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Of note, in a true intra-operative setting, we commonly will draw out the anatomic landmarks and planned anterior portal placement (as described above) and still create our portal under direct arthroscopic visualization into the glenohumeral joint using a spinal needle, as there is no need to create it blindly. However, we have not yet found the need to deviate the skin incision of the portal location from our pre- operative marking. Ultimately, the trajectory of the needle is such that it still enters the joint within the described safe intraarticular triangle of the rotator interval. The description and location of the portal is optimal for arthroscopic distal clavicle excision in the patient undergoing concomitant subacromial or intraarticular procedures, and is versatile in that it can be used as an isolated portal for access to both the glenohumeral and AC joints or as an anterosuperior accessory portal when an more inferior portal is needed to access the glenohumeral joint. Importantly, this portal also provides access to the posterosuperior aspect of the distal clavicle so that adequate resection can be undertaken, and places the arthroscopic instruments parallel (or nearly parallel) to the AC joint allowing for ease of resection.
02
03
Clinical Relevance:
This method of establishing the anterior portal for distal clavicle excision provides the surgeon with a safe corridor for placement of instruments in a reliable manner that does not disrupt the important stabilizers of the glenohumeral or AC joint.
PEARLS & PITFALLS – SURGICAL TECHNIQUE
01 Fig 1
02 Fig 2
03 Fig 3
Superior view of a left shoulder identifying the surface landmarks of the shoulder. (A) Nevaiser’s Point, (B) AC Joint, (C) Coracoid, (D) Anterior border of Acromion, (E) Posterior border of Acromion. The proposed anterior portal (X) is marked a distance of 1.5 cm from the anterior border of the clavicle and just superior and lateral to the tip of the coracoid process. Superior view of a disarticulated left shoulder with a point for portal entry (X) located 1.5cm inferior to the anterior edge of the clavicle along the line created between Nevaiser’s Point and the lateral margin of the coracoid.
Superior view of a cadaveric shoulder specimen with dissection of the anterior portal. This portal placement reveals no iatrogenic damage to the CA ligament and is in line with
the AC joint.
ISAKOS NEWSLETTER 2015: Volume I 11