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

Bibliometric and visualized analysis of arthroscopic treatment of acromioclavicular joint injury

BACKGROUND

Since arthroscopy was discovered to treat acromioclavicular joint injury, people have had great interest and attention to this beautiful and minimally invasive operation, and related research has been increasing worldwide. At present, there is no bibliometric and visualized analysis in this field. The purpose of this study is to explore the research hotspots and trends of arthroscopic treatment of acromioclavicular joint injury through bibliometric and visualized analysis and look forward to the future development direction of clinical practice.

METHODS

The publications on arthroscopic treatment of acromioclavicular joint injury diseases from its establishment to April 2023 were obtained from the Web of Science (WOS) Core Collection database. CiteSpace, VOSviewer, Scimago graphica and Origin were used for bibliometric and visualized analysis.

RESULTS

This study included a total of 330 publications. The number of publications tends to increase every year. The USA has the most significant number of publications and citations. Imhoff AB is the most relevant scholar with the largest number of publications in this field, and the scholar with the highest citation and average citations is Mazzocca AD. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. Tech Univ Munich, Rush University and Charite are the three institutions with the greatest contribution. In addition, "Arthroscopy-the Journal of Arthroscopic and Related Surgery" and "American Journal of Sports Medicine" are the institutions with the most significant number of publications and average citations, respectively. The most common keywords are "acromioclavicular joint dislocation," "arthroscopic resection," "arthroscopic reconstruction" and "coracoclavicular ligament."

CONCLUSION

The number of publications shows a steady upward trend as a whole. However, there is still a lack of cooperation among countries, institutions and scholars around the world, so various countries, institutions and scholars need to strengthen academic exchanges and expand the field of cooperation, so as to promote further research and development in related fields. However, minimally invasive methods such as arthroscopy are still the hotspots and frontiers in the treatment of acromioclavicular joint injury in the future.

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.

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.

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.

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.

Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial

BACKGROUND

The treatment of symptomatic acromioclavicular joint (ACJ) injury in the rotator cuff (RC) tear has not been well clarified.

PURPOSE

To compare the clinical results between patients who had distal clavicle resection (DCR) and those who did not during RC repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

From August 2008 to December 2009, a total of 56 consecutive patients (58 shoulders) were included. All patients had either a full-thickness or high-grade (>50%) RC tear, ACJ tenderness, arthritic change visible on plain radiographs, and a positive ACJ lidocaine injection test the day before surgery. Patients were randomized into 2 groups: DCR and RC repair (DCR+RCR group) and RC repair only (isolated RCR). Evaluation was performed preoperatively, at 6 months postoperatively, and at a final follow-up a minimum of 24 months postoperatively using the American Shoulder and Elbow Surgeons (ASES) score, the Constant shoulder score, range of motion examination, and pain visual analog scale (VAS).

RESULTS

After simple randomization, 26 shoulders were allocated in the DCR+RCR group, and 32 were placed in the isolated RCR group. Five shoulders in the DCR+RCR group and 6 in the isolated RCR group were excluded from analysis due to loss of follow-up. Therefore, the evaluation was performed for 21 shoulders in the DCR+RCR group and 26 shoulders in the isolated RCR group. The mean follow-up period was 44.2 months in the DCR+RCR group and 44.0 months in the isolated RCR group. There were no differences in age, sex, symptom duration, RC tear size, or preoperative ASES, Constant, and VAS scores between the 2 groups (P > .05). At final follow-up, the ASES, Constant, and VAS scores were significantly improved in both groups (P < .001). There were no differences in ASES, Constant, and VAS scores between the 2 groups at final follow-up (P > .05), and there was no difference in residual ACJ tenderness (7 in the DCR+RCR group and 5 in the isolated RCR group) between the 2 groups (P = .270).

CONCLUSION

There was no difference in the clinical evaluations between the combined arthroscopic DCR and RCR group and the isolated RCR group at a minimum 24-month follow-up. Arthroscopic DCR should be carefully considered in patients who have symptomatic ACJ arthritis with RC tears.

Demographic analysis of open and arthroscopic distal clavicle excision in a private insurance database

PURPOSE

The purpose of this study was to evaluate and quantify the demographic characteristics of patients undergoing open and arthroscopic distal clavicle excision (DCE) in the United States while also describing changes in practice patterns over time.

METHODS

Patients who underwent DCE from 2004 to 2009 were identified by Current Procedural Terminology (CPT) codes in a national database of orthopaedic insurance records. The year of procedure, age, sex, geographic region, and concomitant rotator cuff repair or subacromial decompression (SAD) were recorded for each patient. Results were reported as the incidence of procedures identified per 10,000 patients searched in the database.

RESULTS

Between 2004 and 2009, 73,231 DCEs were performed; 74% were arthroscopic and 26% were open. The incidence of arthroscopic DCE increased from 37.8 in 2004 to 58.5 in 2009 (P < .001), whereas the incidence of open DCE decreased from 21.1 in 2004 to 14.1 in 2009 (P < .001). Sixty-one percent of DCEs were performed in men (P < .001). Women were more likely to undergo an arthroscopic procedure (P < .001). Arthroscopic DCE was most common in patients aged 50 to 59 years (P < .001). Open DCE was most common in patients aged 60 to 69 years (P < .001). Open rotator cuff repair and SAD were concomitantly performed in 38% and 23% of open DCEs, respectively. Arthroscopic rotator cuff repair and SAD were concomitantly performed in 33% and 95% arthroscopic DCEs, respectively.

CONCLUSIONS

This analysis of DCE using a private insurance database shows that arthroscopic DCEs progressively increased, whereas open DCEs concomitantly decreased between 2004 and 2009. The majority of DCEs were performed in men between the ages of 50 and 59 years. Both arthroscopic and open DCEs are frequently performed in conjunction with rotator cuff repair or SAD.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

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.

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.

Asymptomatic acromioclavicular joint arthritis in arthroscopic rotator cuff tendon repair: a prospective randomized comparison study

HYPOTHESIS

Arthroscopic acromioclavicular joint (ACJ) resection for asymptomatic ACJ arthritis combined with rotator cuff repair leads to more satisfactory pain relief and decrease reoperation rate when inferiorly directed osteophytes present at the undersurface of ACJ.

MATERIALS AND METHODS

Between January 2006 and May 2008, a total of 83 patients (83 shoulders), 40 males and 43 females, who were planned to have arthroscopic repair of a tear measuring 1-3 cm in the anterior-posterior dimension with advanced ACJ arthritis with inferiorly directed osteophytes at the undersurface of the ACJ on MRI were entered into this study. Patients were randomized into two groups. Group 1 included 31 patients, who underwent arthroscopic distal clavicle resection combined with rotator cuff repair. Group 2 included 52 patients, who underwent isolated rotator cuff repair. Patients were evaluated preoperatively and postoperatively using the University of California Los Angeles (UCLA) score and the American Shoulder and Elbow Surgeons (ASES) score. Pain, tenderness on ACJ, and cross body adduction test were compared between groups.

RESULTS

The mean follow-up was 31.7 months (range 34-38). The UCLA scores and ASES scores were lower in group 1 at week 6 (p < .05), and week 12 (p < .05), but higher at the last follow-up at 2 years (p < .05) postoperatively. VAS score was higher in group 1 at week 6 (p < .05), and at week 12 (p < .05), but lower in group 2 at the last follow-up (p < .05). Only in group 2, two (3.8%) cases developed ACJ pain during follow-up and one (1.9%) case underwent reoperation for additional ACJ resection.

CONCLUSIONS

This study shows that distal clavicle resection combined with rotator cuff repair for asymptomatic ACJ arthritis with inferiorly directed osteophytes lower functional scores due to temporary pain in early postoperative periods, but better functional outcomes with satisfactory pain relief and no reoperation rate were observed after 2 years.

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.

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.

Evaluation and treatment of acromioclavicular joint injuries

Acromioclavicular joint injuries and, more specifically, separations are commonplace both in general practice and during athletic participation. This article reviews the traditional classification as well as the clinical evaluation of patients with acute and chronic acromioclavicular joint separations. It also highlights many recent advances, principally in the anatomy and biomechanics of the acromioclavicular joint ligamentous complex. The concept of increases in superior translation as well as disturbances in horizontal translation with injuries to this joint and ligaments are discussed. This information, coupled with the unpredictable long-term results with the Weaver-Dunn procedure and its modifications, have prompted many recent biomechanical studies evaluating potential improvements in the surgical management of acute and chronic injuries. The authors present these recent works investigating cyclic loading and ultimate failure of traditional reconstructions, augmentations, use of free graft, and the more recent anatomic reconstruction of the conoid and trapezoid ligaments. The clinical results (largely retrospective), including acromioclavicular joint repair, reconstruction and augmentation with the coracoclavicular ligament, supplemental sutures, and the use of free autogenous grafts, are summarized. Finally, complications and the concept of the failed distal clavicle resection and reconstruction are addressed. The intent is to provide a current, in-depth treatise on all aspects of acromioclavicular joint complex injuries to include anatomy, biomechanics, benchmark studies on instability and reconstruction, clinical and radiographic evaluation, and to present the most recent clinical research on surgical outcomes.

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.

Visualization of Intraarticular Structures of the Acromioclavicular Joint in an Ex Vivo Model Using a Dedicated MRI Protocol

OBJECTIVE

The purpose of this study was to develop an MRI protocol that could visualize the intraarticular structures of the acromioclavicular (AC) joint.

MATERIALS AND METHODS

Using six fresh specimens from cadaveric shoulders, several MRI sequences were performed on 1.0-T scanners with a superficial coil (the temporomandibular joint coil). After the radiologic examination, the specimens were prepared for histology and 300-microm-thick, toluidine blue-stained sections were prepared that corresponded to the MR images. In each series of sections, immunohistochemistry using a type II collagen antibody was performed to further characterize the intraarticular structures.

RESULTS

The coronal 3D T1-weighted fast-field echo water-selective sequence allowed the identification of the intraarticular disk in all cases. Determination on MRI of other intraarticular structures--adipose tissue, synovial fluid, and the borders between neighboring tissues of different types--that corresponded to the histologic sections was possible. The use of a second plane in the 1.0-T sequences did not reveal additional information.

CONCLUSION

The described MRI protocol allows the visualization of the intraarticular fibrocartilaginous disk and the border between articular cartilage and the disk. Future clinical studies will indicate the diagnostic value of this protocol. We assume that this MRI protocol could help us to better understand AC joint disorders, in particular those located intraarticularly, and dislocations.

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.

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.

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.

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.