Arthroscopic resection of the distal clavicle with a superior approach

A systematic review of the treatment of primary acromioclavicular joint osteoarthritis

Background

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

Methods

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

Results

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

Conclusion

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

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

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.

Ligament Reconstruction and Interposition Arthroplasty of the Acromioclavicular Joint

Distal clavicle excision (DCE) for acromioclavicular (AC) joint primary osteoarthritis and post-traumatic arthritis has been shown to have good to excellent outcomes. However, there are studies that report significant rates of residual AC joint pain and distal clavicle instability after open and arthroscopic techniques. We describe a surgical technique for management of AC joint primary osteoarthritis, post-traumatic arthritis, and revision DCE that involves DCE with ligament reconstruction and tendon interposition arthroplasty. It provides distal clavicle stability and can theoretically reduce residual AC joint pain secondary to acromial abutment after DCE.

Distal clavicle "A-frame" morphology: a reliable intraoperative guide for arthroscopic distal clavicle excision

BACKGROUND

The purpose of this cadaveric study was to describe the characteristics of the "A-frame" morphology of the distal clavicle via computed tomography (CT) to determine whether it can be used as a reliable intraoperative guide for arthroscopic distal clavicle excision.

METHODS

Twenty-eight fresh-frozen human cadaveric clavicles underwent a 3-dimensional CT scan using 1.0-mm cuts. The distance from the most lateral aspect of the clavicle to the point at which the superior cortex of the clavicle paralleled the inferior cortex was measured. Measurements were performed in a blinded fashion by a single author on 2 separate occasions.

RESULTS

The A-frame was present in all specimens (28 of 28). On the first measurement, the mean distance from the distal clavicle to the point at which the A-frame disappeared was 1.00 cm (range, 0.90-1.08 cm; standard deviation, 0.5 mm). On the second measurement, the mean distance was 1.02 cm (range, 0.90-1.11 cm; standard deviation, 0.6 mm). The intrarater reliability between measurement occasions was 0.65 (95% confidence interval, 0.36-0.82; P < .001).

CONCLUSIONS

This study demonstrated that the cross-sectional A-frame morphology of the distal clavicle was consistently visualized on CT scans. The A-frame disappeared 1.00-1.02 cm medial to the most lateral extent of the clavicle on CT scans. The disappearance of the A-frame morphology of the distal clavicle can serve as a reliable intraoperative guide for arthroscopic distal clavicle excision.

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.

No differences between conservative and surgical management of acromioclavicular joint osteoarthritis: a scoping review

PURPOSE

To conduct a scoping review to clarify the management of acromioclavicular joint osteoarthritis, as well as to identify any existing gaps in the current knowledge.

METHODS

Studies were identified by electronic databases (Ovid, Pubmed) from their inception up to April 2nd, 2020. All studies reporting functional outcomes after conservative or surgical treatment of acromioclavicular joint osteoarthritis, either primary or secondary to trauma or distal clavicle osteolysis, were included. Following data were extracted: authors, year of publication, study design (prospective or retrospective), LOE, number of shoulders treated conservatively or surgically, patients' age, OA classification, type of conservative treatment, surgical approach, surgical technique, functional outcomes, complications, revisions, and length of follow-up. Descriptive statistics was used. Quality appraisal was assessed through the Cochrane risk of bias tool for LOE I/II studies, while the MINORS checklist was used for LOE III/IV studies.

RESULTS

Nineteen studies were included for a total of 861 shoulders. Mean age of participants was 48.5 ± 7.4 years. Mean follow-up was 43.8 ± 29.9 months. Four studies reported functional results after conservative treatment, whereas 15 studies were focused on surgical management. No studies directly compared conservative and surgical treatment. Seven studies reported a surgical approach after failure of previous conservative treatment. All studies reported functional improvement and pain relief. Complication rate was low. Overall methodological quality of included studies was very low.

CONCLUSION

Conservative and surgical treatments are both effective in acromioclavicular joint osteoarthritis management. However, available data did not allow to establish the superiority of one technique over another.

LEVEL OF EVIDENCE

Level IV.

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.

Histologic and magnetic resonance image evaluation in acromioclavicular joint osteoarthritis

Introduction

Little is known about the development of specific acromioclavicular joint osteoarthritis. Its histologic alterations are controversial, and radiologic alterations are seen in asymptomatic people. The objective of this study was to evaluate histologically the distal clavicle subchondral bone and to analyze magnetic resonance images in patients with painful and nonpainful acromioclavicular joint osteoarthritis.

Methods

An observational, analytical, and cross-sectional study with a control group was conducted. Between August 2018 and June 2019, we analyzed a total of 41 patients. Group 1 consisted of patients with pain in the acromioclavicular joint (symptomatic osteoarthritis), and group 2 consisted of patients without pain in the acromioclavicular joint (asymptomatic osteoarthritis).

Results

Twelve of the 15 patients with acromioclavicular joint pain (group 1) were female, 13 presented distal clavicle edema on magnetic resonance imaging, and 9 had subchondral bone edema on histologic examination. Patients with acromioclavicular joint pain had longer shoulder pain duration than patients without pain. Women were more likely to have acromioclavicular joint pain compared with men. Patients with edema on magnetic resonance imaging showed a greater chance of presenting pain in the acromioclavicular joint in comparison with patients without edema.

Conclusion

Women had a higher chance of presenting with acromioclavicular joint pain than men. Patients with edema on magnetic resonance imaging were more likely to present with pain than patients without edema. Patients with acromioclavicular joint pain had longer shoulder pain duration than patients without pain, and subchondral bone edema on histologic examination was more frequent in patients with pain.

Current evidence for nonpharmacological interventions and criteria for surgical management of persistent acromioclavicular joint osteoarthritis: A systematic review

BACKGROUND

The primary aim of this systematic review was to investigate the individual/combined effectiveness of nonpharmacological interventions in individuals with persistent acromioclavicular joint osteoarthritis. The secondary aims were to investigate the comparative effectiveness of nonpharmacological versus surgical interventions, and to identify the criteria used for defining failure of conservative interventions in individuals who require surgery for persistent acromioclavicular joint osteoarthritis.

METHOD

Major electronic databases were searched from inception until October 2018. Studies involving adults aged 16 years and older, diagnosed clinically and radiologically with isolated acromioclavicular joint osteoarthritis for at least three months or more were included. Studies must explicitly state the type and duration of conservative interventions. Methodological risk of bias was assessed using the Modified Downs and Black checklist.

RESULTS

Ten surgical intervention studies were included for final synthesis. No studies investigated the effectiveness of nonpharmacological interventions or compared them with surgical interventions. Common nonpharmacological interventions trialed from the 10 included studies were activity modification (n = 8) and physiotherapy (n = 4). Four to six months was the most often reported timeframe defining failure of conservative management (range 3-12 months).

CONCLUSIONS

Currently, there is no evidence to guide clinicians about the individual or combined effectiveness of nonpharmacological interventions for individuals with persistent acromioclavicular joint osteoarthritis.

Distal Clavicular Augmentation with Acromioclavicular and Coracoclavicular Ligament Reconstruction in the Setting of Iatrogenic Induced Acromioclavicular Instability

Although chronic pain and dysfunction of the acromioclavicular (AC) joint can reliably be treated with distal clavicle excision, disruption of the local stabilizing ligamentous structures may result in iatrogenic instability of the joint. Iatrogenic AC joint instability is a rare condition caused by over resection of the distal clavicle with unintended injury to the stabilizing ligaments in the treatment of AC joint pain. Addressing postresection instability can prove to be difficult because most reconstruction techniques are intended for patients with traumatic AC joint instability with the goal of creating an anatomically stable joint. However, in the setting of iatrogenic instability, the decreased bone stock of the distal clavicle results in instability of the AC joint, especially in the horizontal plane, and may cause these techniques to fail. Thus, operative management must aim to correct both the osseous and ligamentous deficits responsible for the genesis of this instability. In this Technical Note, we describe bony augmentation of the distal clavicle with an iliac crest bone autograft for chronic iatrogenic acromioclavicular joint instability with concomitant reconstruction of the AC and coracoclavicular ligaments.

Effect of autologous adipose-derived mesenchymal stem cell therapy in the treatment of acromioclavicular joint osteoarthritis

The aim of this case report is to evaluate the efficacy of mesenchymal stem cell (MSC) therapy in the treatment of small joint osteoarthritis (OA). Acromio-clavicular (AC) joint OA is an under-diagnosed and yet frequent source of shoulder pain. MSCs have shown evidence of benefit in the treatment of knee OA. This is the first report to describe the use of MSC therapy in OA of the upper limb. A 43-year-old patient presents with painful AC joint OA and undergoes MSC therapy. The patient reported pain and functional improvement as assessed by the Disability of Arm, Shoulder and Hand Score and Numeric Pain Rating Scale. Imaging at 12 months showed structural improvement with reduction in subchondral oedema, synovitis and subchondral cysts. This case is the first to show the benefit of MSC therapy in the treatment of small joint arthropathy and also of the upper limb.

Trial registration number: Australian New Zealand Clinical Trials Registry (ACTRN12617000638336).

The Specific AC Score (SACS): a new and validated method of assessment of isolated acromioclavicular joint pathology

BACKGROUND

Acromioclavicular (AC) joint (ACJ) pathology is a common cause of shoulder dysfunction, and treatment recommendations vary. When the efficacy of treatment is evaluated, the ability to measure outcomes specific to the population is essential. The aim of the current research was to develop and validate a specific ACJ questionnaire.

METHODS

Items for the "Specific AC Score" (SACS) were generated through the use of an expert panel, existing questionnaires, and patient feedback. Preliminary data analysis identified redundancy of items resulting in the questionnaire being refined. The final SACS was evaluated in 125 patients requiring surgical intervention of the ACJ. Internal consistency (the Cronbach α and corrected item-total correlation), content validity, criterion validity, responsiveness, and test-retest reliability (intraclass correlation coefficient) were examined and compared with the Shoulder Pain and Disability Index, Oxford Shoulder Score, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. The minimum detectable change score was calculated.

RESULTS

The Cronbach α for the total scale preoperatively and postoperatively was high (preoperatively = 0.91, postoperatively = 0.93). All 3 domains (Pain, Function, Quality of Life) demonstrated acceptable internal consistency (α > 0.70), and the correlation between items in each domain was satisfactory. The responsiveness was excellent (effect size, -2.32; standard response mean, -1.85) and was higher than the other general shoulder questionnaires. There were no relevant floor or ceiling effects. Reliability was high (intraclass correlation coefficient, 0.89) and the minimum detectable change was 6.5 points.

DISCUSSION

This new ACJ-specific questionnaire has been robustly developed, has good measurement properties, and has excellent responsiveness. The SACS is recommended for measuring outcomes in ACJ patients.

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.

Palmaris longus tendon graft versus modified Weaver-Dunn procedure via dynamic button system for acromioclavicular joint reconstruction in chronic cases

BACKGROUND

The hypothesis of this clinical study was that coracoclavicular (CC) reconstruction using autogenic palmaris longus graft through the GraftRope (PLG) system (Arthrex, Inc., Naples, FL, USA) would provide superior clinical and radiologic results compared with modified Weaver-Dunn procedure with the dynamic TightRope (Arthrex, Inc.) system (WDT).

METHODS

Between 2008 and 2013, 32 patients (average age, 39.7 years; range, 22-60 years) underwent surgical reconstruction of chronic acromioclavicular (AC) joint dislocation. A modified WDT procedure was performed in 16 patients and autogenous PLG was performed in the other 16 patients. Patient data were collected retrospectively, with a final follow-up of 44.9 months (range, 29-60 months). The degree of AC joint displacement was evaluated by measuring the CC distance on the anteroposterior and axillary view. Clinical and functional outcomes were compared by American Shoulder and Elbow Surgeons and the Constant scores at final follow-up.

RESULTS

Comparison between the WDT and PLG groups showed a significantly better outcome in the American Shoulder and Elbow Surgeons and the Constant scores (P < .01), in favor of the PLG group. Both groups showed an increased CC distance compared with the uninjured side, with a mean difference of 1.1 mm for the PLG and 3.3 mm for the WDT groups. A tolerable loss of reduction within the follow-up time was observed. Reduction loss was higher with the WDT group (P < .05).

CONCLUSION

CC palmaris longus tendon graft reconstruction with GraftRope system was associated with functional and radiologic benefits. The palmaris longus graft with GraftRope system could be used in chronic cases.

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 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.

Extended Neviaser portal approach to antegrade humeral nailing

Certain arthropathies can distort the normal acromiohumeral relationship and make traditional anterolateral access to the proximal humerus for nailing difficult or impossible. This article presents a case of bilateral antegrade humeral nailing in which the Neviaser portal approach was used for humeral shaft fractures in a patient with distorted shoulder anatomy secondary to severe cuff tear arthropathy and rheumatoid arthritis. Based on a literature review, extending the traditional superomedial (Neviaser) portal to the shoulder to perform humeral nailing has never been described clinically. An 85-year-old woman with rheumatoid arthritis and bilateral cuff tear arthropathy presented after a mechanical fall from standing height with bilateral acute humeral shaft fractures. Preoperative fluoroscopy confirmed the inability to access the traditional starting point with an anterolateral approach due to a shield acromion resulting from cuff tear arthropathy and rheumatoid arthritis. Bilateral locked antegrade humeral nails were successfully placed through a 3-cm incision just off the medial border of the acromion and directly posterior to the acromioclavicular joint (the extended Neviaser portal approach). Postoperatively, the patient demonstrated early evidence of clinical and radiographic union. She was able to return to her preinjury function level, with an active range of motion comparable with her baseline. The Neviaser portal approach to antegrade humeral nailing is an effective solution to diaphyseal humeral fractures when access to the traditional anterolateral proximal humeral starting port is not possible due to distorted shoulder anatomy.

Accuracy of acromioclavicular joint injections

BACKGROUND

Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic.

PURPOSE

The purpose of this study was to evaluate the accuracy of in vivo AC joint injections.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular.

RESULTS

Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint.

CONCLUSION

This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.

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.

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.

Distal clavicle fracture as a complication of arthroscopic distal clavicle resection

Arthroscopic resection of the distal clavicle has been advocated as a surgical treatment option for acromioclavicular (AC) joint pathology. To our knowledge, iatrogenic fracture of the distal clavicle during distal clavicle resection has never been reported. This report describes distal clavicle fracture as a complication of misidentification of the AC joint and subsequent aggressive burring of the distal clavicle during shoulder arthroscopy. This case is further complicated by the development of symptomatic delayed union and adhesive capsulitis. Ultimately, a revision distal clavicle resection was performed, underscoring the fact that special care must be taken to properly identify the AC joint and rule out pre-existing distal clavicle stress fracture or osteolysis before performing the arthroscopic Mumford procedure.

Acromioclavicular joint problems in athletes and new methods of management

The acromioclavicular (AC) complex consists of bony and ligamentous structures that stabilize the upper extremity through the scapula to the axial skeleton. The AC joint pathology in the athlete is generally caused by 1 of 3 processes: trauma (fracture, AC joint separation, or dislocation); AC joint arthrosis (posttraumatic or idiopathic); or distal clavicle osteolysis. This article presents systematically the relevant anatomy, classification, evaluation, and treatment of these disorders. Management of AC joint problems is dictated by the severity and chronicity of the injury, and the patient's needs and expectations.

Semitendinosus tendon graft versus a modified Weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases: a prospective comparative study

BACKGROUND

Biomechanical studies comparing various surgical techniques for acromioclavicular joint reconstruction have reported that semitendinosus tendon graft for coracoclavicular ligament reconstruction provides a substantial improvement in initial stability and a load-to-failure equivalent to the intact coracoclavicular ligaments. Although it represents a biomechanical improvement compared with coracoacromial ligament transfer, there is still a lack of prospective comparative studies confirming the clinical relevance of these biomechanical findings.

HYPOTHESIS

Semitendinosus tendon graft for coracoclavicular ligament reconstruction is associated with superior clinical results compared with a modified Weaver-Dunn procedure in chronic complete acromioclavicular joint dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Twenty-four patients (mean age, 42 years) with painful, chronic Rockwood type III through V acromioclavicular joint dislocations were subjected to surgical reconstruction. In 12 patients, a modified Weaver-Dunn procedure was performed; in the other 12 patients, autogenous semitendinosus tendon graft was used. Clinical evaluation was performed using the American Shoulder and Elbow Surgeons shoulder score and the Constant score after a mean follow-up time of 37 months. Preoperative and postoperative radiographs were compared.

RESULTS

The mean American Shoulder and Elbow Surgeons shoulder score improved from 74 +/- 7 points preoperatively to 86 +/- 8 points postoperatively in the Weaver-Dunn group, and from 74 +/- 4 points to 96 +/- 5 points in the semitendinosus tendon group (P < .001 for both techniques). The mean Constant score improved from 70 +/- 8 points to 81 +/- 8 points in the Weaver-Dunn group, and from 71 +/- 5 points to 93 +/- 7 points in the semitendinosus tendon group (P < .001). The results in the semitendinosus tendon group were significantly better than in the Weaver-Dunn group (P < .001). The radiologic measurements showed a mean coracoclavicular distance of 12.3 +/- 4 mm in the Weaver-Dunn group increasing to 14.9 +/- 6 mm under stress loading, compared with 11.4 +/- 3 mm increasing to 11.8 +/- 3 mm under stress in the semitendinosus tendon group. The difference during stress loading was statistically significant (P = .027). In the semitendinosus tendon group, horizontal displacement of the lateral clavicle end could be reduced in all cases with type IV dislocation.

CONCLUSION

Semitendinosus tendon graft for coracoclavicular ligament reconstruction resulted in significantly superior clinical and radiologic outcomes compared to the modified Weaver-Dunn procedure.

Treatment of distal clavicle fractures using an arthroscopic technique

Whenever indicated, distal clavicle fractures can be treated with a double loop of a nonabsorbable, #5 suture around the clavicle and under the coracoid. We developed an all arthroscopic technique to perform this procedure. From January to September 2004, 7 patients were treated. The mean age was 46 years. The coracoid is identified through the rotator interval. Using a special needle, a double #5 suture is passed around the coracoid. A hole is created at the clavicle and, through another guide wire, is sent to the anterior portal. The double #5 suture is transported to the clavicle. After the reduction of the fracture the sutures are tightened. All 7 cases have healed. The surgical treatment of these fractures is well established, and with the aid of arthroscopy, the morbidity can be decreased. The technique has been shown to be safe with no complications.

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.

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.

The superior-medial shoulder arthroscopy portal is safe

PURPOSE

The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe.

METHODS

Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm.

RESULTS

The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001).

CONCLUSIONS

This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens.

CLINICAL RELEVANCE

Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.

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.

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: 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.

Stabilization of the clavicle after distal resection: a biomechanical study

BACKGROUND

The potential destabilizing effect of distal clavicle resection has received limited attention.

HYPOTHESIS

Suturing the coracoacromial ligament to the undersurface of the distal clavicle after resection could counter clavicle instability.

STUDY DESIGN

Controlled laboratory study.

METHODS

The effect of ligament augmentation on posterior translation of the clavicle after resection was evaluated using 12 fresh-frozen cadaveric shoulders. Posterior clavicular displacement was measured after the application of a 70-N load under 4 different conditions: (1) the intact joint, (2) after distal clavicle resection, (3) clavicle resection plus acromioclavicular capsular ligament repair, and (4) clavicle resection plus acromioclavicular capsular ligament repair plus coracoacromial ligament augmentation.

RESULTS

Mean displacements for each of the test conditions were as follows: (1) 5.60 mm, (2) 7.38 mm, (3) 7.54 mm, and (4) 6.34 mm. A 32% increase in posterior translation was measured after resection compared to the intact specimen. No reduction in posterior displacement was noted after capsular repair; however, displacement decreased significantly when capsular repair was coupled with ligament augmentation.

CONCLUSIONS

Results suggest that the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation.

CLINICAL RELEVANCE

That the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation may be particularly relevant in cases of resection for posttraumatic arthritis after acromioclavicular separation in which some degree of preexisting acromioclavicular capsular attenuation and consequently acromioclavicular joint laxity may be presumed.

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.

Biomechanical function of surgical procedures for acromioclavicular joint dislocations

PURPOSE

Surgical procedures for treatment of acromioclavicular (AC) joint dislocation replace the coracoclavicular (CC) ligaments to minimize motion, allow scarring, and increase the subsequent stability of the joint. The purpose of this study was to evaluate the biomechanical function of the surgically repaired or reconstructed (CC Sling, Rockwood Screw [DePuy Orthopaedics, Warsaw, IN], and Coracoacromial [CA] Ligament Transfer Construct) AC joint after AC joint dislocation.

TYPE OF STUDY

A cadaver study using a convenience sample.

METHODS

Twelve cadaveric shoulders were tested using a robotic/UFS testing system. Three external loading conditions (anterior, posterior, or superior load of 70 N) were applied to intact and surgically repaired or reconstructed AC joint. The resulting kinematics of the AC joint and in situ forces in the CC ligaments or surgical constructs was determined.

RESULTS

For the CC Sling, anterior and posterior translation significantly increased by 110% and 330% in response to an anterior and posterior load, respectively. However, the posterior translation for the Rockwood Screw significantly decreased by 60%. Anterior, posterior, and superior translation for the CA Ligament Transfer Construct significantly increased by 110%, 360%, and 100%, respectively. The coupled translations also significantly increased for the CC Sling and CA Ligament Transfer Construct in response to all loading conditions. In contrast, the coupled translations for the Rockwood Screw tended to decrease. Furthermore, the in situ forces increased significantly for all 3 surgical constructs compared with the intact CC Ligaments in response to an anterior and posterior load.

CONCLUSIONS

At time zero, increases in the primary and coupled motion for the CC Sling and CA Ligament Transfer Construct could comprise the initial healing period prescribed for AC joint dislocation. Our findings also suggest that the Rockwood Screw provides a highly rigid fixation and may explain the complications frequently seen in clinical practice.

CLINICAL RELEVANCE

Current surgical procedures do not have the appropriate stiffness to restore the stability of the intact joint before healing. Therefore, our results may lead to the design and development of new repairs, reconstructions, and rehabilitation protocols for AC joint dislocation.

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.