Outcome of distal clavicle resection in patients with acromioclavicular joint osteoarthritis and full-thickness rotator cuff tear

Evaluating the Effect of Rotator Cuff Repair With Concomitant Distal Claviculectomy on 2 and 4 Year Reoperation Rates

BACKGROUND

The current literature has differing views on the efficacy of concomitant distal claviculectomy (DC) during rotator cuff repair (RCR) in preventing revision surgery. Our aim was to investigate the revision surgery rate between RCR with DC and RCR without DC.

METHODS

A retrospective cohort analysis was conducted using a national claims database. Patients undergoing open or arthroscopic primary RCR with or without concomitant DC were identified. The primary outcome was 4-year revision surgery rates. Univariate analysis was conducted using chi-square or Student t tests. Multivariable analysis was conducted using logistic regression, and an adjusted number needed to harm was calculated.

RESULTS

A total of 131,232 patients met inclusion criteria. After logistic regression, patients undergoing RCR with DC had higher odds of requiring a subsequent DC procedure [OR; 95% CI; P-value (1.49; 1.35-1.64; P < 0.001)] but lower odds of any revision surgery (0.87; 0.80-0.91; P < 0.001) within 4 years than those who underwent RCR without DC.

CONCLUSION

Although associated with a lower rate of overall revision surgeries within 2 and 4 years of RCR, those who underwent RCR with DC were 85% more likely at 2 years and 49% more likely at 4 years to undergo revision surgery of the distal clavicle than those without concomitant DC.

A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

Background

This systematic review aims to comprehensively summarise and present the available evidence for the treatment of primary acromioclavicular joint (ACJ) osteoarthritis (OA).

Methods

Five databases were searched for studies investigating the management of ACJ OA. Included were studies with participants with clinical/radiological signs of primary ACJ OA, an intervention and included a functional outcome measure.

Results

Forty-eight studies were included. Treatments consisted of physiotherapy (n = 1 study), medical only (n = 11) and operative management (n = 36). Operative studies included five comparative trials - physiotherapy versus surgery (n = 1) and open versus arthroscopic resection (n = 4). A total of 1902 shoulders were treated for ACJ OA, mean age (51 years), 58% male and mean follow-up (28.5 months). Treatment with injection showed a mean improvement of 50% in pain levels at follow-up (mean = 7.5 months). The commonest surgical procedure was arthroscopic excision of the distal clavicle and operative studies averaged 6 months of conservative management and a mean functional outcome of 87.8%.

Conclusion

Studies varied in indication, intervention and quality but it did not provide evidence that both non-operative and operative interventions are effective. There was no significant difference between open or arthroscopic distal clavicle excision (DCE). Participants having between 0.5 and 2 cm of clavicle excised had good outcomes and those requiring concomitant shoulder procedures had similarly good outcomes.

Patient outcomes following arthroscopic distal clavicle excision: a prospective case series

Background

Distal clavicle excision for acromioclavicular joint (ACJ) pathology is currently the mainstay of surgical management in patients with symptoms refractory to nonoperative treatment. There have been few high quality studies outlining the efficacy of arthroscopic excision of the distal clavicle as a single procedure in patients with isolated disease.

Aim

To characterize function and pain outcomes in patients undergoing arthroscopic distal clavicle excision by utilizing stringent inclusion criteria to isolate ACJ pathology.

Methods

Prospective data collection was undertaken with a minimum two year follow-up of 59 patients undergoing arthroscopic distal clavicle excision for ACJ osteoarthritis or distal clavicle osteolysis. Stringent eligibility criteria were applied to each patient. Data collection consisted of demographic data, clinical assessment of range of motion, and patient-reported outcome measures (PROMs), utilizing the standardized Shoulder Pain and Disability Index (SPADI) and the Visual Analogue (VAS) score to characterize pain. Furthermore, time to return to work and sport and a subjective measure of how 'normal' the shoulder felt were assessed. Data was recorded preoperatively, and at six, 12, and 24 months postoperatively. Statistical analysis was conducted utilizing institutional support.

Results

Statistically significant improvements in range of motion measurements (abduction, forward elevation and external rotation), and PROMs (SPADI and VAS scores) were reported. VAS scores reduced from an average of 8.20 preoperatively to 3.39 (P < .001), 2.13 (P < .001) and 1.36 (P < .001) at 6, 12, and 24 month follow-up, respectively. Similarly, SPADI scores reduced from an average of 62.65 preoperatively to 19.96 (P < .001), 12.6 (P < .001), and 6.13 (P < .001) at 6, 12, and 24 months, respectively. The majority of patients were able to return to sport and work, within an average time of 1.72 and 3.02 months.

Conclusion

In patients who presented with isolated ACJ pathology, arthroscopic distal clavicle excision, as a single procedure, results in statistically significant improvements in PROMs and functional outcomes.

Morphology of the acromioclavicular-joint score (MAC)

INTRODUCTION

To date there is no generally accepted specific definition or classification of acromioclavicular (AC) joint osteoarthritis. The aim of this study is to analyze morphological parameters using magnetic resonance imaging (MRI) and to develop a scoring system as a basis for decision making to perform an AC-joint resection.

MATERIALS AND METHODS

In a retrospective-monocentric matched pair study, healthy and affected subjects were investigated using T2 MRI scans in the transverse plane. There were two groups, group 1 (n = 151) included healthy asymptomatic adults with no history of trauma. In group 2, we included n = 99 patients with symptomatic AC joints, who underwent arthroscopic AC-joint resection. The central and posterior joint space width and the AC angle were measured. Morphological changes such as cartilage degeneration, cysts and bone edema were noted. Malalignment of the joint was defined as: posterior joint space width < 2 mm in conjunction with an AC angle > 12°. A scoring system consisting of the measured morphologic factors was developed.

RESULTS

Symptomatic and asymptomatic patients showed significant differences in all measured items. We observed a significant difference in the MAC score for symptomatic and asymptomatic patients (mean 10.4 vs. 20.6, p = 0.0001). The ROC (receiver operator characteristic) analysis showed an excellent AUC of 0.899 (p = 0.001). The sensitivity of the MAC score was 0.81 and the specificity 0.86. The MAC score shows a significant moderate correlation with age (r = 0.358; p = 0.001). The correlation of age and the development of symptoms was only weak (r = 0.22, p = 0.001). Symptomatic patients showed significantly more frequent malalignment compared to asymptomatic patients (p = 0.001), but the positive predictive value that a patient with malalignment is also symptomatic is only 55%.

CONCLUSION

Patients with symptomatic AC joints showed a typical pattern of morphological changes on axial MRI scans with early posterior contact of the joint surfaces, reduction of joint space and malalignment as the basis for the development of a scoring system. The MAC score shows excellent test characteristics, and therefore, proved to be both an appropriate guidance for clinical practice as well as an excellent tool for comparative studies and is superior to the assessment of malalignment alone.

LEVEL OF EVIDENCE

Level IV, retrospective diagnostic study.

Prognostic factors for improvement of shoulder function after arthroscopic rotator cuff repair: a systematic review

Background

The identification of factors that specify prognostic models for postoperative results should be based on the best scientific evidence and expert assessment. We aimed to identify, map, and evaluate potential prognostic factors for the improvement of shoulder function in patients undergoing arthroscopic rotator cuff repair.

Methods

Longitudinal primary studies of arthroscopic rotator cuff repair reporting any multivariable factor analyses for shoulder function improvement with an endpoint assessment of at least 6 months were included. We systematically searched EMBASE, Medline, and Scopus for articles published between January 2014 and June 2021. The risk of bias of included studies and the quality of evidence were assessed using the Quality in Prognosis Studies tool and an adapted Grading of Recommendations, Assessment, Development, and Evaluations framework.

Results

Overall, 24 studies including 73 outcome analyses were included. We classified younger age and smaller tear size as probably prognostic for a greater improvement in objective outcomes. Shorter symptom duration, absence of a worker compensation claim, low preoperative level of functional status, and high preoperative pain level were classified as probably prognostic for greater improvement in patient-reported outcome measures. The quality of the synthesized evidence was low. Twenty-one studies had an overall high risk of bias.

Conclusion

Six potential prognostic factors for shoulder function after arthroscopic rotator cuff repair were identified. Along with ongoing expert opinion assessments, they will feed into a prognostic model-building process.

Shoulder impingement: various risk factors for supraspinatus tendon tear: A case group study

A total of 680 cases of monolateral shoulder pain and functional impairment were included, and Chi-Squared tests was incorporated to test for possible associations.No relation between impingement syndrome and potential risk factors was found, such as presence of down slopping (P = .083), presence of ossification acromiale (P  = .102), presence of calcific tendinitis (P  = .144), types of acromion (I [P = .600], II [P = .536], III [P = .633] and IV [P = .832]) and grade of acromioclavicular degenerative changes (mild [P = .077], moderate [P = .111], and severe [P = .700]). However, a significant relationship was uncovered between impingement syndrome and risk factors such as gender (X2 = 7.004, df = 1, P = .08) (where females were more prone), history of shoulder dislocation (X2 = 19.440, df = 1, P = .001), presence of supraspinatus tendon tear or tendinopathy (X2 = 69.344, df = 1, P = .001) and supraspinatus complete tear (X2 = 13.593, df = 1, P = .001). A significant relationship was found between the type of supraspinatus pathology and factors such as gender (female more prone) (X2 = 34.719, df = 3, P = .01), presence of down slopping (X2 = 57.765, df = 3, P = .01), history of shoulder dislocation (X2 = 148.880, df = 3, P = .001), type III of the acromion (X2 = 12.979, df = 3, P = .005), presence of acromioclavicular generative changes mild (X2 = 76.408, df = 3, P = .001) and moderate (X2 = 29.697, df = 3, P = .001), and acromiohumeral distance of ≤3 mm (X2 = 18.915, df = 3, P = .001), 3.1 to 6 mm (X2 = 13.212, df = 3, P = .004), and 9.1-12 mm (X2 = 15.066, df = 3, P = .002). Overall, the Magnetic Resonance Imaging results yielded high sensitivity for detecting full-thickness supraspinatus tears.Considering the findings, this study may help radiologists understand the salient risk factors and identify which factors are mainly responsible for supraspinatus tendon tears and the respective grade of tear (articular partial, bursal partial, complete, or tendinopathy).

Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair

PURPOSE

To evaluate the significance of untreated primary acromioclavicular joint (ACJ) osteoarthritis, encountered during arthroscopic rotator cuff repair (RCR), as a cause of persistent symptomatology and need for revision surgery.

METHODS

In a cohort of 811 consecutive patients older than 55 years who underwent RCR, the effect of primary ACJ osteoarthritis presence was prospectively examined. A total of 497 patients with mild/moderate and severe ACJ osteoarthritis based on preoperative MRI evaluation were allocated to Group A (n = 185, symptomatic ACJ) and Group B (n = 312, asymptomatic ACJ). Distal clavicle excision was not performed regardless of the presence of pain. The minimum follow-up was 28 months (28-46). The visual analogue scale (VAS) pain scores were assessed for ACJ pain on palpation, the cross body adduction test, the Constant-Murley, and the American Shoulder and Elbow Surgeons (ASES).

RESULTS

The overall loss to follow-up rate was 3.82% (19 patients: 11 in Group A and eight in Group B). The mean ASES score at the latest follow-up was 91.16 ± 9.3 and 92.37 ± 10.44 in Groups A and B, respectively, and the mean Constant-Murley score was 96.36 ± 5.7 and 95.76 ± 4.6 in Groups A and B, respectively. There was no statistical significance between regarding both scores. Localised ACJ pain on palpation and pain on cross body adduction were diminished in both the symptomatic and asymptomatic group. There were five cases (1%: two in Group A and three in Group B) with persistent ACJ pain who had failed the conservative treatment, and ACJ excision was necessary to alleviate the symptoms. All revision operations were uncomplicated with symptom resolution.

CONCLUSION

Untreated ACJ osteoarthritis, symptomatic or not, encountered during arthroscopic RCR is associated with a low percentage of failure. Routine distal clavicle excision is not absolutely necessary, even in patients with symptomatic ACJ osteoarthritis.

LEVEL OF EVIDENCE

II, Prospective cohort study.

Management of Acromioclavicular Osteoarthritis in Rotator Cuff Tears: A Scoping Review

Purpose  The treatment of acromioclavicular joint (ACJ) osteoarthritis during shoulder arthroscopy is a discussed topic. The aim of this scoping review is to report the current recommendations regarding the management of this disorder in patients undergoing surgery for rotator cuff tears.

Methods  A scoping review was performed in Pubmed\Medline and Embase in March 2017, restricted to English language literature. The following keywords were used: (“rotator cuff tear” OR ” rotator cuff” OR “rotator cuff repair”) AND (“acromioclavicular joint arthritis” OR “ac joint arthritis” OR “ac joint” OR “acromioclavicular joint”). Inclusion criteria were randomized controlled trials, prospective cohort studies, retrospective trials, and therapeutic case series. Exclusion criteria were reviews, meta-analyses, and expert opinions.

Results  Two retrospective studies and three randomized controlled trials were identified. Clinical studies reported results of 443 shoulders, with an average age of 60.48 years and a mean follow-up of 31.7 months. Many differences were found regarding the design of the studies, patient's selection, surgical procedures, and instrumental and clinical evaluations. No statistically significant differences were found in clinical outcome scores between patients that underwent rotator cuff repair in association with distal clavicular resection and patients with isolated rotator cuff repair.

Conclusion  Results of this scoping review underline a lack of evidence-based recommendations about the management of ACJ osteoarthritis in association with arthroscopic rotator cuff repair. Surgical procedures such as distal clavicle resection (DCR) should be performed carefully in this cohort of patients. More prospective randomized studies are needed to reach a consensus about the correct surgical approach to DCR in patients with signs of ACJ osteoarthritis and rotator cuff tears.

Level of Evidence  Level III.

Arthroscopic Distal Clavicle Resection Through the Supraspinatus Fossa Portal

Disorders of the acromioclavicular (AC) joint quite often necessitate distal clavicle resection (DCR). Arthroscopic DCR is favored because of it is mini-invasive and convenient to treat concomitant intraarticular or subacromial lesions. In previous reports, arthroscopic DCR was performed through the anterior portal with the patient in beach chair position. However, when the patient is in the lateral decubitus position, it is inconvenient to perform DCR through the anterior portal. Thus, we introduce a special DCR technique through the supraspinatus fossa (SSF) portal. The critical point of this technique is viewing the acromioclavicular joint through the routine posterior portal, creating the SSF portal at the anterior edge of the scapular spine and the same medial-to-lateral level to the AC joint, and enough removal of the posterior edge of the distal clavicle. We believe the introduction of this technique will provide a special technical option when DCR is needed.

Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

BACKGROUND

Asymptomatic acromioclavicular osteoarthritis (AC-OA) is a frequent finding in shoulder magnetic resonance imaging (MRI). Its natural course is unknown. Therefore, the question arises whether a resection should be performed simultaneously with shoulder surgery for another reason to prevent future pain and reoperation. The purpose of this study was to investigate the mid-term course of asymptomatic AC-OA.

METHODS

Overall, 114 asymptomatic AC-OA diagnosed on MRI were followed for 7 years between 2011 and 2018. At baseline, MRI signal enhancement in the clavicle and acromion, OA grade, physical demand as well as the parameters (1) Constant Score Visual Analogue Scale, (2) pain on AC-joint compression, and (3) cross-body adduction test were measured. All patients were followed up after 7 years by interview, and in case of symptoms by clinical examination. The endpoint "deterioration" was reached if 2 of the 3 parameters turned worse.

RESULTS

Asymptomatic AC-OA remained asymptomatic in 83% of cases, 7% turned better, 10% turned worse. Physical demand and osteoarthritis grade increased the risk of deterioration, whereas MRI signal enhancement in the clavicle or acromion had no influence on outcome. During follow-up, the frequency of pain on AC-joint compression increased from 11% to 16% (P = .24), the frequency of a positive cross-body adduction test increased from 6% to 20% (P = .017), and the mean Constant Score Visual Analogue Scale increased from 10 to 13 points (P < .001) indicating less pain.

CONCLUSIONS

Asymptomatic AC-OA remained asymptomatic in 90% over 7 years. A simultaneous resection of an asymptomatic AC-OA during shoulder surgery for another reason is not indicated in every patient.

Preoperative Factors Associated With Subsequent Distal Clavicle Resection After Rotator Cuff Repair

Background:

Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident.

Purpose:

To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision.

Results:

In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery.

Conclusion:

This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered.

Is routine distal clavicle resection necessary in rotator cuff repair surgery? A systematic review and meta-analysis

BACKGROUND

The objective of the present study was to perform a systematic review and meta-analysis of randomized controlled trials looking at the effect of distal clavicle resection in patients undergoing rotator cuff repair (RCR).

METHODS

A systematic literature search was undertaken to identify randomized controlled trials looking at RCR +/- distal clavicle resection. Primary clinical outcome measures included in the meta-analysis were American Shoulder Elbow Society (ASES) score, pain on visual analogue scale and range of motion in forward elevation.

RESULTS

The systematic review identified three studies with a total of 203 participants. Those who underwent distal clavicle resection in conjunction with RCR had worse pain and acromioclavicular joint tenderness at 3-month follow-up. This difference, however, was not observed at the 24-month follow-up. The mean difference (95% confidence interval) for the ASES score was 0.45 (-3.67 to 4.58) and pain on visual analogue scale was - 0.27 (-0.70 to 0.16).

CONCLUSIONS

Routine distal clavicle resection in the setting of rotator cuff repair does not result in improved outcomes for patients with no difference being observed at 24 months post surgery. The results of our systematic review and meta-analysis do not support routine distal clavicle resection when performing RCR.

Does Distal Clavicle Resection Decrease Pain or Improve Shoulder Function in Patients With Acromioclavicular Joint Arthritis and Rotator Cuff Tears? A Meta-analysis

BACKGROUND

Acromioclavicular joint arthritis is a common, painful, and often missed diagnosis, and it often accompanies other shoulder conditions such as rotator cuff disease. Whether distal clavicle resection is important to perform in patients undergoing surgery for rotator cuff tears and concomitant acromioclavicular joint arthritis is controversial.

QUESTIONS/PURPOSES

The purpose of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of distal clavicle resection on (1) outcome scores; (2) shoulder ROM, joint pain or tenderness, and joint instability; and (3) risk of reoperation among patients treated surgically for rotator cuff tears who had concomitant acromioclavicular joint arthritis.

METHODS

We systematically searched the PubMed, EMBASE, and Cochrane databases to find RCTs that met our eligibility criteria, which, in summary, (1) compared rotator cuff repair plus distal clavicle resection with isolated rotator cuff repair for patients who sustained a full- or partial-thickness rotator cuff tear and concomitant acromioclavicular joint arthritis; and (2) the followup period was at least 2 years. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis. Statistical heterogeneity among studies was quantitatively evaluated with the I index. No heterogeneity was detected (I = 0%; p = 0.75) in terms of acromioclavicular joint pain or tenderness, Constant score, forward flexion, external rotation, and risk of reoperation, so fixed-effect models were used in these endpoints. Heterogeneity was moderate for the American Shoulder and Elbow Surgeons (ASES) score (I = 53%; p = 0.12) and low for the visual analog scale (VAS) score (I = 35%; p = 0.22), so random-effect models were used in these endpoints. Subgroup analysis was stratified by the symptom of acromioclavicular joint arthritis. Three RCTs with 208 patients were included. We evaluated the risk of bias using the Cochrane risk-of-bias tool; in aggregate, the three RCTs included showed low to intermediate risk, although not all parameters of the Cochrane tool could be assessed for all studies.

RESULTS

There was no difference between the distal clavicle resection plus rotator cuff repair group and the isolated rotator cuff repair group in ASES score (mean difference =1.41; 95% confidence interval [CI], -3.37 to 6.18; p = 0.56) nor in terms of the VAS score and Constant score. Likewise, we found no difference in ROM of the shoulder (forward flexion, internal rotation, and external rotation) or acromioclavicular joint pain or tenderness between the groups (pooled results of acromioclavicular joint pain or tenderness: risk ratio [RR], 1.59; 95% CI, 0.67-3.78; p = 0.30). Acromioclavicular joint instability was only detected in the rotator cuff repair plus distal clavicle resection group. Finally, we found no difference in the proportion of patients undergoing repeat surgery between the study groups (pooled results of risk of reoperation for the rotator cuff repair plus distal clavicle resection and isolated rotator cuff repair: one of 52 versus two of 78; RR, 0.86; 95% CI, 0.11-6.48; p = 0.88).

CONCLUSIONS

Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder ROM and was not associated with a lower risk of reoperation. Distal clavicle resection might cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Arthroscopic distal clavicle resection is not recommended in patients with rotator cuff tears and concomitant acromioclavicular joint arthritis. Additional well-designed RCTs with more participants, long-term followup, and data on patient-reported outcomes are needed.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Editorial Commentary: The "Mumford" & Sons: For Distal Clavicle Excisions, What Are Our Young Surgeons Doing, and How Well Are They Doing It?

The distal clavicle excision (DCE, also known as the "Mumford" procedure), either open or arthroscopic, is a time-honored procedure with generally excellent and predictable results. Surgeons have a choice to make regarding which technique to perform, and most surgeons choose the arthroscopic approach. This choice is justified, as complication rates are lower for arthroscopic DCE than for open DCE. A well-performed arthroscopic DCE should have a very low complication rate and high success rate.