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Distal Clavicular Augmentation with Acromioclavicular And Technical Note Distal Clavicular Augmentation with Acromioclavicular and Coracoclavicular Ligament Reconstruction in the Setting of Iatrogenic Induced Acromioclavicular Instability Liam A. Peebles, B.A., Travis J. Dekker, M.D., Ramesses A. Akamefula, B.S., Petar Golijanin, B.S., W. Jeffrey Grantham, M.D., and Matthew T. Provencher, M.D., CAPT, MC, USNR. Abstract: Although chronic pain and dysfunction of the acromioclavicular (AC) joint can reliably be treated with distal clavicle excision, disruption of the local stabilizing ligamentous structures may result in iatrogenic instability of the joint. Iatrogenic AC joint instability is a rare condition caused by over resection of the distal clavicle with unintended injury to the stabilizing ligaments in the treatment of AC joint pain. Addressing postresection instability can prove to be difficult because most reconstruction techniques are intended for patients with traumatic AC joint instability with the goal of creating an anatomically stable joint. However, in the setting of iatrogenic instability, the decreased bone stock of the distal clavicle results in instability of the AC joint, especially in the horizontal plane, and may cause these techniques to fail. Thus, operative management must aim to correct both the osseous and ligamentous deficits responsible for the genesis of this instability. In this Technical Note, we describe bony augmentation of the distal clavicle with an iliac crest bone autograft for chronic iatrogenic acromioclavicular joint instability with concomitant reconstruction of the AC and coracoclavicular ligaments. he acromioclavicular (AC) joint is a common Three main ligaments stabilize the AC joint. The AC Tlocation of pathology including instability, fracture, ligament comprises superior, inferior, anterior, and osteolysis, and osteoarthritis. Persistent pain and posterior components that contribute to overall stabil- dysfunction at the AC joint are often treated with distal ity. Specifically, the superior and posterior ligaments clavicle excision. This has been shown to be a reliable are the strongest, and these primarily serves to provide way to improve pain symptoms with low morbidity.1-5 stability in the horizontal plane. Nakazawa et al.6 However, disruption of the surrounding ligaments, demonstrated in a 2016 study that the AC ligament mainly the AC and coracoclavicular (CC) ligaments could be further divided into a bundle at the super- can lead to instability. oposterior (SP) part and a bundle at the anteroinferior part of the joint. They found the SP bundle to be thicker and wider relative to the anteroinferior bundle, with From the Steadman Philippon Research Institute (L.A.P., R.A.A., M.T.P.), the SP bundle spanning obliquely at an average Vail, Colorado, U.S.A.; The Steadman Clinic (T.J.D., W.J.G., M.T.P.), Vail, Æ Colorado, U.S.A; and Geisel School of Medicine at Dartmouth (P.G.), Han- 30 6 in relation to the AC joint surface, from the over, New Hampshire, U.S.A. anterior part of the acromion to the posterior part of The authors report that they have no conflicts of interest in the authorship the distal clavicle.6 The CC ligament complex consists of and publication of this article. Full ICMJE author disclosure forms are the conoid and trapezoid ligaments, which insert on the available for this article online, as supplementary material. posteromedial and anterolateral region of the under- Received June 6, 2019; accepted August 16, 2019. 7 Address correspondence to Matthew T. Provencher, Steadman Philippon surface of the distal clavicle, respectively. This liga- Research Institute, The Steadman Clinic, 181 West Meadow Drive, Suite 400, mentous complex mainly serves to provide vertical Vail, CO 81657, U.S.A. E-mail: [email protected] stability within the AC joint. Finally, the coracoacromial Ó 2019 Published by Elsevier on behalf of the Arthroscopy Association of ligament is a robust triangular band, connecting the North America. This is an open access article under the CC BY-NC-ND license coracoid process to the acromion and also contributing (http://creativecommons.org/licenses/by-nc-nd/4.0/). 6,8,9 2212-6287/19728 to vertical stability of the AC joint. A quantitative 10 https://doi.org/10.1016/j.eats.2019.08.013 anatomical study by Chahla et al. demonstrated that Arthroscopy Techniques, Vol 8, No 12 (December), 2019: pp e1583-e1589 e1583 e1584 L. A. PEEBLES ET AL. the coracoacromial ligament has a single consistent distal clavicle with an iliac crest bone autograft for acromial attachment and then bifurcates into 2 distinct chronic iatrogenic acromioclavicular joint instability bundles, anterior and posterior, that separately insert (Video 1). This investigation was performed at the on the lateral aspect of the coracoid. On average, the Steadman Philippon Research Institute. anterior and posterior bundles attach 10.6 mm and 24.8 mm medial and proximal to the apex of the Surgical Technique coracoid process, respectively.10 For the reconstruction of the AC and CC ligaments, a recent systematic review Preoperative Planning and Assessment 11 by Moatshe et al. reported hook plates and K-wires Careful attention should be paid to a patient seen in having the highest rate of complications (26.3%) versus the clinical setting with chief complaint of AC joint suspensory devices and synthetic ligament techniques, instability after a distal clavicle resection (Mumford which had the lowest complication rates (6.2% and procedure). A thorough evaluation of the patient’s 4.4%, respectively). Moreover, reconstructions per- shoulder to include areas of tenderness, range of mo- formed with a modified Weaver-Dunn technique were tion, neurovascular status, and strength tests should be found to have the highest rates of unplanned reopera- performed. More specifically, patient’s reported symp- 11 tion at 5.4%. toms of instability along with any anteroposterior (AP) Excessive resection of the lateral end of the distal and/or superior-to-inferior translation of the distal clavicle has been found to disrupt native AC articula- clavicle with manipulation on physical and exam tion and creates the potential for abnormal motion and should be noted. Standard shoulder radiographs, AP/ instability of the AC joint, ultimately resulting in Grashey/scapular Y/axillary lateral views, along with 12-14 persistent pain of the operative shoulder. A study clavicle AP and Zanca views can help with the diagnosis 12 by Blazar et al. demonstrated a significant increase and appreciation of the position of clavicle with respect in anteroposterior translation of the AC joint following to the acromion (Fig 1 A and B). An AP view of bilateral either open or arthroscopic distal clavicle excision clavicles allows comparisons of the two sides to deter- compared with the contralateral, nonoperative shoul- mine the amount of prior resection and superior der. Moreover, there was a strong correlation between migration. Computed tomography (CT) scans can also the total anteroposterior translation and postoperative be helpful to understand the amount of prior resection 12 visual analog pain scores. An anatomic study of the to plan the appropriate size and shape of iliac crest 14 AC joint by Renfree et al. reported on the amount of autograft to be harvested (Fig 1C). distal clavicle that may be arthroscopically resected Patients with persistent symptoms at the AC joint without compromising the ligamentous restraints of the following distal clavicle resection and appropriate con- joint, determining that as little as 2.6 mm of the distal servative measures may be considered for this tech- clavicle in males and 2.3 mm in females may violate the nique of AC and CC reconstruction with superior AC ligament and thus contribute to post- semitendinosus tendon allograft and distal clavicle 15,16 operative instability. Further studies have demon- augmentation with iliac crest autograft. strated that AC joint stability decreases with increasing excisions and thus the current guidance recommends Patient Positioning and Anesthesia 5 mm of bony resection to adequately maintain Regional blocks at our local institution include an maximal stability and reliably good patient outcomes. interscalene indwelling nerve catheter placed as well as Although not a frequent entity, instability of the distal a single-shot Pecs2 block. General anesthesia is pro- clavicle may occur in the setting of postresection. The vided for all patients and all are transitioned to the result of this is the patient presents with horizontal beach chair position, paying careful attention to pad all instability, pain, scapular disfunction, dyskinesia of the bony prominences and neurovascular structures at risk scapula, and chronic pain. This may be further of compression. The patient is placed in approximately complicated by “over-resection” of the distal clavicle. 45 of inclination to allow access to the ipsilateral iliac Treatment of postresection instability can be difficult crest; this may be modified based on the habitus of the with most reconstruction techniques intended for pa- individual patient because larger patients may need to tients with traumatic AC joint instability with the goal be first placed completely supine for the iliac crest of creating an anatomically stable joint. In the setting of harvest for adequate exposure and then repositioned to iatrogenic instability, the decreased bone stock of the the beach chair position for the remainder of the pro- distal clavicle may cause these techniques to fail. The cedure. The
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