Navigated vs arthroscopic-guided drilling for reconstruction of acromioclavicular joint injuries: accuracy and feasibility

3D C-arm navigated suture button implantation for AC joint dislocations - the pilot study

PURPOSE

The surgical treatment of acute traumatic AC joint dislocations is still a subject of scientific debate in the literature. The arthroscopically assisted stabilization procedure with a suture button system has been successfully established and is widely used in daily practice. It is minimally invasive and allows the anatomical reconstruction of the torn coracoclavicular ligaments in one step with a permanent implant that does not have to be removed in a second operation. This clinical pilot study is the first to describe the new method of navigated suture button implantation with the future aim of further reducing surgical invasiveness and further increasing surgical precision.

MATERIALS AND METHODS

10 patients with a Rockwood 3b/5 injury could be included in the prospective study (DRKS00031855) within 5 months according to inclusion and exclusion criteria. Surgical stabilization was performed with a suture button system via a navigated coracoclavicular drill tunnel. Demographic and radiological data as well as information on health and shoulder function were collected from patient records, X-rays, DVT scan and 3 questionnaires (DASH, NHS and Eq. 5D) at the preoperative, intraoperative and postoperative (discharge, 6 weeks and 3 months) time points.

RESULTS

All operations could be performed within 8.8 days (± 6.81) after trauma. The average operation time was 50.3 min (± 8.81). The mean distance of the drill hole in the clavicle to the AC joint was 26.6 mm (± 2.63). The radiologically measured vertical coracoclavicular distance was 38.8 mm (± 6.16) at discharge and 41.11 mm (± 7.51) at 3 months. This loss of reduction was not statistically significant. In contrast, the DASH, NHS and Eq. 5D results showed significant improvement from discharge to 3 months postoperatively.

CONCLUSION

Image-guided 3D C-arm navigated AC joint suture button stabilization is feasible in everyday surgical practice. It may be possible to achieve a further reduction in invasiveness while at the same time increasing the accuracy of implant positioning. Further clinical studies with a larger number of patients and a longer follow-up period are necessary to enable a comparison with conventional methods.

3D C-arm navigated acromioclavicular joint stabilization

INTRODUCTION

Surgical treatment options for acromioclavicular joint separations are varied. Frequently, suspension devices (SD) are inserted for stabilization under arthroscopic view. This study investigates the feasibility and accuracy of three-dimensional (3D) digital-volume-tomography (DVT) C-arm navigated implantation with regard to the general trend toward increasingly minimally invasive procedures.

MATERIALS AND METHODS

The implantation of a TightRope® suture button system (SD) via a navigated vertical drill channel through the clavicle and coracoid was investigated in 10 synthetic shoulder models with a mobile isocentric C-arm image intensifier setup in the usual parasagittal position. Thereby, in addition the placement of an additive horizontal suture cerclage via a navigated drill channel through the acromion was assessed.

RESULTS

All vertical drill channels in the Coracoclavicular (CC) direction could be placed in a line centrally through the clavicle and the coracoid base. The horizontal drill channels in the Acromioclavicular (AC) direction ran strictly in the acromion, without affecting the AC joint or lateral clavicle. All SD could be well inserted and anchored. After tensioning and knotting of the system, the application of the horizontal AC cerclage was easily possible. The image quality was good and all relevant structures could be assessed well.

CONCLUSION

Intraoperative 3D DVT imaging of the shoulder joint using a mobile isocentric C-arm in the usual parasagittal position to the patient is possible. Likewise, DVT navigated SD implantation at the AC joint in CC and AC direction on a synthetic shoulder model. By combining both methods, the application in vivo could be possible. Further clinical studies on feasibility and comparison with established methods should be performed.

An Accuracy Comparison of Minimally Invasive Transclavicular-Transcortical Drilling with Free-Hand, C-Shape and Assembly-Type Guide Device: An In Vitro Study

OBJECTIVES

Ensuring the accuracy of transclavicular-transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular-transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C-shape guide devices and free-hand techniques.

METHODS

An assembly-type guide device was designed and produced using computer-aided design and three-dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free-hand drilling, C-shape device drilling, and assembly-type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty-four human shoulder specimens were randomly assigned into free-hand (n = 18), C-shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular-transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid's medial (d_m ) and lateral (d_l ) edges, operation time, and tunnel location zones on the coracoid's inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.

RESULTS

All specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d_d ) between d_m and d_l in the free-hand, C-shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d_d of the free-hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free-hand group, C-shape group, and assembly-type group, respectively (p = 0.012). The operation time in the free-hand, C-shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).

CONCLUSION

The assembly-type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly-type guide devices achieved higher accuracy than free-hand techniques.

Efficacy of Transosseous Tunnel Placement for Triple Endobutton Plate in Acromioclavicular Joint Reconstruction: A Three-Dimensional Printing Guide Design Technology

Objective

Explore an accurate transosseous tunnel drilling method based on three‐dimensional (3D) printing technology for acromioclavicular joint reconstruction (ACD), design a guide design, and evaluate its accuracy.

Methods

Using Mimics software to reconstruct 100 cases of acromioclavicular joint computed tomography (CT) data. In design 2, the non‐collinear tunnel is superimposed on the 3D model, and a virtual drilling is performed between the clavicle and the coracoid using a triple inner gusset. Then, in the Geomagic Studio software model, an elliptical plane is calculated and extracted as a guide design for precise drilling. Then put the design and the 3D shoulder model together for 3D printing. Ten lengths were measured, and the effects of the virtual model, the actual model, and the guide rail design were compared.

Results

We successfully compared 10 parameters of 3D virtual model and actual model. There was no significant difference between actual and virtual bone tunnels in 10 measurements (P > 0.05).

Conclusions

The accuracy of ACD combined with 3D printing guidance design technology in the transosseous tunnel of adult shoulder is reliable.

Computer-Assisted Orthopedic and Trauma Surgery

BACKGROUND

There are many ways in which computer-assisted orthopedic and trauma surgery (CAOS) procedures can help surgeons to plan and execute an intervention.

METHODS

This study is based on data derived from a selective search of the literature in the PubMed database, supported by a Google Scholar search.

RESULTS

For most applications the evidence is weak. In no sector did the use of computer-assisted surgery yield any relevant clinical or functional improvement. In trauma surgery, 3D-navigated sacroiliac screw fixation has become clinically established for the treatment of pelvic fractures. One randomized controlled trial showed a reduction in the rate of screw misplacement: 0% with 3D navigation versus 20.4% with the conventional procedure und 16.6% with 2D navigation. Moreover, navigation-assisted pedicle screw stabilization lowers the misplacement rate. In joint replacements, the long-term results showed no difference in respect of clinical/functional scores, the time for which the implant remained in place, or aseptic loosening.

CONCLUSION

Computer-assisted procedures can improve the precision of certain surgical interventions. Particularly in joint replacement and spinal surgery, the research is moving away from navigation in the direction of robotic procedures. Future studies should place greater emphasis on clinical and functional results.

Arthroscopically guided navigation for repair of acromioclavicular joint dislocations: a safe technique with reduced intraoperative radiation exposure

Background

Accuracy evaluation of navigated image free placement of double cortical fixation buttons for coracoclavicular tunnel position in comparison to conventional drill guide based placement.

Methods

Twenty-six patients with acute acromioclavicular joint instability were included in this non-randomized cohort study. All patients were treated with a Double- TightRope technique. In 13 cases the conventional drill guide based placement was used (group 1). In 13 patients surgery was performed as a navigated procedure with a fluoro-free optoelectronic system (group 2). The number of coracoclavicular drillings per patient (First pass accuracy; FPA (%)) was documented, the subcoracoidal position of the fixation buttons has been evaluated and graded as “intended position achieved (IPA)” or “intended position not achieved (IPnA)”.

Results

In group 1 drilling had to be repeated in four patients (30.8 %) to achieve proper placement of the subcoracoidal fixation buttons. 100 % first pass accuracy was observed in group 2 (p = 0.03). In group 1, the intended position of the subcoracoid buttons was not achieved (IPnA) in six patients (46.2 %). In group 2 all intended positions were achieved (p = 0.005).

Conclusion

Arthroscopic controlled fluoro-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation has higher first pass accuracy in comparison to conventional drill guide based placement. Therefore the navigation enables a precise position of the drill holes, may reduce the risk of an iatrogenic coracoid fracture and migration of fixation devices.

Trial registration

Local institutional review board No. 061-14-10032014

Image-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation: a cadaver study

BACKGROUND

Reconstruction of the coracoclavicular ligament functions to restore anatomic alignment of the clavicle and may improve biomechanical function and clinical outcomes. Improper placement of the coracoclavicular tunnel may inherently weaken the coracoid. The purpose of this study was to evaluate the feasibility and accuracy of navigated image-free placement of K-wires for coracoclavicular tunnel position in comparison to conventional drill guide-based placement.

MATERIALS AND METHODS

Eight human shoulder specimens were assigned for conventional technique with a coracoclavicular guide device (group CP) and the paired contralateral side for the navigated procedure (group NP) with an optoelectronic system with a fluoro-free software module. First-pass accuracy (%) and the K-wire trajectory (lateral-center orientation (LC), center-center (CC) orientation and medial-center orientation (MC) were measured.

RESULTS

In all navigated K-wires a 100 % first-pass accuracy was observed. In three of the eight (37.5 %) specimens of the drill guide-based group, drilling had to be repeated. One of them had to be repeated twice, resulting in eight versus twelve drillings for the navigated versus conventional group, respectively (p = 0.021). K-wire trajectory showed an MC orientation in most of the specimen (n = 9, group NP 4, group CP 5).

CONCLUSIONS

Image-free navigated coracoclavicular drilling for the repair of acromioclavicular joint dislocation has higher first-pass accuracy in comparison to conventional drill guide-based placement and, therefore, may enable a precise anatomic position of the drill holes and reduce the risk of an iatrogenic coracoid fracture.