Arthroscopic acromioclavicular joint debridement and distal clavicle resection

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.

The arthroscopic Mumford procedure: an analysis of results

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

Comparison of open and arthroscopically assisted rotator cuff repairs

Open rotator cuff repair has shown reliable results in terms of pain relief and improved shoulder function. Recently, however, arthroscopically assisted rotator cuff repair has shown promising preliminary results. We compared the results of these two procedures with regard to pain, function, range of motion, strength, patient satisfaction, and return to previous activity. Thirty-seven rotator cuff repairs were evaluated in 36 patients with a minimum followup of 2 years. The open repair group comprised 20 shoulders with an average followup of 3.3 years; the arthroscopically assisted repair group comprised 17 shoulders with an average followup of 3.2 years. Overall, the open repair group had 80% good-to-excellent results and 88% patient satisfaction, and the arthroscopically assisted repair group had 85% good-to-excellent results and 92% patient satisfaction. Shoulder flexion and abduction strength, the size of the tear repaired, and the functional outcome did not differ significantly between the two groups. In general, however, small and moderate-sized tears (< 3 cm) had better functional outcome with arthroscopically assisted repair. The arthroscopically assisted repair group was hospitalized 1.2 days less and returned to previous activity an average of 1 month earlier. In the surgical treatment of symptomatic complete rotator cuff tears, arthroscopically assisted rotator cuff repair is as effective as open repair.

Arthroscopic resection of the distal clavicle with a superior approach

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