Surgical Techniques in Sports Medicine
1st Edition

7
Arthroscopic Subacromial Decompression, Distal Clavicle Resection, and Coracoplasty
Steven B. Singleton MD
James M. Bothwell MD
John E. Conway MD
Arthroscopic Subacromial Decompression
History of the Technique
Subacromial decompression as a treatment for impingement syndrome was first described by Neer in 1972.1,2,3,4 The goal of the procedure was to reduce extrinsic compression on the rotator cuff musculature by increasing the volume of the subacromial space. The original description entailed the open exposure of the anterior acromion and subacromial space to resect the coracoacromial ligament, the anterior lip of the acromion, and the subacromial bursa. Over the past 30 years, multiple investigators have noted satisfactory results with this procedure when performed in the proper setting.3,4,5
The advent of shoulder arthroscopy has furthered the evolution of the subacromial decompression. Neer’s description of the open technique has been the gold standard by which arthroscopic techniques have been measured. Many, including Ellman,6 have proposed various techniques for arthroscopic subacromial decompression that differ slightly in their means, but have the very same end point: that is, to increase the volume of the subacromial space. The main advantage of arthroscopic subacromial decompression is sparing of the deltoid muscle origin and, therefore, an expedited recovery. In general, most authors report good to excellent results in the majority (73% to 88%) of their patients.3,4,5,6,7,8,9,10
Indications and Contraindications
The main indications for arthroscopic subacromial decompression include the following: (a) Symptomatic subacromial impingement refractory to a comprehensive rehabilitation program usually lasting 6 to 12 months, where the impingement is either classical extrinsic or chronic secondary with adaptive changes; (b) when rotator cuff repair is performed.
The contraindications for arthroscopic subacromial decompression include the following: (a) Shoulder stiffness, (b) massive or irreparable rotator cuff tear, (c) inaccurate diagnosis: be aware of instability.
Preoperatively, consider the amount of anterior acromion to be resected. The supraspinatus outlet view enables one to determine the acromial morphology and may prove helpful in determining the appropriate volume of bone removal for adequate acromioplasty. Similarly, postoperative radiographic evaluation utilizing the supraspinatus outlet view to evaluate the decompression may be useful, especially for those learning the arthroscopic technique.
Surgical Technique
Anesthesia and patient positioning are the same for the three procedures described in this chapter. General anesthetic or interscalene regional block is used. Hypotensive anesthesia maintaining systolic blood pressure at or below 95 mm Hg will assist visualization by minimizing intraoperative bleeding. Our preference in performing arthroscopic shoulder procedures is the lateral decubitus position. The arm is suspended with 10 to 12 lb of arm traction in 30 degrees of abduction, and in 20 degrees to 30 degrees of forward flexion. The spine of the scapula, lateral acromion, and anterior and posterior borders of the clavicle are marked on the skin. When indicated, the location and angle of obliquity of the acromioclavicular (AC) joint is also noted on the skin (Fig. 7-1).
Procedure
A 30-degree arthroscope is placed in the standard posterior portal. This portal is located approximately 2 cm inferior
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and 1.5 cm medial to the posterior angle of the acromion in the “soft spot.” An anterior portal is established approximately 1 cm anterior to the anterior edge of the acromion. If this procedure is done in conjunction with an arthroscopic distal clavicle excision, an AC joint portal, as described below, can be utilized. A thorough diagnostic examination of the glenohumeral joint is performed. Any indicated intra-articular procedures may be accomplished. In the same posterior portal, the arthroscope is removed from the glenohumeral joint and reintroduced into the subacromial space. The anterior cannula is redirected into the subacromial space and is utilized primarily as an inflow portal. A midlateral portal (working portal) is established approximately 4.0 cm lateral to the midportion of the lateral acromion, in line with the posterior border of the clavicle. A complete bursectomy of the subacromial space is performed using an arthroscopic shaver. Cautery or a radiofrequency device is used for hemostasis. This is an essential step because visualization of the complete undersurface of the acromion is necessary for this procedure. After completion of the subacromial bursectomy, the cautery or radiofrequency device is used to outline the anterior and lateral aspects of the acromion. The coracoacromial ligament is detached in its entirety from the anterior aspect of the acromion. Care should be taken to coagulate the acromial branch of the thoracoacromial artery because this can be a significant source of bleeding as the ligament is detached. The ligament should be further resected until the anterior deltoid fascia is visualized. The undersurface of the acromion should be visualized in its entirety from its posterior border to its anterior border such that its morphology is visualized and confirmed based on preoperative radiographs (Fig. 7-2). An arthroscopic burr is inserted via the midlateral working portal and used to remove the appropriate amount of anterior acromion to produce a flat undersurface from its lateral to medial borders. Caution should be exercised to not violate the capsule of the acromioclavicular joint or to excessively detach the deltoid fascia from the acromion. The anterior border of the acromion should be resected to be coplanar with the anterior edge of the clavicle (usually a resection of 5 to 8 mm from the anterior border). It is essential for adequate decompression that the resection of the acromion be flat from its lateral to medial borders, including the acromioclavicular joint (Fig. 7-3A). An arthroscopic rasp may be utilized to smooth the resection of the undersurface of the acromion. Final evaluation and visualization of the acromion after resection is performed by tilting the angle of the lens parallel to acromion (medial or lateral) (Fig. 7-3B). Also, one may visualize the undersurface of the acromion from the midlateral portal and place a switching stick from the posterior border to the anterior border of the acromion to confirm that the decompression is adequate. A last option is to use digital palpation to evaluate the acromial undersurface. Portals are reapproximated and dressings applied. The patient’s extremity is placed in an immobilizer for comfort; however, passive motion is begun immediately and full range of motion is the short-term immediate goal, followed by strengthening once full range of motion is encountered.
Fig. 7-1. Anterior view of shoulder with portal locations noted. Note location of AC joint portal (AC) for distal clavicle excision and of anterolateral portal (AL) for coracoplasty. P, posterior portal; L, lateral portal.
Fig. 7-2. Thirty-degree arthroscope location: Posterior portal. Undersurface of acromion during arthroscopic acromioplasty.
Pitfalls of the Technique
There are several potential complications to be aware of and to avoid. It is important to choose a burr for the resection that is able to smoothly resect the appropriate amount of bone from the undersurface without being too aggressive. Our personal choice is a 12-fluted barrel burr that is able to
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spin at 9,000 revolutions per minute. A lack of familiarity with an arthroscopic burr can result in a burr that is overly aggressive and resecting excessive amounts of bone in inappropriate areas of the acromion. This may result in an acromion that is not well contoured and rough upon completion of the acromioplasty. Excessive resection of the anterior acromion can lead to a fracture of the acromion. Preoperative planning and templating with correlation of the postoperative supraspinatus outlet view is an important part of evaluation of the technique utilized for the arthroscopic acromioplasty. Lateral acromionectomy should be avoided due to detachment of the deltoid insertion; loss of acromial fulcrum and development of adhesions between the undersurface of the rotator cuff and the deltoid can all lead to loss of deltoid function and pain. Inadequacy of the decompression is a relatively common cause of failure. Resection of the coracoacromial ligament may be important part of this procedure. Retention or regeneration of the coracoacromial ligament has been implicated as a frequent cause of failures.11,12 Also, residual anterior or medial acromial spurs can also be a cause for failure of this procedure13,14 (Figs. 7-4, 7-5).
Fig. 7-3. A: Thirty-degree arthroscope location: Posterior portal. Arthroscopic acromioplasty. Note the amount of anterior acromion resected. B: Thirty-degree arthroscope location: posterior portal. Completed acromioplasty. The undersurface is now flat anterior to posterior and medial to lateral.
Alternative Techniques: Posterior Cutting Block Technique
Utilizing the previously outlined portals, after completion of a thorough bursectomy and coracoacromial resection, the arthroscope is positioned in the midlateral portal and the shaver is inserted in the posterior portal. The midhalf of the acromion is marked and the burr is inserted from the posterior portal. The shaft of the burr is laid upon the posterior one half of the acromion. The burr is advanced anteriorly while sweeping medially to laterally removing the bone that is posterior to this line. The anterior acromion is resected to be coplanar with the bone removed from the anterior one half of the acromion. Final evaluation of the resection can be made by inserting the arthroscope into the posterior portal to ensure that the acromion is flat in a medial to lateral
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plane. Portals are closed and dressings applied in a similar manner to the method described above.
Fig. 7-4. Thirty-degree arthroscope location: Posterior portal. Revision acromioplasty. Note the large anterior medial spur and the uneven undersurface of the acromion. This patient previously had an arthroscopic acromioplasty, but presented with a recurrence of impingement symptoms.
Fig. 7-5. Thirty-degree arthroscope location: Posterior portal. Completed revision arthroscopic acromioplasty.
Rehabilitation
Immediate passive and active assist range of motion can be initiated on postoperative day 1 following the procedure. Active range of motion can be initiated on postoperative day 7 to 10. Emphasis is placed on achieving full range of motion prior to instituting strengthening. Similar to the rehabilitation program discussed in the other sections of this chapter, emphasis is placed on scapular stabilization and control of the trunk. As the patient progresses, the return to full activity and sports may occur as early as 6 weeks. The return to play for the overhead athlete may require a more prolonged rehabilitation.
Arthroscopic Distal Clavicle Resection
History of the Technique
In 1941, Mumford15 and Gurd16 described excision of the distal clavicle using an open surgical technique. In the past 15 years, at least two arthroscopic techniques for resection of the distal clavicle have evolved. Arthroscopic excision of the distal clavicle may offer several benefits relative to traditional open techniques: Improved cosmesis, less postoperative pain, ligament preservation, and the potential for less soft tissue dissection around the deltoid and its attachments. These four factors may allow the patient to proceed through the rehabilitation process more quickly than following a standard open procedure.
The direct superior and subacromial bursal approaches are the two primary options for arthroscopic approaches to AC joint pathology. Quantitative comparisons of these two techniques when compared to open techniques have demonstrated that an adequate amount of bone can be resected to allow for successful surgical results with either technique.17 The direct, or superior, arthroscopic approach allows for entry into the AC joint without violating the subacromial bursa or glenohumeral joint.18 The direct approach minimizes AC capsule disruption, inoperative bleeding, and postoperative swelling. However, this technique can be very challenging for the novice arthroscopist. The variable angles of AC joint inclination in the anteroposterior plane and the variable angles of obliquity in the superior-inferior plane may inhibit appropriate entry into the joint and make visualization of all aspects of the distal clavicular and acromial facets difficult.19,20
Our preference for performing distal clavicle resection is that of the subacromial, or indirect, approach that uses three portals. The advantages of this particular approach are that a standard 30-degree 4-mm arthroscope is used throughout the procedure, and that the surgeon has an opportunity to identify and address any subacromial space pathology.21,22 One must weigh the advantages and disadvantages of both of these techniques in the face of all individual patient factors in selecting the most appropriate technique to address AC joint pathology.
Indications and Contraindications
The indications for arthroscopic distal clavicle resection include the following: Symptomatic posttraumatic degenerative arthrosis, symptomatic osteoarthrosis or rheumatoid arthrosis, symptomatic distal clavicle osteolysis, symptomatic AC joint meniscal pathology, or some pathologic processes or infectious processes involving the AC joint and distal clavicle.
Resection of the distal clavicle may be required for reconstruction of the chronic, unstable AC joint. This procedure should not be performed, however, without simultaneous stabilization of the AC joint. In general, one should not depend on intraoperative findings to determine whether or not to pursue resection of the distal clavicle. This is a decision that must be made preoperatively based on the patient’s history, physical examination, and radiographs.
Procedure
The 30-degree arthroscope is placed in the standard posterior portal, which is located approximately 2 cm inferior and 1.5 cm medial to the posterior angle of the acromion. An anterior portal is established that parallels the AC joint, approximately 1 cm inferior to the inferior border of the AC joint. Creation of this portal should take into account the superior-inferior obliquity and the anterior-posterior inclination of the joint. Proper creation of this portal facilitates performance of the procedure. Thorough diagnostic arthroscopy
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of the glenohumeral joint is performed. Any other intra-articular pathology is addressed. The arthroscope is placed into the subacromial space. A lateral portal is established in line with the posterior border of the clavicle, approximately 1.5 cm inferior to the lateral edge of the acromion. Adequate bursectomy is performed for visualization throughout the subacromial space. If a subacromial decompression is being performed in conjunction with the resection of the distal clavicle, then the arthroscopic subacromial decompression is performed first. A radiofrequency device or electrocautery is used to delineate the inferior clavicle and its anterior and posterior borders. The inferior AC joint capsule is resected (Figs. 7-6, 7-7). A 4.0 mm or 4.5 mm shaver (Straight Incisor or Curved Incisor—Concave “Ultra” 7209026, Dyonics, Smith & Nephew, Memphis, Tenn) is used via the anterior portal to debride the AC joint of all remaining cartilage. Then, a 4.0-mm burr (Stonecutter 7205330, Dyonics, Smith & Nephew, Memphis, Tenn) is used to resect 2 mm of the inferior acromion, and the resection is extended up through the medial acromial facet. When the AC joint orientation is oblique, this step greatly improves visualization of the distal clavicle. However, in cases in which the pathology is isolated to just one side of the joint (i.e., distal clavicle osteolysis) or in which joint orientation is longitudinal, this step may be superfluous and unnecessary. The anterior portal is used almost exclusively as the working portal. Resect 10 mm of the inferior portion of the distal clavicle, working from the posterior border of the clavicle to the anterior border (Fig. 7-8). Visualization of the posterior border of the distal clavicle may be difficult through the standard posterior portal.
Fig. 7-6. Thirty-degree arthroscope location: Posterior portal. Distal clavicle (Cl) prior to resection. Note cannula is located parallel to AC joint.
When this is the case, the arthroscope is placed into the lateral portal so that the distal clavicle is viewed end-on, and the posterior margin may be easily delineated. The goal is to create 10 to 12 mm of space between the remaining distal clavicle and acromion. In general, this is accomplished by removing 2 mm of acromial facet and 8 to 10 mm of distal clavicle. Extreme care is taken not to leave any residual inferior osteophytes and to remove bone from the distal clavicle in a line that parallels the acromion. The tendency is to leave bone posteriorly and superiorly. One can best gauge that the
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resection is adequate by using one or both of the following criteria: The shape of the remaining clavicle will change to a flat, oval configuration, and the color of the superior AC joint ligaments and capsule will be gray or silver as opposed to the white superior cortical margin of the distal clavicle. One should clearly be able to delineate the superior AC joint capsule by looking directly up into the AC interval through the lateral portal (Fig. 7-9). Use 18-gauge needles to check the margins of resection and the distance between the acromion and remaining distal clavicle. The tendency is to remove less bone superiorly than inferiorly. This tendency may be obviated by appropriate anterior portal placement paralleling the joint that facilitates removing an even amount of distal clavicle. When viewing the AC interval through the lateral portal with a 30-degree arthroscope, one may be fooled into thinking that an adequate amount of superior bone has been removed. Instead, review the resection by placing the arthroscope and inflow into the anterior portal. From this perspective, the margins of the AC interval should be parallel and separated by a distance of 10 to 12 mm. An 18-gauge needle is placed directly parallel and adjacent to the distal end of the remaining clavicle, and a second 18-gauge needle is placed in a similar fashion relative to the acromion. A final measurement of the resection may be obtained by measuring the distance between the needles, either on the skin or within the subacromial space. One may also use the 4.0-mm burr or an instrument of known size to gauge the resection. After confirming adequate resection, the subacromial space is thoroughly irrigated to remove residual osseous debris. The portals are reapproximated using either simple nylon sutures or a subcuticular suture of the surgeon’s choice. Appropriate dressings are applied to the portals and an abduction sling is utilized. Passive and active assist motion is begun immediately. The patient progresses to active range of motion as comfort allows. We emphasize regaining full range of motion before strengthening activities begin.
Fig. 7-7. Thirty-degree arthroscope location: Posterior portal. Anterior margins and posterior margins of the distal clavicle (Cl) marked with needles.
Fig. 7-8. Thirty-degree arthroscope location: Posterior portal. Distal clavicle resection in progress with a barrel-shaped burr. A, acromion.
Fig. 7-9. Thirty-degree arthroscope location: Lateral portal. Note final margins of resection with 18-gauge needles.
Pitfalls of the Technique
On occasion, it may be difficult to visualize the AC joint anatomy, and, in particular, the posterior border of the clavicle, with the 30-degree arthroscope. Use of localization needles to identify landmarks, including the posterior angle of the AC joint, facilitates performance of the procedure. If needed, one may utilize the 70-degree arthroscope to view the posterior border of the clavicle through the posterior portal.
Careful planning for the anterior portal will ensure that it parallels the AC joint. If this portal is offset by more than 5 mm, then another portal should be created to allow access to the joint with an instrument that parallels the angle of the joint. If the joint is extremely degenerative, or if there is an extremely high coronal angle of angulation, then resection of the medial 2 mm of the acromial facet is crucial to improving visualization of the AC joint.
Finally, ensuring that the superior and posterior cortical margins of the distal clavicle have been adequately resected is crucial to the long-term success of this procedure. Take care to place the arthroscope in the anterior portal to ensure that the superior and posterior cortical margins have been resected adequately. In difficult cases, one may be able to press the distal clavicle downward during resection to improve visualization of the superior margin and to stabilize the distal clavicle as it is resected.
Alternative Techniques
The direct approach to AC joint resection is sometimes called the two-portal technique. All landmarks are noted on the skin. To assist with localization, two or three 22-gauge needles are placed anterior to the AC joint, posterior to the AC joint, and in the center of the AC joint, respectively. The joint is insufflated with saline with the needle placed in the center of the joint. Adequate backflow ensures appropriate placement of the needles into the joint. An anterior superior portal and a posterior superior portal are made in line with the AC joint. These portals are adjacent to the respective borders of the joint. A 2.7 mm arthroscope is placed into the anterior superior portal, and a small shaver is placed via the posterior superior portal. Any meniscal tissue and joint debris are removed. A small joint radiofrequency device or electrocautery is used to subperiosteally elevate the AC joint ligaments to improve visualization and to “shell-out” the distal clavicle. In some cases, a 4-mm arthroscope may now be inserted, which will, at least for most, improve visualization. A small burr is placed through the posterior superior portal into the posterior portion of the AC joint to start the bone resection. The posterior superior border of the clavicle is addressed with the burr initially, and the resection of the superior clavicle is brought as far anterior as possible.
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Approximately 2 mm of the medial acromial facet may also be debrided. As the joint space opens, a larger 4-mm burr may be inserted. This will hasten the bony debridement; however, it may also obscure visualization by leading to bleeding or fluid control problems. The arthroscope is then switched to the posterior superior portal to allow burr access to the more anterior portions of the distal clavicle and the acromion. This portion of the bony debridement is addressed in a similar fashion as that which began in the posterior portion of the joint. Care is taken to ensure that an adequate bony debridement of the most posterior and anterior portions of the joint is performed. The remaining AC interval should measure approximately 10 to 12 mm. Appropriately done, the inferior AC joint capsule/ligaments are not disrupted. The AC interval is thoroughly irrigated with saline; then, closure is performed with simple nylon sutures or a simple absorbable subcuticular stitch of the surgeon’s choice. Sterile dressings are placed. The postoperative care and rehabilitation will proceed in a fashion identical to that of the arthroscopy indirect approach.
Fig. 7-10. Thirty-degree arthroscope location: Posterior portal. Note coracoid (Co) in this view through a window in the rotator interval just superior to the superior border of the subscapularis tendon (Sub). Spinal needle (SN) enters the coracohumeral space via the anterolateral portal. The probe touches the posterolateral tip of the coracoid.
Fig. 7-11. Thirty-degree arthroscope location: Posterior portal. Note impingement of subscapularis tendon onto coracoid tip with the upper extremity moved into a position of forward flexion, adduction, and internal rotation.
Fig. 7-12. Thirty-degree arthroscope location: Posterior portal. Referencing the coracoplasty (Co) after resection of the posterolateral coracoid using a 4-mm burr as a reference tool.
Rehabilitation
As noted previously, rehabilitation begins immediately with passive and active assisted range of motion. Active range of motion begins by postop day 7 to 10. We place an emphasis on regaining full active range of motion prior to instituting any strengthening activity. The rehabilitation program should focus on scapula stabilization and control of the trunk. As the patient progresses, return to full activity and sports may occur as early as 6 weeks. However, in a throwing athlete, a more reasonable time frame for return may be as long as 3 to 4 months. Keep in mind that when resection of the distal clavicle is performed in conjunction with a subacromial decompression or other intra-articular procedure, the latter may provide constraints to the rehabilitation program, and the patient’s return to sports will be slower.
Subcoracoid Impingement
History of the Technique
Subcoracoid, or coracoid, impingement is an increasingly recognized cause of persistent anterior shoulder pain. Subcoracoid impingement is defined as the mechanical contact between the coracoid and the lesser tuberosity of the humerus.23 Patients note pain and tenderness in the anterior shoulder that is exacerbated with increasing degrees of flexion, adduction, and internal rotation. The origin of the pain presumably occurs because of impingement of the subscapularis tendon between the coracoid process and the lesser tuberosity.
Several investigators have noted that many factors may decrease the coracohumeral space, thus leading to subcoracoid stenosis and possibly impingement.24,25,26 A strong association has been noted recently between subcoracoid stenosis and anterior superior rotator cuff tears.27,28,29,30 Controversy exists as to whether this coracohumeral narrowing leads to the development of these rotator cuff tears, or if the subcoracoid impingement develops secondary to the anterosuperior translation of the humeral head that may be present in patients with large rotator cuff tears. Further, it is postulated that contracture of the posterior glenohumeral joint capsule may play a role in the development of subcoracoid impingement.
The coracohumeral space in asymptomatic shoulders has been reported to be between 8.7 and 11 mm. Gerber et al.,24 Dines et al.,25 Karnaugh et al.,26 Dumontier et al.,27 and Burkhart et al.28,29,30 have demonstrated different means by which to assess the subcoracoid space using preoperative imaging and intraoperative observation. These investigators have also proposed different techniques for surgical decompression of the subcoracoid space for patients with persistent subcoracoid impingement that is unresponsive to nonoperative management. These techniques include osteotomy of the neck of the coracoid process, resection of the tip of the coracoid, or resection of most all of the coracoid process. The technique we now favor, and that currently proposed by Burkhart, is to perform an arthroscopic coracoplasty. In the arthroscopic coracoplasty, the coracohumeral space is increased by resecting the posterolateral aspect of the coracoid in line with the subscapularis tendon.
Indications
The indications for arthroscopic coracoplasty are evolving. At this time, the indications for this procedure include the following: Recalcitrant anterior shoulder pain in patients whose clinical findings, preoperative imaging, and intraoperative examination confirm the presence of subcoracoid stenosis and subcoracoid impingement, isolated subscapularis tendon tears with associated subcoracoid stenosis and subcoracoid impingement, anterior superior rotator cuff tears and rotator interval lesions associated with subcoracoid stenosis and subcoracoid impingement.
It is recognized that both subacromial impingement and subcoracoid impingement may occur in patients with combined subscapularis, supraspinatus, and infraspinatus tendon tears.
Procedure
During arthroscopic coracoplasty, a 70-degree arthroscope may be helpful by providing an “aerial” view of the coracoid and the subscapularis tendon. A standard posterior portal is used typically for visualization of the coracoid. In cases where the rotator interval tissue obstructs visualization and the proper angle of approach, the portion of the rotator interval directly over the coracoid is resected using a radiofrequency and shaver device. Although it may be visualized through the subacromial space, the coracoid is more easily seen and coracoplasty more easily performed through a small window in the rotator interval. The anterolateral
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portal is used for approaching the coracoid and the subscapularis tendon. This portal is located 2 to 3 mm anterior to the biceps and 2 to 4 cm from the anterolateral corner of the acromion. Proper placement of this portal to allow adequate access to the posterolateral coracoid and access to the subscapularis tendon for repair is essential. Localization initially with an 18-gauge spinal needle is helpful (Fig. 7-10). After completing a thorough intra-articular glenohumeral joint examination, a shaver or radiofrequency device is introduced through an anterolateral portal. The coracoid is identifiable by palpating through the rotator interval tissue just above the superior edge of the subscapularis tendon. A window in the rotator interval tissue is created in this location directly adjacent to the coracoid tip. Via the anterolateral portal, all soft tissue is resected from the posterior aspect of the coracoid tip. Care is taken to avoid dissection medial to the coracoid. A 4-mm burr (Stonecutter 7205330, Dyonics, Smith & Nephew, Memphis, Tenn) is then introduced into the anterolateral portal, and the coracoid is resected in line with the subscapularis tendon. The goal is to resect the posterolateral aspect of the coracoid space and prevent impingement of the coracoid against the subscapularis tendon and lesser tuberosity (Fig. 7-11). Manipulating the arm into forward flexion and internal rotation with the traction removed helps assess the adequacy of the coracoplasty. The humerus may be pushed posteriorly by an assistant while burring the posterolateral tip of the coracoid to improve access to this space. The 4-mm burr or an arthroscopic probe with a known tip length may be used as a reference tool to estimate the distance between the remaining coracoid and subscapularis tendon. The end point for the resection is to obtain 7 mm of clearance between the remaining coracoid and subscapularis tendon (Fig. 7-12). After subcoracoid decompression, any remaining pathology may be addressed. This may include isolated subscapularis tendon repair, repair of larger
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tears that involve portions of the subscapularis, supraspinatus, and infraspinatus tendons, or repair of rotator interval and proximal biceps tendon lesions.
Rehabilitation
Following isolated coracoplasty, patients may begin a program of rehabilitation that is similar to that for patients who have had subacromial decompressions. The arm position of forward flexion, adduction, and internal rotation is avoided for 4 to 6 weeks in the immediate postoperative period. For patients who have other intra-articular pathology addressed, the rehabilitation program should be modified based on any limitations necessitated by the other procedures.
Technical Alternatives/Pitfalls of the Technique
The most important aspect of this procedure is appropriate anterolateral portal placement. This will allow the surgeon access to the coracoid tip and to the leading edge of the subscapularis tendon. Using a spinal needle to assist in placement of this portal is essential. Care must be taken to avoid dissection medial to the coracoid tip to avoid neurologic injury. To that end, only the posterolateral portion of the coracoid need be resected. The goal is to increase the coracohumeral distance. This is done by resecting the posterolateral portion of the tip of the coracoid just anterior to the superior border of the subscapularis tendon.
Visualization of the coracoid through the subacromial space is possible but difficult because of the large amount of fibro-fatty bursal tissue that surrounds the coracoid. The coracoid is much more easily approached intra-articularly through a small window in the rotator interval for three reasons: (a) It avoids the large amount of subacromial bursal tissue surrounding the coracoid, which provides for better visualization, (b) it allows for a direct assessment of the coracohumeral space both before and after coracoplasty, which will help to ensure that the coracoid decompression is adequate, and (3) it facilitates surgeon evaluation of the subscapularis tendon.
References
1. Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg. 1972;54A:41–50.
2. Neer CS II. Impingement lesions. Clin Orthop. 1983;173:70–77.
3. Altchek DW, Carson EW. Arthroscopic acromioplasty: current status. Orthop Clin North Am. April 1997;28(2):157–168.
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11. Hunt JL, Moore RJ, Krishnan J. The fate of the coracoacromial ligament in arthroscopic acromioplasty: an anatomical study. J Shoulder Elbow Surg. November–December 2000;9(6):491–494.
12. Levy O, Copeland SA. Regeneration of the coracoacromial ligament after acromioplasty and arthroscopic subacromial decompression. J Shoulder Elbow Surg. July–August 2001;10(4):317–320.
13. Ogilvie-Harris DJ, Wiley AM, Sattarian J. Failed acromioplasty for impingement syndrome. J Bone Joint Surg. 1990;72:1070–1072.
14. Connor PM, Yamaguchi K, Pollock RG, et al. Comparison of arthroscopic and open revision decompression for failed anterior acromioplasty. Orthopedics. June 2000;23(6):549–554.
15. Mumford EB. Acromioclavicular dislocation. J Bone Joint Surg Am. 1941;23:799–802.
16. Gurd FB. The treatment of complete dislocation of the outer end of the clavicle: a hitherto undescribed operation. Ann Surg. 1941;113:1094–1098.
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