Arthroscopic resection of the outer end of the clavicle from a superior approach: a critical, quantitative, radiographic assessment of bone removal

Acromioclavicular joint disorders

The acromioclavicular joint is commonly involved in athletic injuries. Most commonly, a sprain to the joint occurs with variability in the amount of ligamentous damage and displacement that occurs. In all but the most severe dislocations, treatment consists of initial sling immobilization and early functional rehabilitation. The outcome is usually excellent with full return of function following these injuries. The rarer types (IV, V, and VI) require operative reduction and fixation. Distal clavicle fractures are related injuries, which many times disrupt the stabilizing ligaments of the acromioclavicular joint. Many can be treated nonoperatively, but there are several subtypes that should be considered for early fixation to reduce complications of pain and shoulder dysfunction. An atraumatic, overuse condition, which is becoming more prevalent and seems related to weight training, is osteolysis of the distal clavicle. There is insidious onset of shoulder pain with symptoms and signs consistent with acromioclavicular pathology. Activity modification is the best method of controlling symptoms. Failure of the conservative approach necessitates operative excision of the distal clavicle.

Arthroscopic distal clavicle resection for isolated atraumatic osteolysis in weight lifters

Ten consecutive patients with isolated atraumatic osteolysis of the distal clavicle who had failed results with conservative treatment were treated with arthroscopic resection of the involved distal clavicle (average, 4.5 mm). All patients were men with an average age of 30.4 years, had unilateral involvement, and were considered aggressive amateur to elite weight lifters or bodybuilders. Postoperative symptoms consisted of pain at the incision and discomfort from extravasation of the irrigation fluid. At an average followup of 18.7 months, all patients had returned to their sport (average, 3.2 days) and to their preoperative weight training program (average, 9.1 days). They continued to be asymptomatic throughout the follow-up period and were able to increase both their training volume and strength from preoperative levels. Limited arthroscopic resection of the distal clavicle for isolated atraumatic osteolysis is a viable alternative for the weight lifter or bodybuilder. The ability to continue training without significant interruption as well as a more acceptable cosmetic appearance are benefits for these patients. Limited arthroscopic resection of the distal clavicle may be sufficient for this entity in this patient population, rather than the 1 to 2 cm previously reported. A sport-specific functional outcome questionnaire has been developed for this patient population.

The results of operative resection of the lateral end of the clavicle

Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, fine to thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups. The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p<0.01). Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity, and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p<0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p<0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular osteoarthrosis. We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters.

The arthroscopic Mumford procedure: an analysis of results

A total of 50 arthroscopic distal clavicle resections were performed for acromioclavicular joint pathology at our institution between 1990 and 1993. Follow-up on 50 shoulders (100%) was obtained at an average postoperative time of 2 years. Data were collected via physical examination, radiograph review, University of California at Los Angeles (UCLA) shoulder score, and questionnaire. Average patient age was 42 years. Preoperatively all patients showed acromioclavicular joint tenderness, whereas 80% had a positive adduction test. The diagnosis of acromioclavicular degeneration was made by a combination of physical examination and radiographs (100%), acromioclavicular joint injection (4%), bone scan (44%), and magnetic resonance imaging (30%). Intraoperatively, a Claviculizer (Smith-Nephew Dyonics, Andover, MA) burr was used through standard portals in a subacromial approach to the acromioclavicular joint. There were no intraoperative complications. Forty-one patients (82%) had their general anesthetic augmented with an intrascalene block, and all procedures were done on an outpatient basis. The average distal clavicle resection was 14.8 mm. Calcifications within the resected clavicle zone were noted in the shoulders of four of the patients (16%) who returned for radiographic follow-up. The UCLA shoulder score ranked 47 shoulders (94%) good to excellent and 3 fair (6%). Subjective patient satisfaction recorded 47 (94%) good to excellent results, with an average pain relief grade of 87%. Forty-five patients (98%) would recommend the procedure. The arthroscopic Mumford procedure effectively treats acromioclavicular joint pathology. The amount of bone removed can be precisely determined with the Claviculizer burr and reliably reproduced. The procedure has low associated morbidity and high patient satisfaction regarding functional outcome.

Arthroscopic resection of the distal clavicle with a superior approach

Forty-one patients (41 shoulders) with acromioclavicular joint disease refractory to conservative treatment underwent arthroscopic distal clavicle resection. Thirty-one men and 10 women with an average age of 32 years were studied. The dominant extremity was involved in 68% of the patients. At an average follow-up period of 31 months (range 24 to 49 months), 18 excellent, 16 good, and seven poor results were found. Twenty-seven (93%) of 29 shoulders with acromioclavicular arthritis or osteolysis of the distal clavicle went on to have satisfactory results compared with only seven (58%) of 12 shoulders with previous grade II acromioclavicular separations or acromioclavicular hypermobility. Total amount of bone removal did not correlate with success, if the resection was even. Five reoperations were done; one uneven resection was revised with arthroscopy, and four shoulders underwent acromioclavicular stabilization procedures. The high failure rate in patients with even subtle acromioclavicular instability (42%) suggests that in these cases formal stabilization with ligament reconstruction should be considered in addition to resection of the distal clavicle.