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DVD-1090_007 | A | Distal Clavicle Resection Using A 70deg Scope

Stephen S. Burkhart

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Distal Clavicle Resection Using A 70deg Scope

Okay. And so now I'm going to switch to a lateral viewing portal. Anytime I'm going to do distal clavicle and excise the distal clavicle. What I want to do, I want to be sure and expose the scapular spine. Because the reason is you see here this I'm pushing against the distal clavicle. That's the AC joint to have the best straight line of sight view. I want my my scope to go right here where this fat is. So I want to get all that fat out of there so that I can see. And you see that fat is covering up the spine of the scapula. So once I can see a spine of scapula clearly, I know that I've done enough fat excision to get my scope in there and see everything clearly. I'd like to come over here into the posterior gutter, so I'm sure that I can see things back there, see the tendon of the infraspinatus and be sure there's not an isolated tear there. I see several isolated infraspinatus tears every year, and you'll never see them if you don't expose that part of the infraspinatus and posterior gutter. If you remember when I made my anterior lateral portal, I came in over the lateral half of the subscapular. And if you do that, that almost always is the exact perfect angle of approach to come in parallel to the AC joint. And that way you don't have to make a new skin puncture. So here, here we are coming through that same skin portal. And just like always, it lines up exactly in line with the AC joint right down the pike. Also, you see what a good view I have because I parked my scope right there alongside the scapular spine where I cleared all that fat out of the way, and so I can see all the way back to the posterior aspect of distal clavicle without any problem. I want to end up with a one centimeter space at the AC joint when I'm finished. So generally if your bone on bone here, you're going to take a centimeter. If you've got a couple of millimeters of space, you'll take eight millimeters, but end up with a one centimeter space. Our Bir is 5.5mm and its outer diameter. So we want a couple of Bir widths basically is what we're going to take. So we'll make a provisional cut here. It's going to be about two widths. Now the next thing I want to do is I'm going to switch to a 70 degree scope. And the reason for that is I can look right up the pike and always see the end of the distal clavicle. Plus there's some of these that are sort of ski slope AC joints that can have 45, even a 60 degree angle to them, and you could not possibly see the distal end of the upper clavicle with just a 30 degree scope. In fact, you see, this one has maybe a 20 degree angle or something like that, but it'll be a lot easier to see all the way out to the tip using a 70 degree scope. So now what I want to do is just concentrate on the anterior first. Now you hear some people say you've got to preserve the ligaments. The only ligaments that are preserved are the superior AC joint ligaments. As far as I'm concerned, you have to remove some of the anterior ones and posterior ones in order to do a distal or complete distal clavicle excision. Typically have to alternate some between shaver and bur. So this lady has this sort of tissue in there that they used to call meniscus of the AC joint. I don't know what it really is, but just thick tissue that can obscure the end of the bone particularly superiorly. Now the other thing that's really nice with this 70 degree scope is you can look sequentially, you can just rotate your cable. I'm looking at Arrow, superior mid superior posterior superior straight posterior. And you can get a huge range of field of view. I want to take down these posterior ligaments. As I said I don't think you can get all the bone unless you take down some ligaments posteriorly. I've never seen a problem destabilizing the joint. That's what people will warn you about. But I've never seen that. As long as you leave the superior ligaments intact, which I think are most important. And when you think about how we used to always do the open distal clavicle excision, you sacrifice the superior ligaments and they're the most important. That's why so many people have that big, ugly dent in their shoulder when they get a distal clavicle excision done open. I was having a little trouble getting that posterosuperior part just rounding the corner because of the arc shape of this AC joint. Pretty much got it now. So now we get the posterior ligaments here a little bit better down to the margin of the bone, because you can leave some cortex there. If you don't expose that totally to the cortical margin, it'll be covered up in soft tissue. We just fine tune it and we just make sure that we've got a centimeter space, and then we'll be done with that. Your end point here is to have about a one centimeter space between your distal clavicle and the medial AC joint like that. And you want to have the distal clavicle roughly parallel to the medial facet of your acromion. So that's just about 11mm. So that's a good endpoint there.

Distal Clavicle Resection Using A 70deg Scope

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