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

Iatrogenic Excessive Clavicle Resection as a Complication of Arthroscopic Distal Clavicle Excision

Arthroscopic distal clavicle excision (DCE) is a reliable procedure to treat acromioclavicular joint arthritis. Typically, only 1 to 2 cm of distal clavicle should be removed. Resection of too much bone can lead to instability of the joint or lack of support to the shoulder. We describe 2 patients who had excessive clavicular bone removed arthroscopically, leading to irreparable clavicular pain and dysfunction. The 2 female patients, ages 56 and 60 years, presented to our clinic with continued pain after DCE. Both had pain intractable with nonoperative treatment and loss of range of motion of the shoulder. Radiographs revealed a distal clavicle defect of 7.5 cm in 1 patient. The second patient had a 2-cm distal clavicular defect with an adjacent 2-cm clavicle bone fragment between the defect and residual clavicle shaft. Both underwent surgery with subtotal claviculectomy for pain control. During surgery, 1 patient had a subclavian vein requiring vascular repair. After 1 year of follow-up, both patients had reduced but residual pain and restricted range of motion. Only 1 patient could rejoin her preinjury occupation. Neither patient could continue with preinjury recreational sports. Excessive removal of the distal clavicle during DCE can result in continued pain and disability of the shoulder. Methods to visualize the anatomy of the distal clavicle and its articulation to the acromion should be considered when performing this operation arthroscopically. Reoperation to remove subtotal clavicle has good clinical outcomes but may lead to serious complications due to the proximity to major neurovascular structures. [Orthopedics. 2024;47(1):e57-e60.].

Nanoscopic Distal Clavicle Resection

Acromioclavicular joint pathology such as osteoarthritis has historically been treated with either an open or arthroscopic distal clavicle resection. Over the years the trend has been toward more minimally invasive treatment options with the arthroscope. In this article we highlight the use of the nanoscope to visualize the resection which can be performed through a small percutaneous incision. The advantages of this technique include the use of smaller portals, which should lead to improved earlier outcomes, and less iatrogenic damage to the shoulder.

Arthroscopic distal clavicle excision is associated with fewer postoperative complications than open

Background

The rate of complications of open compared to arthroscopic distal clavicle excision remain poorly studied. Therefore, the purpose of this investigation was to (1) Identify most recent national trends in the usage of open vs. arthroscopic approaches for distal clavicle excision (DCE) from 2007 to 2017; (2) to identify and compare the complication rates for both approaches, and to identify patient-specific risk factors for complications; (3) to identify and compare the revision rate for both approaches; and (4) to identify and compare the reimbursement of each approach.

Methods

The PearlDiver database was reviewed for patients undergoing DCE from 2007 to 2017. Patients were stratified into 2 cohorts: those undergoing arthroscopic DCE (n = 8933) and those undergoing open DCE (n = 2295). The rate of postoperative complications within 90 days was calculated and compared. The revision rate and reimbursement of the arthroscopic and open approach were compared. Statistical analysis included chi-square testing to compare the rates of postoperative complications and multivariate logistic regression analysis to identify risk factors for complications within 90 days. Results were considered significant at P < .05.

Results

The percentage of DCEs performed arthroscopically has significantly increased from 53.9% in 2007 to 69.8% in 2016, with a concomitant decrease in the use of open DCE from 46.1% in 2007 to 30.2% in 2016. The open approach was associated with significantly more postoperative complications, including a significantly greater incidence of surgical site infection (1.9% vs. 0.3%; P < .001), wound disruption (0.3% vs. 0.1%; P < .001), hematoma (0.9% vs. 0.2%; P = .001), and transfusion (0.6% vs. 0.1%; P < .001), than arthroscopic DCE. Several risk factors, including open approach, diabetes, heart disease, tobacco use, chronic kidney disease, and female gender, were identified as independent risk factors for complications after DCE. There was no significant difference in revision rate between open and arthroscopic approaches (P = .126). The reimbursement of open and arthroscopic DCE procedures were comparable, with median reimbursements of $5408 and $5,447, respectively (P = .853).

Conclusion

Both arthroscopic and open DCE techniques were found to have similar reimbursement amounts, with a low rate of complications, although the open technique had a higher rate of early complications such as surgical site infection. Over the study period, there was an increase in the utilization of arthroscopic DCE, while the incidence of the open technique remained constant.

Percutaneous distal clavicle excision for acromioclavicular joint arthritis: our experience and early results of a novel surgical technique

PURPOSE

Symptomatic acromioclavicular joint (ACJ) osteoarthritis causes pain and limitations in activities of daily living. Open and arthroscopic distal clavicle excision techniques have been described with good outcomes. However, both techniques have their own sets of advantages and disadvantages. This study describes a novel technique of percutaneous distal clavicle excision for symptomatic ACJ osteoarthritis and our two-year results.

METHODS

Fifteen consecutive patients underwent percutaneous distal clavicle excision for ACJ arthritis. These patients had failed a trial of conservative treatment. The ACJ was confirmed as the pain generator with an intraarticular steroid/lignocaine injection, and shoulder MRI was used to exclude alternative pain generators in the shoulder. They had a minimum of two years of follow-up.

RESULTS

At a mean of 26.8 months postoperatively, the mean VAS pain score was 0, and the mean Constant score for the shoulder was 87.3 points (range 50-94), which corresponded to 1 good, 1 very good and 13 excellent results. The mean SF-36 score was 94.9 points (range 65-100). There were statistically significant improvements in the VAS scores, Constant shoulder scores and SF-36 scores at one year and two years of follow-up (p < 0.05). Three unique complications, namely subcutaneous emphysema, "missing" of the distal clavicle and thermal skin injury, were encountered. Our surgical technique has since been modified to circumvent these complications.

CONCLUSION

Our novel technique of percutaneous distal clavicle excision yields a 93.3% good-to-excellent results based on the Constant shoulder score and durable pain relief based on VAS at two years.

Open versus arthroscopic acromioclavicular joint resection: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a meta-analysis comparing open and arthroscopic surgical techniques for distal clavicle resection.

METHODS

A systematic review of Medline, Embase, Scopus, and Google Scholar identified relevant publications in the English and German literature between 1997 and 2017. All included studies were levels I-IV, describing both treatments, with a minimum of 12 month follow-up, had at least one validated outcome score and documented patient recruitment, study design, demographic details, and surgical technique. Studies were excluded if they were only abstracts or conference proceedings, involved revision procedures, or the loss to follow-up exceeded 20%. Publication bias and risk of bias were assessed using the Cochrane Collaboration tools, and heterogeneity was assessed using the I² statistic.

RESULTS

Four studies (n = 319 patients) met the criteria for inclusion. The pooled estimate for clinical outcomes (Constant, ASES) demonstrated no significant differences (SMD 0.323, I² = 0%, p = 0.065) between open and arthroscopic resection, although the analysis favored open resection. The pooled estimate for clinical outcomes (SST) also demonstrated no significant differences (SMD 0.744, I² = 49.82%, p = 0.144) between open and arthroscopic resection, but the analysis again favored open resection. The pooled estimate for VAS assessment of pain demonstrated no differences (SMD 0.217, I² = 58.96%; p = 0.404) between open and arthroscopic resection.

CONCLUSION

The results of this study suggest that similar functional and clinical outcomes can be achieved with either open or arthroscopic distal clavicle resection. The observed trend that open resection may have a more favorable outcome warrants further investigation.

LEVEL OF EVIDENCE

Level 3; systematic review and meta-analysis.

Trends in the Surgical Management of Acromioclavicular Joint Arthritis Among Board-Eligible US Orthopaedic Surgeons

PURPOSE

(1) Define the epidemiologic trend of distal clavicle excision (DCE) for acromioclavicular (AC) joint arthritis among board-eligible orthopaedic surgeons in the United States, (2) describe the rates and types of reported complications of open and arthroscopic DCE, and (3) evaluate the effect of fellowship training on preferred technique and reported complication rates.

METHODS

The American Board of Orthopaedic Surgery (ABOS) database was used to identify DCE cases submitted by ABOS Part II Board Certification examination candidates. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into 2 groups: open or arthroscopic DCE. The 2 groups were then analyzed to determine trends in annual incidence, complication rates, and surgeon fellowship training.

RESULTS

From April 2004 to September 2013, there were 3,229 open and 12,782 arthroscopic DCE procedures performed and submitted by ABOS Part II Board Eligible candidates. Overall, the annual incidence of open DCE decreased (78-37 cases per 10,000 submitted cases, P = .023). Although the annual number of arthroscopic DCE remained steady (1160-1125, P = .622), the percentage of DCE cases performed arthroscopically increased (65%-79%, P = .033). Surgeons without fellowship training were most likely to perform a DCE via an open approach (31%) whereas surgeons with sports medicine training were more likely to perform DCE arthroscopically compared with other fellowship groups (88%, P < .001). Open DCE was associated with a higher surgical complication rate overall when compared with arthroscopic DCE (9.4% vs 7.6%, respectively; P < .001). When compared with other fellowship-trained surgeons, sports medicine surgeons maintained a lower reported surgical complication rate whether performing open or arthroscopic DCE (5.5%, P = .027).

CONCLUSIONS

In recent years, open management of AC joint arthritis has declined among newly trained, board-eligible orthopaedic surgeons, possibly because of an increased complication rate associated with open treatment. Fellowship training was significantly associated with the type of treatment (open vs arthroscopic) rendered and complication rates.

LEVEL OF EVIDENCE

Level IV, case series.

Bipolar Acromioclavicular Joint Resection

Acromioclavicular (AC) joint arthropathy remains one of the most common causes of shoulder pain. In the case of AC joint arthropathy resistant to conservative treatment, most authors have recognized distal clavicle resection as the gold-standard treatment. However, some challenges remain to be solved. One is the difficulty in visualization of the superior and posterior part of the distal clavicle from the midlateral portal, causing an incomplete resection of the distal clavicle. This could potentially lead to unresolved pain and therefore surgical failure. We propose a technique for arthroscopic resection of the distal clavicle and the medial portion of the acromion, without any added portal: bipolar AC joint resection. The term "bipolar" is used because both the acromion and the clavicle are resected, without injuring the superior capsule.

Influence of disruption of the acromioclavicular and coracoclavicular ligaments on glenohumeral motion: a kinematic evaluation

Background

Changes to the integrity of the acromioclavicular (AC) joint impact scapulothoracic and clavicular kinematics. AC ligaments provide anterior-posterior stability, while the coracoclavicular (CC) ligaments provide superior-inferior stability and a restraint to scapular internal rotation. The purpose of this cadaveric study was to describe the effect of sequential AC and CC sectioning on glenohumeral (GH) kinematics during abduction (ABD) of the arm. We hypothesized that complete AC ligament insult would result in altered GH translation in the anterior-posterior plane during abduction, while subsequent sectioning of both CC ligaments would result in an increasing inferior shift in GH translation.

Methods

Six cadaveric shoulders were studied to evaluate the impact of sequential sectioning of AC and CC ligaments on GH kinematics throughout an abduction motion in the coronal plane. Following an examination of the baseline, uninjured kinematics, the AC ligaments were then sectioned sequentially: (1) Anterior, (2) Inferior, (3) Posterior, and (4) Superior. Continued sectioning of CC ligamentous structures followed: the (5) trapezoid and then the (6) conoid ligaments. For each group, the GH translation and the area under the curve (AUC) were measured during abduction using an intact cadaveric shoulder. Total translation was calculated for each condition between ABD 30° and ABD 150° using the distance formula, and a univariate analysis was used to compare total translation for each axis during the different conditions.

Results

GH kinematics were not altered following sequential resection of the AC ligaments. Disruption of the trapezoid resulted in significant anterior and lateral displacement of the center of GH rotation. Sectioning the conoid ligament further increased the inferior shift in GH displacement.

Conclusion

A combined injury of the AC and CC ligaments significantly alters GH kinematics during abduction. Type III AC separations, result in a significant change in the shoulder’s motion and may warrant surgical reconstruction to restore normal function.

The Orientation and Variation of the Acromioclavicular Ligament: An Anatomic Study

BACKGROUND

Several biomechanical studies have shown that the acromioclavicular (AC) ligament prevents posterior translation of the clavicle in the horizontal plane. In anatomy textbooks, however, the AC ligament is illustrated as running straight across the AC joint surface.

HYPOTHESIS

The AC ligament does not run straight across the joint surface, and the configuration of the AC ligament may vary.

STUDY DESIGN

Descriptive laboratory study.

METHODS

We used 16 pairs of shoulder girdles in this study. After identifying the AC ligament, we macroscopically investigated the orientation and attachment of the ligament and measured the angle between the ligament and the line perpendicular to the AC joint surface by using a digital goniometer. In addition, the AC joint inclination angle was measured, and the Spearman rank correlation coefficient between the joint inclination and the ligament angle was calculated. Finally, we sought to classify the AC ligament based on its configuration. Of the 16 pairs of specimens, 3 pairs of shoulders were histologically examined.

RESULTS

The AC ligament was divided into 2 parts: a bundle at the superoposterior (SP) part and a bundle at the anteroinferior (AI) part of the joint. The well-developed SP bundle was consistent and ran obliquely at an average ± SD 30° ± 6° in relation to the AC joint surface, from the anterior part of the acromion to the posterior part of the distal clavicle. The joint inclination was 70° ± 12°, and a negative moderate correlation was found between the joint inclination and the ligament angle (P = .02, r = -0.46). In comparison, the AI bundle was thin and narrow, and it could be categorized into 3 types according to its various configurations.

CONCLUSION

The AC ligament could be separated into the SP bundle and the AI bundle. The SP bundle ran posteriorly toward the distal clavicle from the acromion at an average angle of 30° to the joint surface.

CLINICAL RELEVANCE

Anatomic reconstruction, based on the current findings in combination with findings regarding the coracoclavicular ligament, could facilitate improved outcome in the treatment of AC joint disruption.

Effect of pain scrambler therapy on shoulder joint pain and range of motion in patients who had undergone arthroscopic rotator cuff repair for the first time

[Purpose] This study aimed to determine the effect of pain scrambler therapy on shoulder joint pain and range of motion in patients who had undergone arthroscopic rotator cuff repair for the first time. [Subjects and Methods] Pain scrambler therapy was administered once a day every 40 minutes for 10 days to patients that had undergone arthroscopic rotator cuff repair for the first time. The visual analog scale was used to measure pain, and a goniometer was used to measure shoulder range of motion. [Results] After 10 sessions of pain scrambler therapy, pain was significantly reduced from that before the treatment. In addition, shoulder range of motion was increased after 10 treatment sessions. [Conclusion] Thus, pain scrambler therapy greatly reduced pain and increased should range of motion in the patients who had undergone arthroscopic rotator cuff repair for the first time.

Autologous distal clavicle versus autologous coracoid bone grafts for restoration of anterior-inferior glenoid bone loss: a biomechanical comparison

BACKGROUND

Treating anterior glenoid bone loss in patients with recurrent shoulder instability is challenging. Coracoid transfer techniques are associated with neurologic complications and neuroanatomic alterations. The purpose of our study was to compare the contact area and pressures of a distal clavicle autograft with a coracoid bone graft for the restoration of anterior glenoid bone loss. We hypothesized that a distal clavicle autograft would be as effective as a coracoid graft.

METHODS

In 13 fresh-frozen cadaveric shoulder specimens, we harvested the distal 1.0 cm of each clavicle and the coracoid bone resection required for a Latarjet procedure. A compressive load of 440 N was applied across the glenohumeral joint at 30° and 60° of abduction, as well as 60° of abduction with 90° of external rotation. Pressure-sensitive film was used to determine normal glenohumeral contact area and pressures. In each specimen, we created a vertical, 25% anterior bone defect, reconstructed with distal clavicle (articular surface and undersurface) and coracoid bone grafts, and determined the glenohumeral contact area and pressures. We used analysis of variance for group comparisons and a Tukey post hoc test for individual comparisons (with P <.05 indicating a significant difference).

RESULTS

The articular distal clavicle bone graft provided the lowest mean pressure in all testing positions. The coracoid bone graft provided the greatest contact area in all humeral positions, but the difference was not significant.

CONCLUSION

An articular distal clavicle bone graft is comparable in glenohumeral contact area and pressures to an optimally placed coracoid bone graft for restoring glenoid bone loss.

LEVEL OF EVIDENCE

Basic Science Study; Biomechanics.

Limited distal clavicle excision of acromioclavicular joint osteoarthritis

INTRODUCTION

Resection of the distal aspect of clavicle has a well-documented treatment modality in case of acromioclavicular joint osteoarthritis resistant to conservative treatment.

HYPOTHESIS

Limited (mean ∼0.5cm distal end of clavicle resection) distal clavicle excision of A-C joint arthritis in cases resistant to conservative treatment may reduce the pain and improve the shoulder function.

MATERIAL AND METHODS

In this study, we retrospectively evaluated the results of limited distal clavicle excision of acromioclavicular joint osteoarthritis resistant to conservative treatment. All patients were evaluated by using the Visual Analogue Scale (VAS) and UCLA shoulder rating scale (University of California Los Angeles), either before surgery or final follow-up period for pain and functional results, respectively.

RESULTS

A total of 110 patients (48 male, 62 female) with AC joint arthritis, treated between the years of 2008-2012, were retrospectively analyzed. A total of 30 patients (12 male, 18 female) who failed to show improvement with conservative treatment underwent limited surgical open excision of distal clavicle. The mean age of the study population was 52.5±1.2 years. The mean follow-up period was 27±1.3 months. The mean preoperative VAS score was 83.6±5.58 (range, 70-90) while mean VAS was 26.6±9.3 (range, 10-50) at the final follow-up. There was a statistically significant difference between pre- and postoperative VAS scores in patients who had treated by surgical approach (P<0.001). The mean UCLA score of the patients increased postoperatively from 11.5 (range, 9-14) to 29.2 (range, 27-32) at the final follow-up. There was a statistically significant difference between the two time periods with respect to UCLA scores (P<0.001).

DISCUSSION AND CONCLUSION

In patients with AC osteoarthritis resistant to conservative therapy, the hypothesized limited clavicle excision (mean ∼0.5cm distal end of clavicle resection with preserving coracoclavicular ligaments and inferior capsule) reduced the pain and improved the shoulder function.

CONCLUSION

Our midterm follow-up (mean 27 months) results showed that limited distal clavicle excision of patients with AC joint osteoarthritis resistant to conservative treatment (0.5cm distal end of clavicle resection with preserving inferior capsule, and coracoclavicular ligaments) reduced the pain and improved the shoulder function.

LEVEL OF EVIDENCE

IV (Retrospective study).

Arthroscopic resection of the distal clavicle in osteoarthritis of the acromioclavicular joint

BACKGROUND

Symptomatic acromioclavicular joint (ACJ) lesions are a common cause of shoulder complaints that can be treated successfully with both conservative and surgical methods. There are several operative techniques, including both open and arthroscopic surgery, for excising the distal end of the clavicle. Here, we present a new modified arthroscopic technique for painful osteoarthritis of the ACJ and evaluate its clinical outcomes. Our hypothesis was that 4- to 7-mm resection of the distal clavicle in an en bloc fashion would have several advantages, including no bony remnants, maintenance of stability of the ACJ, and reduced prevalence of heterotopic ossification, in addition to elimination of the pathologic portion of the distal clavicle.

MATERIALS AND METHODS

20 shoulders of 20 consecutive patients with painful and isolated osteoarthritis of the ACJ who were treated by arthroscopic en bloc resection of the distal clavicle were included in the study. There were 10 males and 10 females with an average age of 56 years (range 42-70 years). The mean duration of followup was 6 years and 2 months (range 4-8 years 10 months). The results were evaluated using the University of California Los Angeles (UCLA) shoulder rating score.

RESULTS

The overall UCLA score was 13.7 preoperatively, which improved to 33.4 postoperatively. All subscores were improved significantly (P < 0.001). There were no specific complications at the latest followup.

CONCLUSION

It is critical in this procedure to resect the distal clavicle evenly from superior to inferior in an en bloc fashion without any small bony remnants and to preserve the capsule and acromioclavicular ligament superoposteriorly. This arthroscopic procedure is a reliable and reproducible technique for painful osteoarthritis of the ACJ lesions in active patients engaged in overhead throwing sports and heavy labor.

Evaluation and management of adult shoulder pain: a focus on rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral arthritis

Shoulder pain is a common reason for a patient to see their primary care physician. This article focuses on the evaluation and management of 3 common shoulder disorders; rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral joint arthritis. The typical history and physical examination findings for each of these entities are highlighted, in addition to treatment options.

[Arthroscopic resection of the acromioclavicular joint]

OBJECTIVE

Arthroscopic resection of the painful and degenerative altered acromioclavicular (AC) joint without destabilization of the joint and therefore pain relief and improvement in function.

INDICATIONS

Conservative failed therapy of painful AC joint osteoarthritis. Impingement caused by caudal AC joint osteophytes. Lateral clavicular osteolysis.

CONTRAINDICATIONS

General contraindications (infection, local tumor, coagulation disorders), higher grade instability of the AC joint (resection only together with stabilization).

SURGICAL TECHNIQUE

Diagnostic glenohumeral arthroscopy. Treatment of accompanying lesions (subacromial impingement, rotator cuff, long head of biceps). Subacromial arthroscopy with bursectomy (partial) and visualization of the AC joint. Resection of caudal osteophytes. Localization of the anterior portal using a spinal needle in the outside-in technique. Resection of 2-3 mm of the acromial side and the 3-4 mm of the clavicular side with shaver/acromionizer.

RESULTS

An isolated open AC joint resection was performed in 9 studies and an arthroscopic resection in 6 studies. Good and very good results were obtained in 79% (range 54-100%) in open resection and 91% (range 85-100%) in arthroscopic resections. Patients were able to return to activities of daily life more quickly after arthroscopic resections than after open surgery.

How long should arthroscopic clavicular resection be in acromioclavicular arthropathy? A radiological-clinical study (with computed tomography) of 18 cases at a mean 4 years' follow-up

INTRODUCTION

Endoscopic clavicular resection is a common procedure, but few studies have analyzed predictive factors for outcome.

HYPOTHESES

1) Computed tomography (CT) of clavicular resection is reproductible; 2) Functional outcome correlates with resection length; 3) Other factors also influence outcome.

MATERIAL AND METHODS

Patients operated on between 2005 and 2010 were called back to establish functional scores (Constant, Simple Shoulder Test [SST], satisfaction) and undergo low-dose bilateral comparative computed tomography (CT) centered on the acromioclavicular joints. The assessment criteria were resection edge parallelism and resection length, measured using OsiriX software. Radiological and clinical data were correlated.

RESULTS

18 out of 21 patients (85%: 3 female, 15 male) were assessed. Mean age at surgery was 49 years (range, 40-62 yrs); mean follow-up was 4.2 years (1.6-7.2 yrs). Mean Constant score rose from 57.7 (25-85) to 70.2 (30-96); mean postoperative SST was 9.3 (3-12). 11 patients had very good and 4 poor results. CT resection length was reproducible, with intraclass, intra- and interobserver correlation coefficients >95%. There was no significant correlation between articular resection length on CT and functional scores (P=0.2). Functional scores were negatively influenced by an occupational pathologic context (P<0.01) and by associated tendinopathy.

DISCUSSION AND CONCLUSION

Low-dose CT enabled reproducible analysis of clavicular resection. The hypothesized correlation between resection length and functional result was not confirmed. Work accidents and occupational disease emerged as risk factors.

LEVEL OF EVIDENCE

Single-center retrospective analytic cohort study. Level 4, guideline grade C.

Comparison between open and arthroscopic procedures for lateral clavicle resection

PURPOSE

Arthroscopic lateral clavicle resection (LCR) is increasingly used, compared to an open approach, but literature does not clearly indicate which approach is preferable. The goal of this study was to compare function and pain between patients who underwent lateral clavicle resection using an open approach and patients treated using an arthroscopic approach.

METHODS

Patients who underwent LCR between January 2008 and December 2011 were reviewed. After exclusion, 149 shoulders (143 patients) were eligible for analysis: 41 open and 108 arthroscopic. Disabilities of arm, shoulder and hand (DASH) questionnaire and visual analogue scale (VAS) score were used to assess shoulder function and pain. Complications, operative time, length of hospitalization and resection distance were compared.

RESULTS

At a mean follow-up of three years, patients in the open group had significantly less pain by VAS (mm) (Mdn 10, IQR 23) compared with arthroscopic patients (Mdn 20, IQR 50) (p = 0.036). Operative time (minutes) was significantly less for the open approach (Mdn 24.0, IQR 12) compared with arthroscopic (Mdn 38.0, IQR 15) (p < 0.001). Resection distance (mm) was larger for the open approach (Mdn 7.1, IQR 7.0) compared with the arthroscopic approach (Mdn 3.2, IQR 3.1) (p = 0.006), but was not associated with outcome. No significant differences were found for DASH score, complication rate or length of hospitalization.

CONCLUSIONS

Both arthroscopic and open approaches for LCR provide excellent outcome in patients with acromioclavicular pain. Less residual pain was found for the open approach, which has shorter operating time and is likely more cost effective.

Degenerative joint disease of the acromioclavicular joint: a review

Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities. This most commonly occurs in middle-aged individuals because of degeneration to the fibrocartilaginous disk that cushions the articulations. Diagnosis relies on history, physical examination, imaging, and diagnostic local anesthetic injection. Diagnosis can be challenging given the lack of specificity with positive physical examination findings and the variable nature of AC joint pain. Of note, symptomatic AC osteoarthritis must be differentiated from instability and subtle instability, which may have similar symptoms. Although plain radiographs can reveal degeneration, diagnosis cannot be based on this alone because similar radiographic findings can be seen in asymptomatic individuals. Nonoperative therapy can provide symptomatic relief, whereas patients with persistent symptoms can be considered for resection arthroplasty by open or arthroscopic technique. Both techniques have proven to provide predictable pain relief; however, each has its own unique set of potential complications that may be minimized with an improved understanding of the anatomical and biomechanical characteristics of the joint along with meticulous surgical technique.

Symptomatic residual instability with grade II acromioclavicular injury

PURPOSE

Our objective was to evaluate the effectiveness of arthroscopic distal clavicle resection in cases presenting with pain and subtle instability after neglected grade II acromioclavicular (AC) joint dislocation.

METHODS

From February 1998 to May 2006, 17 patients with symptomatic AC instability following chronic grade II AC joint injury were studied. Sixteen patients were male and one female, with a mean age of 48 years. An all-arthroscopic procedure comprising disk removal and distal clavicle resection was performed in all cases. All patients were reviewed clinically, preoperatively and at final follow-up (mean 38 months) using the pain score on a visual analog scale and the Constant score. Strength was measured using an Isobex digital strength analyzer. Patient's personal satisfaction after the procedure was documented as excellent, good or poor. Postoperative AC joint radiographs were routinely obtained in all patients to measure the amount of clavicle resection.

RESULTS

Two patients underwent additional reconstructive surgery for disabling pain and dysfunction even after the arthroscopic resection procedure. The remaining 15 patients were analyzed. The pain scores improved significantly (p = 0.03). The mean pain score was 5.8 (range 5-9) before treatment and 1.6 (range 0-3) at follow-up. The Constant scores had improved significantly at the final follow-up (p = 0.001). The median Constant score increased from 46 (range 36-69) preoperatively to 71 (range 48-84) postoperatively. Strength had improved at the last follow-up. Eleven patients were satisfied and six were not satisfied with this procedure at the final follow-up.

CONCLUSIONS

Arthroscopic distal clavicle resection statistically improved the pain score, Constant score and strength for grade II AC injury with subtle distal clavicle instability. However, six patients (33.5 %) were not satisfied subjectively. This procedure seemed to be a reasonable initial treatment option with lower morbidity.

Arthroscopic versus open distal clavicle excision: a comparative assessment at intermediate-term follow-up

BACKGROUND

While few comparative studies exist, it has been suggested that open distal clavicle excisions (DCEs) provide inferior results when compared with the all-arthroscopic technique.

PURPOSE

The purpose of this study was to compare the intermediate-term (5-year follow-up) results of patients undergoing arthroscopic versus open DCE for the treatment of recalcitrant acromioclavicular joint pain.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent an arthroscopic or open DCE between January 1999 and September 2006 were reviewed. Forty-eight patients (49 shoulders; 32 arthroscopic, 17 open) following DCE without significant glenohumeral pathologic changes were included. The mean follow-up for group I (open) and group II (arthroscopic) was 5.3 years and 4.2 years, respectively. The American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, surgical time, and minimum radiographic acromioclavicular joint distance were calculated. Each patient completed a questionnaire assessing their scar satisfaction, percentage of normal shoulder function, and willingness to have the surgery again. Risk factors for poor outcomes were analyzed.

RESULTS

Arthroscopic patients had significantly less pain (P = .035) by VAS (0.61 ± 1.02) compared with open (1.59 ± 2.15) at final follow-up. There was no significant difference between group I and group II with regard to ASES (87.5 ± 17.6 vs 94.6 ± 8.6), percentage of normal shoulder function (89.7% ± 12.5 vs 92.9% ± 8.6), average operative time (53.1 minutes vs 48 minutes), or radiographic resection distance (12.8 ± 2.1 mm vs 9.5 ± 2.9 mm). In the open group, patients with 16 of 17 shoulders were satisfied with their scar and 100% would do it again. In the arthroscopic group, patients with 31 of 32 shoulders (97%) were both satisfied and would have the surgery again.

CONCLUSION

Open and arthroscopic DCE are both effective surgeries to treat recalcitrant acromioclavicular joint pain. At intermediate-term follow-up, they provide similarly good to excellent results with regard to patient satisfaction and shoulder function. Although both are effective treatments, less residual pain was found using the arthroscopic technique.

Open versus arthroscopic distal clavicle resection

PURPOSE

The purpose of this systematic review was to critically evaluate the available literature in an attempt to compare the outcome of open versus arthroscopic distal clavicle resection in the treatment of acromioclavicular joint pathology.

METHODS

From January 1966 to December 2008, Medline was searched for the following key words: "acromioclavicular joint arthritis," "acromioclavicular osteolysis," "distal clavicle excision," "acromioclavicular joint excision," "Mumford," and "clavicle." Inclusion criteria included studies that compared the outcome of open versus arthroscopic distal clavicle resection. Studies that could not be translated into the English language or were not published in a peer-reviewed journal were excluded. Data were abstracted from the studies, including patient demographics, surgical procedure, rehabilitation, strength, range of motion, and clinical scoring system.

RESULTS

Seventeen studies met the inclusion criteria, including 2 Level II studies, 1 Level III and 14 Level IV studies. Arthroscopic distal clavicle excision results in more "good" or "excellent" outcomes compared with the open procedure. Both arthroscopic techniques result in success rates in excess of 90%, with the direct procedure permitting a quicker return to athletic activities. Performing distal clavicle excision in conjunction with either subacromial decompression or rotator cuff repair also has a high degree of success. A trend toward more "poor" results is seen when distal clavicle excision is performed in patients with post-traumatic acromioclavicular instability or in Workers' Compensation patients.

CONCLUSIONS

Our analysis suggests that among patients undergoing distal clavicle excision for acromioclavicular joint pathology, those having an arthroscopic procedure, specifically through the direct approach, can expect a faster return to activities while obtaining similar long-term outcomes compared with the open procedure.

LEVEL OF EVIDENCE

Level III, systematic review.

The relation of the coracoclavicular ligament insertion to the acromioclavicular jointA cadaver study of relevance to lateral clavicle resection

Resection of the lateral end of the clavicle is a common procedure for arthrosis of the acromioclavicular joint (AC-joint). However, no anatomical data on the distance between the insertions of the coracoclavicular ligaments and the AC-joint have been reported. In 36 cadaver shoulders (18 male), we studied the relation between the AC-joint and the insertions of the joint capsule, trapezoid and conoid ligaments. The distance from the AC-joint to the medial end of its capsule was, on average, 0.7 cm (0.4-0.9) cm in women and 0.8 (0.4-1.2) cm in men. In women, the trapezoid ligament began, on average, at 0.9 (0.4-1.6) cm and ended at 2.4 (2.0-2.8) cm and in men, it began at 1.1 (0.8-1.6) cm and ended at 2.9 (2.1-3.8) cm medial to the AC joint. The corresponding figures for the conoid ligament were 2.6 (2.0-3.7) cm and 4.7 (3.9-6.2) cm. A resection of 1 cm of the lateral clavicle detaches 8%, a resection of 2 cm 60% and a resection of 2.5 cm 90% of the trapezoid ligament. We recommend a maximum resection of 1 cm of the lateral clavicle because a resection of 2 cm or more may cause postoperative AC-joint instability and related pain.

Miscellaneous conditions of the shoulder: anatomical, clinical, and pictorial review emphasizing potential pitfalls in imaging diagnosis

The purpose of this article is to review the key imaging findings in major categories of pathology affecting the shoulder joint including hydroxyapatite deposition disease, rotator cuff interval pathology, acromioclavicular joint pathology, glenohumeral osteoarthrosis, and synovial inflammatory processes, with specific emphasis on findings that have associated pitfalls in imaging diagnosis. The pathophysiology and clinical manifestations of the above mentioned categories of pathology will be reviewed, followed in each section by a detailed pictorial review of the key imaging findings in each category including plain film, computed tomography, and magnetic resonance imaging findings as applicable. Imaging challenges that relate to both diagnosis and characterization will be addressed with each type of pathology. The goal is that after reading this article, the reader will be able to recognize the key imaging findings in major categories of pathology affecting the shoulder joint and will become familiar with the potential pitfalls in their imaging diagnosis.

Complications after open distal clavicle excision

Isolated distal clavicle excision performed as an open procedure has been considered safe and, in the literature, has been considered the standard for comparison with arthroscopic distal clavicle excisions. However, we noticed isolated open distal clavicle excision was associated with a number of complications. We therefore raised two questions about the complication rate in a cohort of our patients who had undergone this procedure: (1) What was the complication rate and how did it compare to that in the existing literature on this subject? and (2) Were the complications in our cohort similar to those previously reported? We studied 42 patients who underwent an isolated distal clavicle excision between 1992 and 2003. There were 27 complications (64%), which was substantially higher than rates previously reported. Complications in our cohort not previously reported included continued acromioclavicular joint tenderness and scar hypertrophy. Our study suggests complications after open distal clavicle excisions may be more frequent than and may differ from previously reported rates and types.

Arthroscopic distal clavicle resection: a biomechanical analysis of resection length and joint compliance in a cadaveric model

PURPOSE

The purposes of this study were to assess the effects of a distal clavicle resection of less than 5 mm on bony contact and compliance in the acromioclavicular (AC) joint and to localize areas of persistent contact in the AC joint. The hypothesis of this study was that AC contact can be avoided by excising less than 5 mm of bone from the distal clavicle.

METHODS

Ten human AC joints underwent compressive loading of the distal clavicle into the acromion after the following: disk excision, distal clavicle resection of 2.5 mm, and distal clavicle resection of 5 mm. The joint resistance force, stiffness, and presence and location of contact were monitored.

RESULTS

Excising 2.5 mm or less resulted in no bone-to-bone abutment in 6 of 10 specimens. A 5-mm resection resulted in successful decompression in all specimens. The specimens that required a 5-mm resection had minimal contact after the 2.5-mm resection (inferior-posterior quadrant only). AC joint stiffness decreased significantly with increasing amounts of clavicular resection (P = .01).

CONCLUSIONS

A 5-mm distal clavicle resection guaranteed no abutment but decreased joint stiffness. Persistent contact occurred only in the inferior-posterior quadrant of the joint after a 2.5-mm resection.

CLINICAL RELEVANCE

These findings support the efficacy of a 5-mm distal clavicle resection for eliminating bony contact but suggest that there is a bony contribution to AC joint stiffness. A resection of 2.5 to 5.0 mm could be adequate if care is taken to excise a greater depth of bone in the inferior-posterior quadrant.

Anatomy of the clavicle and coracoid process for reconstruction of the coracoclavicular ligaments

BACKGROUND

Recently acromioclavicular joint reconstruction techniques have focused on anatomic restoration of the coracoclavicular (CC) ligaments. Such techniques involve creating bone tunnels in the distal clavicle and coracoid.

PURPOSE

To define the anatomy of the human clavicle and coracoid process of the scapula, in order to guide surgeons in reconstructing the CC ligaments.

STUDY DESIGN

Descriptive laboratory study.

METHODS

One hundred twenty (60 paired) cadaveric clavicles and corresponding scapulae (mean age +/- and standard deviation, 48.3 +/- 16.6 years) devoid of soft tissue were analyzed (dry osteology). Differences related to race and sex were recorded. Nineteen fresh-frozen cadaveric clavicles with intact CC ligaments were measured as well (fresh anatomic).

RESULTS

The mean clavicle length was 149 +/- 9.1 mm. In the dry osteology group, the distance from the lateral edge of the clavicle to the medial edge of the conoid tuberosity in male and female specimens was 47.2 +/- 4.6 mm and 42.8 +/- 5.6 mm, respectively (P = .006). The distance to the center of the trapezoid tuberosity was 25.4 +/- 3.7 mm in males and 22.9 +/- 3.7 mm in females (P = .04). The ratio of the distance to the medial edge of the conoid tuberosity divided by clavicle length was 0.31 in males and females. This ratio for the trapezoid was 0.17 in both sexes. The mean coracoid length was 45.2 +/- 4.1 mm. The mean width and height of the coracoid process were 24.9 +/- 2.5 mm and 11.9 +/- 1.8 mm, respectively. No interracial differences in measurements were observed. In the fresh anatomic samples, the ratio of the distance to the conoid center to clavicle length was 0.24. This ratio for the trapezoid was 0.17.

CONCLUSIONS

While absolute differences in the origin of the CC ligaments exist between men and women, the ratio of these origins to total clavicle length is constant.

CLINICAL RELEVANCE

Clavicle length can be obtained intraoperatively. These findings allow the surgeon to predict the origin of the conoid and trapezoid ligaments accurately and to correctly create bone tunnels to reconstruct the anatomy of the CC complex.

Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial

The purpose of this report is to compare outcomes after arthroscopic versus open distal clavicle excision in the treatment of refractory acromioclavicular joint pain. A randomized, prospective clinical trial comparing the 6-month and 1-year outcomes of patients undergoing open distal clavicle excision (group 1) with those undergoing arthroscopic distal clavicle excision (group 2) was carried out. The Modified American Shoulder and Elbow Surgeons form, visual analog scale pain score, Short Form 36, and satisfaction questions were assessed preoperatively and at 6 months and 1 year postoperatively. Seventeen patients were enrolled. There was a trend across all measures for earlier or better outcomes (or both) after arthroscopic over open treatment. The improvement in visual analog scale pain score from preoperatively to 1 year postoperatively was significant for group 2 but not group 1 (P = .006 vs P = .13). Occult intra-articular pathology was detected and treated in 50% of group 2 patients. Arthroscopic and open distal clavicle excisions both provide significant pain reduction at 1 year. Both are effective surgeries for the treatment of refractory acromioclavicular joint pain. The ability to diagnosis and treat subtle concomitant shoulder pathology is a unique advantage of the arthroscopic approach.

[Arthroscopic surgery of the acromioclavicular joint.]

Lesion of the acromioclavicular joint is a usual clinical condition because of it superficial situation. It is often involved in trauma of the shoulder girdle. Moreover, degenerative changes are quite always observed for patients over 40. Distal clavicle resection as a treatment of acromioclavicular joint disease had been first described in 1941. Clinical results in term of mobility and shoulder pain are good and durable in time. Referring to the expansion arthroscopic techniques, distal clavicle resection lead to same middle and long term results as open surgery. Arthroscopic procedures have the theoretical advantages of no deltoid disruption and may help the surgeon to diagnose and treat associated lesions such as rotator cuff ruptures. More recently, arthroscopic surgeries for fresh and/or chronic acromioclavicular disjunctions were proposed. These procedures remain in development and need further evaluations.

Surgical treatment of symptomatic acromioclavicular joint problems: a systematic review

Excision of the distal clavicle has become the mainstay of surgical treatment for acromioclavicular joint arthritis and osteolysis refractory to nonoperative management. Surgical options for symptomatic acromioclavicular joint abnormalities refractory to nonoperative treatment are the classic open distal clavicle excision, direct (superior) arthroscopic excision, and indirect (bursal) arthroscopic distal clavicle excision. We asked whether any of these three procedures provided a better result. We systematically reviewed the medical literature (Medline, EMBASE), assigned a level of evidence for available studies, and critically identified the flaws and biases in the studies to provide comparisons between the published reports. We limited the literature review to clinical reports in the English language published in peer-reviewed journals. The literature supports surgical excision, but the reports are all Level III or IV evidence consisting largely of retrospective case series. Arthroscopic distal clavicle resection has provided more "good or excellent" results than has the open procedure, but is comprised of low-level evidence. Distal clavicle resection has provided satisfactory results when combined with other procedures. Simple distal clavicle resection may have worse outcomes when performed after preceding trauma. The published reports of the removal of medial acromial and inferior distal clavicle osteophytes when performing subacromial decompression are conflicting and may increase post-operative acromioclavicular symptoms.

Arthroscopic distal clavicle resection in athletes: a prospective comparison of the direct and indirect approach

BACKGROUND

The clinical success of arthroscopic distal clavicle resection for athletes has been well documented. There are, however, no published studies that prospectively compare the recovery rates in athletes as well as the outcomes of the indirect versus direct approaches.

HYPOTHESIS

Both procedures are equally successful; however, the direct approach affords faster return to sports.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

Thirty-eight consecutive athletes with osteolysis of the distal clavicle or isolated posttraumatic arthrosis of the acromioclavicular joint without instability underwent arthroscopic distal clavicle resection. The patients were randomized into 2 groups: a direct superior approach and an indirect subacromial approach. American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores were measurable outcomes.

RESULTS

Thirty-four athletes were available for a minimum 2-year follow-up. The 2 groups were similar, including preoperative American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores. Both groups demonstrated significant improvement in both scores at final follow-up when compared with preoperative scores (P < .001). The direct group demonstrated higher American Shoulder and Elbow Surgeons (82 vs 64) and Athletic Shoulder Scoring System (74 vs 56) scores at week 2 (P < .001) and week 6 (American Shoulder and Elbow Surgeons, 88 vs 77; Athletic Shoulder Scoring System, 87 vs 73) (P < .001). At final follow-up, both groups demonstrated excellent clinical outcomes, even though there was a statistical difference in scores, with the direct group scoring better (American Shoulder and Elbow Surgeons, 95.7 vs 91.2; Athletic Shoulder Scoring System -94.9 vs 88.3). The direct group demonstrated faster return to sports (mean, 21 days) than the indirect group (mean, 42 days) (P < .001). Radiographic analysis demonstrated an equivalent resection. One patient in each group had a clinically insignificant increase in coracoclavicular distance.

CONCLUSIONS

Both the direct superior approach and the indirect subacromial approach to the arthroscopic distal clavicle resection result in successful clinical outcome with clinically insignificant difference at final follow-up. Athletes treated with the direct superior approach improved faster clinically and returned to sports earlier.

Arthroscopic distal clavicle resection: a comparison of bursal and direct approaches

PURPOSE

To test the hypothesis that the direct (superior) approach to arthroscopic distal clavicle resection is as safe and effective as the bursal (subacromial) approach.

METHODS

All patients who had an arthroscopic distal clavicle resection in our institution between 1994 and 2002 were reviewed. Patients with a history of acromioclavicular joint (ACJ) instability, previous shoulder surgery, glenohumeral pathology, full-thickness rotator cuff tear, or other significant orthopaedic comorbidity were excluded. Outcome data were collected including the American Shoulder and Elbow Surgeons (ASES) score as well as subjective ratings of pain and instability.

RESULTS

Follow-up was completed on 66 shoulders of 60 patients. Twenty-four shoulders had a bursal approach (group I) and 42 had a direct approach (group II). There were 45 men and 15 women with an average age of 46 years (range, 21 to 78 years). Follow-up averaged 6.0 years (range, 2 to 11.5 years). The average ASES score was 90 (range, 53-100) in group I and 94 (range, 55-100) in group II. Four patients (10%) in group II required reoperation: 2 patients required ACJ stabilization at 6 and 9 months postoperatively because of anteroposterior instability, and 2 patients required resection again at 5 years because of recurrent symptoms.

CONCLUSIONS

Both the direct and bursal approaches lead to satisfactory outcomes in the majority of patients with ACJ arthrosis. However, the direct approach to the ACJ may damage the superior capsular ligaments, potentially leading to distal clavicle instability. Care should be taken when performing the direct ACJ resection to avoid disrupting the capsular restraints.

LEVEL OF EVIDENCE

Level IV therapeutic case series.

Assessment of clavicular translation after arthroscopic Mumford procedure: direct versus indirect resection--a cadaveric study

PURPOSE

To compare the horizontal stability of the distal clavicle following arthroscopic resection of its lateral end by direct and indirect techniques.

TYPE OF STUDY

Biomechanical test of cadaveric specimens.

METHODS

We performed arthroscopic distal clavicle resection on 12 fresh-frozen human cadaveric shoulders using direct (group 1, n = 6) or indirect (group 2, n = 6) approaches. In both groups 5 mm of distal clavicle were resected using an arthroscopic burr. The specimens were mounted on a materials testing device that allowed translation of the clavicle along the anteroposterior axis. The degree of posterior translation was measured from maximum anterior displacement of the clavicle.

RESULTS

Mean posterior translation was 19.4 mm (range, 18 to 23 mm; SD, 2.2) and 21.3 mm (range, 18 to 25 mm; SD, 3.1) for groups 1 and 2, respectively. This difference was not statistically significant ( P = .27).

CONCLUSIONS

This study suggests that there is no significant difference in anteroposterior stability of the clavicle following arthroscopic distal clavicle resection with either a direct or indirect approach.

CLINICAL RELEVANCE

Clinically, this study addresses concerns about increased potential instability associated with the indirect technique of distal clavicle resection. From a biomechanical standpoint, based on this study, there is no concern for increased instability with the indirect technique of distal clavicle resection compared to a direct technique.

Ultrasonography for intraoperative control of the amount of bone resection in arthroscopic acromioclavicular joint resection

Remaining superior osteophytes or osseous spurs after arthroscopic lateral clavicle resection can cause persistent pain and could lead to revision surgery. A new method of intraoperative ultrasonographic imaging of the result of the operation during arthroscopic lateral clavicle resection is presented. In 10 patients with acromioclavicular arthritis, standardized arthroscopic lateral clavicle resection was performed. Intraoperatively, the space between the clavicle and the acromion was measured before and after arthroscopic acromioclavicular resection using a Sonosite 180 plus (SonoSite, Bothell, WA) with a 10-MHz broadband linear array in a sterile bag. The width of the joint space between the clavicle and the acromion was between 0.38 and 0.56 cm before operation and 0.92 cm and 1.28 cm after operation (nine cases). In one case, the anticipated minimum resection of 0.5 cm was not achieved at the sonographic measurement and further resection was required. Real-time ultrasonography allows exact measurement of the amount of resected bone during arthroscopic lateral clavicle resection. This could avoid revision surgery resulting from persisting disability caused by insufficient or extensive bone resection.

Diagnostic value of physical tests for isolated chronic acromioclavicular lesions

PURPOSE

Chronic acromioclavicular joint lesions are a common source of pain and disability in the shoulder. The goal of this study was to evaluate diagnostic values of physical tests for isolated, chronic acromioclavicular joint lesions.

STUDY DESIGN

A retrospective case-control study.

METHODS

Between 1994 and 2002, 35 patients underwent a distal clavicle excision for isolated acromioclavicular joint lesions. The results of 3 commonly used examinations for acromioclavicular joint lesions were calculated for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy.

RESULTS

The cross body adduction stress test showed the greatest sensitivity (77%), followed by the acromioclavicular resisted extension test (72%) and active compression test (41%). The active compression test had the greatest specificity (95%). All tests had a negative predictive value of greater than 94%, but the positive predictive value was less than 30% for all tests. The active compression test had the highest overall accuracy (92%), followed by the acromioclavicular resisted extension test (84%) and the cross arm adduction stress test (79%). Combinations of the tests increased the diagnostic values for chronic acromioclavicular joint lesions.

CONCLUSIONS

These tests have utility in evaluating patients with acromioclavicular joint pathologic lesions, and a combination of these physical tests is more helpful than isolated tests.

Isolated Acromioclavicular Joint Pathology in the Symptomatic Shoulder on Magnetic Resonance Imaging

The acromioclavicular (AC) joint is a synovial joint that is predisposed to painful syndromes because of mechanical stress or developmental variation. It is often overlooked in the evaluation of patients with shoulder pain, however. Isolated AC joint pathology was studied on magnetic resonance imaging scans of patients with symptoms suggesting rotator cuff pathology. The conditions identified included osteoarthritis, distal clavicle osteolysis, and os acromiale syndrome.

Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression

PURPOSE

The goal of the study was to evaluate the long-term outcome of combined arthroscopic distal clavicle excision and subacromial decompression.

TYPE OF STUDY

Retrospective, long-term cohort evaluation.

METHODS

Twenty patients with an average follow-up of 6 years (range, 3.9 to 9 years) were reviewed. All patients had ipsilateral impingement syndrome and acromioclavicular joint disease at the time of surgery and underwent arthroscopic subacromial decompression combined with arthroscopic distal clavicle excision. All patients returned for evaluation in person, in addition to filling out a questionnaire incorporating the University of California, Los Angeles (UCLA), and Constant scoring systems. Preoperative and postoperative radiographs were available for all patients.

RESULTS

Postoperatively, all patients had pain relief and were satisfied with the result. The average postoperative UCLA Shoulder score was 29.8 +/- 0.6, compared with 17.5 +/- 3.0 before surgery (P =.001). The Constant Shoulder score averaged 98.5 +/- 2.1 postoperatively, compared with 70.5 +/- 11.2 preoperatively (P =.001). There was 100% good to excellent results using both scoring systems. Individual components of the UCLA scoring system (pain, function, and power) all showed significant postoperative improvement (P =.001). Constant categories of pain, activities of daily living, range of motion, and power also improved. Follow-up radiographs showed maintenance of the resected distal clavicle in 19 patients. Five patients (25%) had radiographic evidence of calcific density distal to the resected clavicle but were asymptomatic.

CONCLUSIONS

The long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression are uniformly good or excellent. Impingement and acromioclavicular joint disease frequently coexist and should be identified and treated concurrently.

Arthroscopic treatment of acromioclavicular joint injuries and results

Injuries and conditions that affect the AC joint are common. Low-grade separations, degenerative conditions, and osteolysis of the distal clavicle are frequently dealt with by the treating physician. Proper assessment requires a thorough history, examination, and radiologic work-up. An injection of bupivicaine into the AC joint can be a very useful test to evaluate the source of pain about the symptomatic shoulder. Most conditions affecting the AC joint can be treated conservatively, but patients who do not respond to these treatments or athletes who do not wish to modify their activities may require resection of the distal clavicle and the AC joint. Operative intervention can be performed as an open procedure with good results. Recent advances in operative arthroscopic procedures allow us to replicate and exceed the results of the open resection. Arthroscopic resection can be undertaken via a direct approach that does not violate the subacromial space or via an indirect or bursal approach. The indirect approach allows you to assess both the subacromial space and the AC joint because impingement pathology and subacromial compromise are frequently associated with AC change. The advantage of an arthroscopic resection is its ability to be performed as an outpatient procedure with less compromise of musculotendinous structures, shorter rehabilitation, and quicker return to activity. The amount of bone resection necessary is less than with the open procedure because of the ability to preserve the stabilizing properties of the superior AC ligaments. Resection of 4 mm to 8 mm of bone is all that may be required to give uniformly good results. Arthroscopic resection of the distal clavicle is technically demanding and requires skill and familiarity with other arthroscopic shoulder procedures. Complications related to this procedure are relatively infrequent and include infection, residual pain, lack of adequate bone resection, and instability, particularly in patients with previous grade 1 and 2 separations. Less commonly noted is the symptomatic development of heterotopic bone. To the accomplished arthroscopic shoulder surgeon, arthroscopic resection of the symptomatic AC joint gives excellent clinical results that allow a compromised athlete a relatively quick return to desired sport activities.

Radiologic case study. Stress-induced osteolysis of the distal clavicle

Repetitive stress-induced osteolysis of the distal clavicle occurs in athletes who engage in upper extremity weight strengthening exercises and occupational overuse. Repetitive microtrauma is believed to cause microfractures and bone resorption with local pain. Conservative treatment usually is effective. If conservative treatment is unsuccessful. excellent outcomes can be expected after open or arthroscopic resection of the distal clavicle.

Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression

BACKGROUND

Arthroscopic subacromial decompression and arthroscopic resection of the acromioclavicular joint as separate procedures have been well documented. However, there is little information on the success rate of resection with concomitant decompression. In this study, we retrospectively evaluated the results of a consecutive group of patients who underwent arthroscopic resection of the acromioclavicular joint with concomitant subacromial decompression.

METHODS

We evaluated the surgical results in thirty-one consecutive patients (thirty-two shoulders) with acromioclavicular pathology with concomitant subacromial impingement. The mean age of the patients at the time of surgery was thirty-six years (range, eighteen to sixty-seven years). Twenty-five patients, including four professional athletes, were actively involved in sports activities. The mean duration of follow-up was four years and ten months (range, three to eight years). The follow-up examination included clinical evaluation, chart review, radiographic analysis, and isokinetic testing of both upper extremities.

RESULTS

Of the twenty-five patients who participated in sports, twenty-two (including the four professional athletes) returned to their previous level of sports activity. Twenty-six patients had no pain, three reported mild pain on strenuous repetitive overhead activity, two (both weight-lifters) had occasional pain in the acromioclavicular joint and the lateral aspect of the shoulder with bench-pressing, and two (both baseball players) had mild pain in the posterior aspect of the shoulder with throwing. All of the patients were satisfied with the results. In the absence of a complete rotator cuff tear, isokinetic strength-testing of both upper extremities failed to demonstrate any weakness of the involved shoulder. The mean functional score for individual activities was 2.7 points (range, 2.1 to 3.0 points) preoperatively and 3.9 points (range, 3.6 to 4.0 points) postoperatively (p = 0.0001). No patient had superior migration of the clavicle. The amount of distal clavicular resection averaged 9 mm (range, 7 to 15 mm). One patient had heterotopic ossification at the resection site, with mild pain on direct palpation of the acromioclavicular joint and on strenuous overhead activity. Five patients had calcification at the anterior deltoid insertion into the acromion that was asymptomatic, with no impingement on overhead activity and no pain on direct palpation.

CONCLUSIONS

We found excellent results with arthroscopic resection of the acromioclavicular joint and concomitant subacromial decompression. When this procedure is performed on properly selected patients, the results are similar to those of an open approach.

Osteolysis of the distal clavicle: long-term results of arthroscopic resection

PURPOSE

The purpose of this study was to evaluate the outcome of arthroscopic distal clavicle resection by the direct superior approach for treatment of isolated osteolysis of the distal clavicle.

TYPE OF STUDY

Case series.

MATERIALS AND METHODS

Forty-one shoulders in 37 patients underwent arthroscopic resection of the distal clavicle. Thirty-three patients were male and 4 female, with an average age of 39 years. All patients complained of pain localized to the acromioclavicular joint region. Symptoms began after a traumatic event in 18 shoulders and were associated with repetitive stressful activity in 23 shoulders.

RESULTS

At an average follow-up of 6.2 years, 22 shoulders had excellent results, 16 had good results, and 3 were failures. All 3 failures occurred in patients with a traumatic etiology.

CONCLUSIONS

Arthroscopic resection for osteolysis of the distal clavicle has results comparable to open excision with low morbidity. Patients with a traumatic etiology had slightly worse results compared with patients with a microtraumatic etiology.

Arthroscopic debridement of the shoulder for osteoarthritis

Twenty-five patients underwent arthroscopic debridement to treat early glenohumeral osteoarthritis. The group consisted of 19 men and 6 women with an average age of 46 years (range, 27 to 72 years.) The operative procedure consisted of lavage of the glenohumeral joint, debridement of labral tears and chondral lesions, loose body removal, and partial synovectomy and subacromial bursectomy. Follow-up averaged 34 months, with a range of 12 to 63 months. Overall, results were rated as excellent in 2 patients (8%), good in 19 patients (72%), and unsatisfactory in 5 (20%). Two patients had complete relief of pain, 18 patients had only occasional mild pain, and 5 had moderate to severe pain postoperatively. Of the 12 patients with marked preoperative stiffness, 10 (83%) had improvement in range of motion postoperatively. Arthroscopic debridement is a reasonable approach for treating early glenohumeral osteoarthritis that has failed to respond to nonoperative treatment, in which the humeral head and glenoid remain concentric, and where there is still a visible joint space on an axillary radiograph. The procedure is not recommended when there is severe joint incongruity or large osteophytes.

Injuries to the shoulder in the throwing athlete. Part two: evaluation/treatment

In part one of this three-part series (March/April 2000), I concentrated on summarizing the biomechanics of the normal throwing shoulder and the pathophysiology of injury. A classification of injury was presented that was based on the principles contained in that article. Part two of this series will focus on the evaluation and treatment of injuries, expanded from an understanding of the principles learned in part one. The ability to perform a skillful examination, and thus develop an accurate diagnosis, is the foundation for treatment. Fortunately, many difficulties encountered in a thrower's shoulder can be treated with a nonoperative approach. However, in instances where conservative measures fail, an improved understanding of the pathophysiology of injury and the development of improved surgical techniques are leading to more accurate diagnoses and more successful rates of return of the athlete to a premorbid level of activity.

Painful conditions of the acromioclavicular joint

The acromioclavicular (AC) joint may be affected by a number of pathologic processes, most commonly osteoarthritis, posttraumatic arthritis, and distal clavicle osteolysis. The correct diagnosis of a problem can usually be deduced from a thorough history, physical examination, and radiologic evaluation. Asymptomatic AC joint degeneration is frequent and does not always correlate with the presence of symptoms. Selective lidocaine injection enhances diagnostic accuracy and may correlate with surgical outcome. Nonoperative treatment is helpful for most patients, although those with osteolysis may have to modify their activities. In appropriately selected patients, open or arthroscopic distal clavicle resection is necessary to relieve symptoms. Recent biomechanical and clinical data emphasize the importance of capsular preservation and minimization of bone resection; however, the optimal amount of distal clavicle resection remains elusive. Patients with AC joint instability have poor results after distal clavicle resection.

Arthroscopic versus open distal clavicle resection: a biomechanical analysis on a cadaveric model

A fresh cadaver shoulder model was used to evaluate the difference in joint laxity between arthroscopic and open distal clavicle resection procedures. Twelve shoulders were mounted in a load frame that allowed compressive loading of the distal clavicle into the acromion. Specimens were loaded to 100 N (20 N/sec) while load and deformation data were recorded for three conditions: (1) intact, (2) 5-mm closed resection, and (3) 10-mm open resection. The displacement at the 100-N load and the stiffness of the load/displacement curves were compared for the intact, arthroscopic, and open procedures. Significant differences (ANOVA, P< or =.05) in displacement and stiffness were observed between the intact joint and both surgically resected joints. No significant differences were observed between the two surgically resected joints. The amount of bone removed arthroscopically was sufficient to prevent further bony contact in the axially loaded acromioclavicular joint.

The acromioclavicular capsule as a restraint to posterior translation of the clavicle: a biomechanical analysis

Excessive posterior translation of the residual clavicle after distal clavicle resection can be associated with significant postoperative pain. Although the acromioclavicular capsule has been identified as the primary restraint to translation of the clavicle along this axis, the individual contributions of the anterior, posterior, superior, and inferior components of the capsular ligament have not been established. The purpose of this study was to define the relative roles of the individual acromioclavicular capsular ligaments in preventing posterior translation of the distal clavicle in normal acromioclavicular joints in a human cadaver model. Six fresh-frozen human cadaveric acromioclavicular joints were mounted on a specially designed apparatus which, when attached to a standard servohydraulic materials testing device, allowed translation of the distal clavicle along the anteroposterior axis of the acromioclavicular joint (i.e., parallel to the articular surface). Resistance to posterior displacement was measured for standardized displacements in the normal specimens and after serial sectioning of each of the acromioclavicular ligaments was performed. Sectioning of the anterior and inferior capsular ligaments had no significant effect on posterior translation at the 5% significance level. However, sectioning of the superior and posterior ligaments had statistically significant effects (P < .05). These capsular structures contributed 56% +/- 23% (+/- SEM) and 25% +/- 16%, respectively, of the force required to achieve a given posterior displacement. To avoid excessive posterior translation of the clavicle after distal clavicle excision, surgical techniques that spare the posterior and superior acromioclavicular capsular ligaments should be used.