acromioclavicular joint instability: Suture button systems without biological augmentation. Am J Sports Med 2011;39: 2218-2225. Woodmass JM, Esposito JG, Ono Y, et al. Complications following arthroscopic fixation of acromioclavicular separations: A systematic review of the literature. Open Access J Sports Med 2015;6:97-107. Martetschläger F, Horan MP, Warth RJ, Millett PJ. Complications after anatomic fixation and reconstruction of the coracoclavicular ligaments. Am J Sports Med 2013;41: 2896-2903. Theodorides AA, Watkins CEL, Venkateswaran B. Brachial plexus injury following the use of LARS suture passer during an open Weaver-Dunn procedure. J Shoulder Elbow Surg 2013;22:e1-e5. Tragord BS, Bui-Mansfield LT, Croy T, Shaffer SW. Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: A resident’s case problem. J Orthop Sports Phys Ther 2015;45: 299-305. Ebraheim NA, Whitehead JL, Alla SR, et al. The suprascapular nerve and its articular branch to the acromioclavicular joint: An anatomic study. J Shoulder Elbow Surg 2011;20:e13-e17.