Seven-year course of asymptomatic acromioclavicular osteoarthritis diagnosed by MRI

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.

The incidence and treatment of symptomatic acromioclavicular joint osteoarthritis following total shoulder arthroplasty

Background

Acromioclavicular joint (ACJ) Osteoarthritis (OA) is very common in the general population. Despite this, there is little mention of concomitant glenohumeral and ACJ arthropathy in the literature, and no documented incidence of symptomatic ACJ OA post total shoulder arthroplasty (TSA). We present the incidence and timescale of the problem, and the response to treatments.

Methods

Patients who had developed ACJ-related symptoms following a TSA were retrieved from a prospectively collected database. It was determined that these symptoms were not related to the prosthesis or other non-ACJ pathology.

Results

There were 230 primary anatomic total shoulder replacements carried out over a 9-year period, with 219 with adequate follow-up for analysis. Thirty-five (16%) developed a symptomatic ACJ. The majority developed symptoms within the first two years however there was one patient who developed symptoms eight years later. Twenty six percent of patients responded to a period of rest. Seventy one percent had a cortisone injection in the ACJ and in 44% of patients this was effective. Twelve (34%) patients had an arthroscopic excision of distal clavicle with good resolution of the symptoms.

Discussion

ACJ symptoms following a total shoulder replacement appears more common than thought and can be treated successfully.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing

Background

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown.

Purpose

To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing.

Study Design

Case series; Level of evidence, 4.

Methods

Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared.

Results

Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR.

Conclusion

Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Bony Edema and Clinical Examination Findings Predict the Need for Distal Clavicle Excision at the Time of Shoulder Arthroscopy

Background: Deciding to perform a distal clavicle excision for acromioclavicular joint arthritis, especially in conjunction with other arthroscopic shoulder procedures, is challenging for surgeons. Studies have reported mixed results on the value of magnetic resonance imaging (MRI) in decision making. Purpose: We sought to correlate MRI findings with clinical symptoms and the surgeon's decision to perform a distal clavicle excision. Methods: We compared MRI, clinical examination, and MRI findings of 200 patients who underwent distal clavicle excision for symptomatic acromioclavicular joint arthritis with 200 patients who underwent arthroscopic shoulder procedures for other reasons. Univariate statistics were used to determine correlations between physical examination findings, MRI findings, and the decision to perform distal clavicle excision. A binary logistic regression model was used to determine independent predictors of need for distal clavicle excision. Results: There was no difference in mean age, sex, and race between groups. Advanced acromioclavicular joint osteoarthritis was strongly correlated with positive physical examination findings. Bony edema correlated strongly with tenderness at the acromioclavicular joint but not pain with cross-body adduction testing. There was no association between higher MRI grade of osteoarthritis and the need for distal clavicle excision. Regression analysis identified both physical examination findings and bony edema on MRI as independent predictors of the need for distal clavicle excision. Conclusion: In the setting of positive clinical examination findings and bony edema of the distal clavicle, surgeons should feel reassured that distal clavicle excision is likely indicated.

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.

Distal Clavicle Excision for Acromioclavicular Joint Osteoarthritis Using a Fluoroscopic Kirschner Wire Guide

Pathology of the acromioclavicular joint is common and often resistant to conservative treatment, requiring distal clavicle excision for definitive relief. First described as an open technique by Mumford and Gurd in 1941, distal clavicle excision has evolved greatly, with arthroscopic techniques currently predominating. No significant difference has been found in patient satisfaction or rate of complication between the techniques in a recent meta-analysis. Indeed, open excisions are still performed at a high rate, owing to the difficulty in technique and visualization with arthroscopic methods. One major critique of arthroscopic distal clavicle excision is difficulty safeguarding against under- and overexcision of the distal clavicle due to the lack of depth perception and visual reference points of the arthroscopic perspective. This Technical Note and accompanying video describe an indirect subacromial arthroscopic distal clavicle excision using a fluoroscopic Kirschner wire guide placed at the proximal border prior to resection to serve as a visual and mechanical reference to overexcision.

Increased T2 signal intensity in the distal clavicle does not justify acromioclavicular resection arthroplasty during rotator cuff repair

INTRODUCTION

Acromioclavicular (AC) arthropathy can contribute to shoulder pain; it can be treated surgically by distal clavicle resection (DCR). The aim of this study was to determine whether increased T2 signal intensity in the clavicle on MRI is an argument in favour of AC resection arthroplasty by DCR during rotator cuff repair.

METHODS

The MRI images from 107 shoulders in 107 patients were analysed. We looked for statistical relationships and correlations between shoulders with T2 hyperintensity (HI+) and those without (HI-) before surgery and then in shoulders with T2 hyperintensity (HI+) that underwent AC resection arthroplasty (AC+) and those who did not (AC-).

RESULTS

On MRI, T2 hyperintensity in the AC joint was correlated with sex (more often found in men) and radiological signs of AC arthropathy. There was no statistical correlation before surgery, particularly with AC pain, or after surgery, with outcomes in shoulders undergoing DCR.

CONCLUSION

When repairing rotator cuff tears, the presence of T2 hyperintensity on MRI in the distal clavicle is not a predictor of better clinical outcomes after AC resection arthroplasty is done. The AC pain may be related to the rotator cuff tear instead.

LEVEL OF EVIDENCE

II, prospective randomised study.

Is conventional radiography still relevant for evaluating the acromioclavicular joint?

INTRODUCTION

Conventional radiography using an anteroposterior view of the acromioclavicular (AC) joint is the gold standard for evaluating arthritic degeneration.

OBJECTIVE

Based on a standardised AP view of the AC joint, the objective of this study was to determine whether this radiographic view is reliable and reproducible for evaluating the AC joint space.

METHODS

A cadaver scapula-clavicle unit, free of osteoarthritis, was used for this study. The scapula was positioned in a stand; and then with fluoroscopy guidance, a strict AP view of the AC joint was taken. Starting from this "0" position, a radiograph was taken by varying the angle by 5°, 10°, and 15° in every plane in space. All radiographs were taken during a single session to ensure the distance between the X-ray tube and scapula did not change. The images were then exported to OsiriX for processing; the superior and inferior AC distance and the joint area were measured.

RESULTS

There was no reproducibility in the AC joint measurements as a function of the incidence angle relative to a strict AP view.

CONCLUSION

Conventional radiography using an AP view of the AC joint cannot be used to do a fine analysis of arthritic degeneration of this joint. It is likely that only CT scan or MRI is sufficient to analyse osteoarthritis in this joint.

LEVEL OF EVIDENCE

IV, basic science study.

Benefits of distal clavicle resection during rotator cuff repair: Prospective randomized single-blind study

INTRODUCTION

Rotator cuff tears often occur in combination with acromioclavicular (AC) arthropathy. But it can be difficult to separate pain caused by the rotator cuff tear from pain caused by the AC joint, despite clinical and other examinations. Distal clavicle resection (DCR) is increasingly being done at the same time as arthroscopic rotator cuff repair. The aim of this study was to compare the functional outcomes 1 year after arthroscopic rotator cuff repair between patients who simultaneously undergo DCR and patients who do not. The primary hypothesis was that DCR improves the clinical outcomes.

MATERIAL AND METHODS

This was a prospective, multicenter, randomized, single-blind study of 200 patients who underwent isolated supraspinatus repair using the same technique. The patients were randomized into two groups: 97 patients who also underwent DCR and 103 patients who did not. The patients were followed until 1 year postoperative according to a standardized radiological and clinical review protocol.

RESULTS

At 1 year postoperative, all the clinical outcomes were worse in the DCR group, although only external rotation with elbow at side (53° vs. 59°, p=0.04) and the SSV (86.5 vs. 90.1, p=0.04) were statistically different. Overall shoulder pain was higher in the DCR group during the first 3 months postoperative (p=0.04). At 1 year, the DCR group had more residual pain; this pain was mainly located on the superior side of the shoulder (p=0.03), especially when more than 11 mm was resected (p=0.01). More of the shoulders in the DCR group had failures in rotator cuff healing based on ultrasonography (p=0.5).

CONCLUSION

Our hypothesis was not confirmed. We do not recommend doing routine DCR with arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

I, prospective randomized simple blind study.

Magnetic resonance imaging of the shoulder

The aim of this article is to review the use of magnetic resonance imaging (MRI) for the evaluation of shoulder pain, which is a common clinical complaint of the musculoskeletal system. MRI is an essential auxiliary tool to evaluate these patients because of its high resolution and high sensitivity in depicting the soft tissues. This article will review the imaging technique, normal imaging anatomy, and most common imaging findings of disorders of tendons, labrum, and ligaments of the shoulder. It will also discuss common systemic diseases that manifest in the shoulder as well as disorders of the acromioclavicular joint and bursae. New advances and research in MRI have provided additional potential uses for evaluating shoulder derangements.

Imaging of the Acromioclavicular Joint: Anatomy, Function, Pathologic Features, and Treatment

The acromioclavicular joint is an important component of the shoulder girdle; it links the axial skeleton with the upper limb. This joint, a planar diarthrodial articulation between the clavicle and the acromion, contains a meniscus-like fibrous disk that is prone to degeneration. The acromioclavicular capsule and ligaments stabilize the joint in the horizontal direction, while the coracoclavicular ligament complex provides vertical stability. Dynamic stability is afforded by the deltoid and trapezius muscles during clavicular and scapular motion. The acromioclavicular joint is susceptible to a broad spectrum of pathologic entities, traumatic and degenerative disorders being the most common. Acromioclavicular joint injury typically affects young adult males and can be categorized by using the Rockwood classification system as one of six types on the basis of the direction and degree of osseous displacement seen on conventional radiographs. MRI enables the radiologist to more accurately assess the regional soft-tissue structures in the setting of high-grade acromioclavicular separation, helping to guide the surgeon's selection of the appropriate management. Involvement of the acromioclavicular joint and its stabilizing ligaments is also important for understanding and classifying distal clavicle fractures. Other pathologic processes encountered at this joint include degenerative disorders; overuse syndromes; and, less commonly, inflammatory arthritides, infection, metabolic disorders, and developmental malformations. Treatment options for acromioclavicular dysfunction include conservative measures, resection arthroplasty for recalcitrant symptoms, and surgical reconstruction techniques for stabilization after major trauma.