Reducing fluoroscopy in acromioclavicular joint reconstruction: Clinical value of the three-point positioning technique

Abstract

Acromioclavicular joint dislocation (ACJD) is one of the shoulder girdle injuries that particularly affects young and active individuals. Although various surgical techniques have been developed for coracoclavicular ligament reconstruction, TightRope fixation has gained popularity. The procedure relies on frequently repeated intraoperative fluoroscopy to ensure the accuracy of tunnel placement, which increases radiation exposure for both patients and surgical teams. In the recent issue of World Journal of Orthopedics, Chen et al present a novel three-point positioning technique designed to guide tunnel trajectory and implant placement while reducing fluoroscopy time during TightRope fixation. Their retrospective analysis of patients with acute Rockwood type III ACJD demonstrated favorable functional outcomes and, in particular, low intraoperative fluoroscopy exposure. In this editorial, we discuss the clinical significance of radiation reduction in shoulder surgery and highlight the importance of procedural innovations that improve surgical workflow without increasing technical complexity. Simplified intraoperative positioning strategies may represent an important step toward safer and more efficient minimally invasive acromioclavicular joint reconstruction. Furthermore, techniques that minimize radiation exposure while maintaining surgical precision may contribute to improved occupational safety in orthopedic practice. Such practical innovations could play an important role in the future evolution of image-guided shoulder surgery.

Key Words: Acromioclavicular joint dislocation; TightRope fixation; Fluoroscopy reduction; Three-point positioning technique; Coracoclavicular stabilization; Shoulder surgery

Core Tip: The three-point positioning technique represents a pragmatic shift toward reducing fluoroscopy dependence in acromioclavicular joint reconstruction. By enabling accurate tunnel placement through simple anatomical alignment, this approach has the potential to redefine intraoperative workflow and establish a new safety standard in minimally invasive shoulder surgery by prioritizing both surgical precision and radiation minimization.

This editorial refers to “Novel 3-point positioning technique combined with the TightRope system for treating acute Rockwood type III acromioclavicular joint dislocation” by Chen et al, 2026; https://doi.org/10.5312/wjo.v17.i5.118475.

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INTRODUCTION

Acromioclavicular joint dislocation (ACJD) remains one of the most common injuries to the shoulder girdle, particularly among young and physically active individuals[1,2]. The Rockwood classification system continues to guide treatment decisions, with conservative treatment generally recommended for types I and II injuries, while surgical intervention is typically applied to types IV-VI[3,4]. However, the optimal management of Rockwood type III injuries remains controversial, as studies in the literature have shown both surgical and non-surgical approaches to have positive outcomes in different patient populations[5-8].

Over the past two decades, advances in surgical techniques have focused more on minimally invasive methods for coracoclavicular ligament reconstruction[9-13]. Among these approaches, the TightRope system has gained widespread acceptance due to its ability to restore vertical stability while minimizing surgical exposure. Despite these advantages, achieving precise tunnel placement between the clavicle and the coracoid process can be technically challenging. Surgeons often rely on intraoperative fluoroscopy to verify the trajectory of the guidewire and implant position, which inevitably increases radiation exposure for both patients and operating room personnel[14-16]. However, despite its widespread use, there remains a lack of simple and reproducible intraoperative strategies specifically aimed at minimizing fluoroscopy dependence during TightRope fixation.

In this context, Chen et al[17] recently published a study in World Journal of Orthopedics, presenting a practical modification of the TightRope procedure through the application of a three-point positioning technique. This approach aims to reduce reliance on fluoroscopic imaging while maintaining accurate tunnel placement and surgical efficiency.

SIMPLIFIED INTRAOPERATIVE POSITIONING

The conceptual basis of the proposed technique relies on the alignment of three key reference points during surgery: The clavicular tunnel location, a Kirschner wire placed on the skin surface, and the trajectory of the guide wire directed toward the coracoid process. By ensuring linearity between these elements prior to the puncture, the surgeon can establish a stable spatial orientation that guides the creation of the correct tunnel[18]. This strategy transforms a traditionally fluoroscopy-dependent step into a visually guided and repeatable workflow. In the study by Chen et al[17], the reported average fluoroscopy time was significantly lower compared to values reported in many previous TightRope fixation studies.

Beyond radiation reduction, simplified positioning strategies can also improve surgical reproducibility. Correct tunnel placement is crucial for preventing complications such as tunnel malposition, coracoid fracture, implant failure, or permanent instability. Therefore, techniques that improve correct tunnel placement during surgery contribute to both procedural safety and long-term clinical outcomes.

From a practical perspective, the technique can be summarized in a stepwise manner. First, the surgeon identifies the intended clavicular tunnel entry point based on anatomical landmarks. Second, a Kirschner wire is temporarily aligned on the skin surface to simulate the desired trajectory toward the base of the coracoid process. Third, the guidewire is advanced along this predefined linear path, ensuring collinearity between the clavicular entry point, the external reference wire, and the coracoid target. Once alignment is visually confirmed, drilling is performed with minimal need for fluoroscopic verification. This structured approach allows the surgeon to establish spatial orientation prior to bone penetration, thereby reducing reliance on repeated intraoperative imaging.

RADIATION EXPOSURE IN ORTHOPEDIC SURGERY

Although the radiation dose associated with a single procedure is generally low, cumulative exposure throughout a surgical career can pose potential health risks for orthopedic surgeons and operating room staff[19,20]. Previous studies have demonstrated that repeated fluoroscopic exposure may lead to increased occupational risks, particularly in high-volume surgical settings[20,21].

To overcome this challenge, various technological solutions have been proposed, including computer-assisted navigation systems, robotic guidance platforms, and three-dimensional imaging technologies, which continue to evolve and demonstrate improvements in surgical accuracy and reductions in fluoroscopy dependence[22-25]. While these innovations can increase surgical precision and reduce reliance on fluoroscopy, their adoption is often limited due to high costs, infrastructure requirements, and technical complexity. In contrast, procedural innovations based on anatomical principles and simple geometric alignment may offer a more universally applicable solution[26]. Techniques based on easily repeatable intraoperative reference points can reduce radiation exposure without requiring additional technology or specialized equipment.

Innovations that simplify surgical workflows without introducing technological complexity are gaining wider global applicability. Because in many healthcare systems, access to advanced navigation platforms is not possible due to financial constraints. Therefore, modifications such as simplified positioning techniques can offer practical advantages that lead to wider adoption.

Nevertheless, it is important to acknowledge that the clinical impact of fluoroscopy-related radiation exposure in individual procedures is often considered relatively low, particularly when standard protective measures are used. Moreover, experienced surgeons may achieve reduced fluoroscopy times through familiarity with anatomical landmarks and procedural techniques. In addition, advanced technologies such as navigation systems and intraoperative imaging platforms have been developed to address these concerns. However, these solutions are not universally accessible and may introduce additional cost and complexity. Therefore, simple, reproducible techniques that can be readily implemented across diverse clinical settings remain highly relevant, particularly in resource-limited environments.

A range of strategies has been proposed to minimize fluoroscopy use in acromioclavicular joint reconstruction, encompassing preoperative planning, anatomical landmark-based techniques, arthroscopic visualization, and technology-assisted guidance systems (Table 1). These approaches vary in terms of complexity, cost, and accessibility. Within this spectrum, the three-point positioning technique represents a simplified, anatomy-driven method that may offer a practical balance between accuracy and reduced radiation exposure without requiring additional equipment.

Table 1 Strategies for reducing fluoroscopy exposure during acromioclavicular joint reconstruction.

Strategy	Principle	Clinical benefit
Preoperative imaging planning	Evaluation of clavicle–coracoid anatomy	Improves tunnel trajectory planning
Anatomical surface landmarks	Identification of clavicular tunnel using external landmarks	Reduces fluoroscopic verification
Three-point positioning technique	Alignment of K-wire, clavicular tunnel, and guidewire	Enables accurate drilling with minimal fluoroscopy
Arthroscopic visualization	Direct coracoid visualization	Improves tunnel placement accuracy
Navigation-assisted surgery	Real-time guidance systems	Reduces fluoroscopy dependence
Surgical workflow optimization	Standardized operative steps	Shortens operative time and radiation exposure

CLINICAL IMPLICATIONS

The technique discussed in this study has several important clinical implications for surgeons performing acromioclavicular joint reconstruction. Firstly, reducing the duration of intraoperative fluoroscopy can decrease cumulative radiation exposure for both patients and surgical teams. Given the high frequency of fluoroscopy use in orthopedic procedures, gradual reductions in exposure could provide significant long-term occupational health benefits. Secondly, simplified positioning strategies can improve the reproducibility of the procedure. Correct tunnel placement is a critical determinant of successful coracoclavicular fixation, and techniques that improve spatial orientation can reduce technical errors during surgery[27]. Thirdly, an improved surgical workflow can shorten surgery times and increase operating room efficiency. Shorter surgery times can also reduce exposure to anesthesia and potentially improve postoperative outcomes.

This approach may be particularly advantageous in high-volume surgical centers and training environments, where repeated exposure to fluoroscopy is common. In such settings, even small reductions in fluoroscopy time per procedure can translate into meaningful decreases in cumulative radiation exposure over time. Moreover, for trainees and less experienced surgeons, structured positioning strategies may facilitate safer learning curves by reducing dependence on repeated imaging while reinforcing anatomical orientation. Therefore, techniques that standardize intraoperative workflow while minimizing radiation may have important implications not only for patient safety but also for occupational health and surgical education[28-30].

FUTURE PERSPECTIVES

As the popularity of minimally invasive approaches in orthopedic surgery increases, strategies that improve workflow optimization will become increasingly important. Future innovations could integrate simplified positioning techniques with emerging technologies such as three-dimensional surgical planning, intraoperative navigation, or augmented visualization systems. A particularly valuable next step would be a prospective comparative study evaluating the three-point positioning technique against conventional fluoroscopy-guided TightRope fixation. Such a study could include fluoroscopy time, radiation dose, tunnel placement accuracy, operative time, complication rates, and short- to mid-term functional outcomes as primary endpoints. In addition, subgroup analyses based on surgeon experience could help determine whether the technique offers particular advantages in training settings or during the early learning curve.

Prospective comparative studies are needed to further evaluate the effectiveness of radiation exposure reduction strategies in acromioclavicular joint reconstruction. Such studies should evaluate not only the duration of fluoroscopy but also tunnel accuracy, implant positioning, surgery time, and long-term functional outcomes.

CONCLUSION

The three-point positioning technique described by Chen et al[17] involves a practical modification of the TightRope procedure for acute Rockwood type III ACJD. This approach, which reduces reliance on intraoperative fluoroscopy while maintaining accuracy of tunnel placement, contributes to ongoing research aimed at improving the safety and efficiency of minimally invasive shoulder surgery.

While prospective studies with larger patient groups and longer follow-up periods are needed, this concept highlights how incremental procedural innovations can significantly improve surgical practice. Consequently, strategies that reduce radiation exposure while maintaining surgical precision represent a meaningful advance in modern orthopedic surgery.