Post-traumatic osteolysis of the distal clavicle

High Early-onset acromioclavicular secondary pathologies after acute arthroscopic joint reduction: a cohort study

PURPOSE

The research aim was to determine the prevalence and risk factors of early secondary acromioclavicular (AC) joint disease in patients undergoing acute arthroscopic AC joint reduction and fixation and early complications of acute surgical treatment in patients with high-grade AC joint dislocation.

METHODS

Overall, 102 patients diagnosed with Rockwood type V AC joint dislocation and undergoing arthroscopic coracoclavicular fixation were included. Early clinical and radiological complications were evaluated, as well as risk factors of secondary AC joint pathology.

RESULTS

Twenty-nine patients (28%) presented with a secondary AC joint pathology, with 24 and 5 cases of osteolysis and osteoarthritis, respectively. The main complication was a loss of reduction of ≥ 1 mm (78%). Patients aged > 55 years were more likely to develop a secondary AC joint disease (odds ratios (OR) = 10.1, 95% confidence interval (CI): 1.42 - 72.55, p = 0.021). Patients with osteolysis (OR = 3.2, 95% CI 1.16 - 9.27, p = 0.025) or loss of reduction of > 5 mm (OR = 7.4, 95% CI 2.31 - 24.08, p = 0.001) were more likely to develop AC joint pain. Patients with an initial over-reduction were less likely to develop a subluxated AC joint (OR = 0.033, 95% CI 0.0021-0.134, p = 0.001) CONCLUSION: Age > 55 years and female sex were identified as risk factors of early-onset secondary AC joint disease. Osteolysis and a loss of reduction of > 5 mm were risk factors of AC joint pain but not of revision surgery. The main early complication was a loss of reduction of ≥ 1 mm. An initial over-reduction of the distal clavicle was a protective factor to avoid AC joint subluxation.

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.

[Distal clavicle edema]

PURPOSE

Distal clavicle marrow edema: frequency, MRI in the early stage and macroscopic correlation to the bone marrow distribution and to evaluate frequency and diagnostic criteria of a posttraumatic clavicula disorder with an edema pattern on MRI. An additional macroscopic study of the clavicle should elucidate anatomic peculiarities which could explain the reaction of the distal clavicle.

MATERIAL AND METHODS

285 MRI of traumatized patients were analyzed for edema pattern of the distal clavicle. Pattern A edema within the clavicle and the acromion was distinguished from pattern B edema within the clavicle only. Dissection in 20 cadavers should reveal vascular peculiarities and the bone marrow distribution within clavicle and acromion or vascular peculiarities.

RESULTS

In 38 patients (13,3%) we found edema within the distal clavicle. Pattern A was found in 28 (9,8%) and pattern B in 10 patients (3,5%). Pattern A was usually associated with swelling of the AC joint (27 out of 28). Other injuries were not evident. 18 cadavers showed hematopoietic marrow within the distal clavicle and fatty marrow within the acromion.

CONCLUSION

The distal clavicle can frequently react with edema pattern after trauma without evidence for another injury. Distinguish in cases with and cases without synovitis of the AC joint could have impact on therapy. A peculiar vascular supply of the distal clavicle could not be found.

Osteolysis of the Distal Clavicle: Serial Improvement and Normalization of Acromioclavicular Joint Space with Conservative Care

OBJECTIVE

To discuss a case of osteolysis of the distal clavicle (ODC) in a 29-year-old male chiropractic student who showed interval radiographic and clinical evidence of healing.

CLINICAL FEATURES

The patient complained of intermittent left-sided shoulder pain of 8 months' duration that was exacerbated while performing spinal-manipulative procedures. A radiographic examination showed changes consistent with osteolysis involving the distal clavicle.

INTERVENTION AND OUTCOME

A conservative treatment regimen of physiotherapy, nutritional supplementation, and activity modification resulted in an interval reduction in symptomatology and radiographic findings on serial examinations, ultimately resolving both abnormal clinical and radiographic findings after approximately 14 months of treatment. We specifically observed normalization of the acromioclavicular (AC) joint dimension.

CONCLUSIONS

In contrast to the posttreatment radiographic outcome seen in our patient, ODC classically does not result in complete resolution of radiographic findings or normalization of AC joint dimension, and such radiographic normalization of joint space is currently not reported in the literature. This case report serves to document and to show this unique occurrence.

Anatomy and biomechanics of the acromioclavicular and sternoclavicular joints

The acromioclavicular and sternoclavicular joints have important soft-tissue static constraints that, based on biomechanical studies, imply a great deal of stability. The infrequency of significant symptoms following dislocations of these joints certainly highlights the fact that the dynamic muscle support is also very important. In performing resections of these joints for degenerative disease, our goal should be to preserve these important ligamentous supports by minimizing the amount of bone excised, as this seems to optimize results [84]. Precise isometric reconstruction of these complex, three-dimensional ligamentous structures merits further investigation in the laboratory and clinical settings.

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.

Complications of treatment of acromioclavicular and sternoclavicular joint injuries

Although common, AC joint injuries and their treatments are not benign. The injury itself and both nonsurgical and surgical treatments may result in complications yielding persistent pain, deformity, or dysfunction. Sternoclavicular joint injuries are far less common and are typically the result of higher energy trauma. As such, the associated complications may be more serious. Familiarity with the potential complications of these injuries can help the treating physician to develop strategies to minimize their incidence and sequelae.

Posttraumatic osteolysis of the distal clavicle: analysis of 7 cases and a review of the literature

OBJECTIVE

To discuss the clinical manifestation, radiographic features, and treatment of 7 cases of posttraumatic osteolysis of the distal clavicle. Also, to furnish evidence indicating that the current terminology for this disorder is ambiguous and to propose a new classification system.

CLINICAL FEATURES

Three cases resulted from acute trauma, and 4 cases were caused by sports-related repetitive microtrauma. All the cases involved young male patients who had similar clinical presentations that included shoulder pain with decreased shoulder range of motion. Radiographic findings ranged from small erosive changes to aggressive osteolysis of the distal clavicle.

INTERVENTION AND OUTCOME

All the patients were treated with conservative care consisting of sling immobilization, ice, various physiotherapeutic modalities, and mobilization exercises. The patients that followed through with care showed clinical improvement within 3 months. Follow-up radiographic examinations, when performed, demonstrated reconstitution of the distal clavicle of various degrees, although lagging behind clinical evidence of improvement.

CONCLUSION

Traumatic osteolysis of the distal clavicle may result from acute trauma or repetitive microtrauma. Radiographic changes are varied, including irregularity of the distal clavicle, cystic erosions, and blatant osteolysis. Positive outcomes may be achieved with conservative care; however, patient compliance plays a fundamental role in the overall prognosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

TYPE OF STUDY

Case series.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

MR observations of postraumatic osteolysis of the distal clavicle after traumatic separation of the acromioclavicular joint

PURPOSE

The purpose of this work was to characterize the MR features of post-traumatic osteolysis of the distal clavicle in patients who have sustained a previous separation of the ipsilateral acromioclavicular (AC) joint.

METHOD

We studied eight male patients (mean age 25 years) with intractable pain in the AC joint after sustaining a traumatic joint separation. With use of the Rockwood classification, the separations were classified as Type 1 in one patient, Type 2 in two patients, and Type 3 in five patients. The MR studies were evaluated for periarticular soft tissue swelling, cortical irregularity defined as thinning or absence of portions of the cortex in the acromial and clavicular articular surfaces, hypertrophic osseous changes, periostitis, bone marrow edema, periarticular cyst-like changes, and joint space widening exceeding 6 mm. Radiographs were evaluated independently of the MR studies. Osteolysis of the distal clavicle was confirmed pathologically in seven patients and with surgery in one patient.

RESULTS

The incidence of osteolysis in patients who have had a previous AC joint separation was estimated to be approximately 6%. Observations on MRI included soft tissue swelling, bone marrow edema in the distal clavicle, and cortical irregularity associated with periarticular cyst-like erosions in eight patients, joint space widening in six patients, clavicular periostitis in three patients, and marrow edema in the cromion in five patients. Only one patient had osteophyte formation. Radiographic observations of periarticular soft tissue swelling, osteopenia of the distal clavicle, articular erosions, and joint space widening allowed diagnosis in only four patients prospectively.

CONCLUSION

The MR features of posttraumatic osteolysis are characteristic of this process. We advocate the use of MRI in patients with chronic AC joint pain who have had a prior AC joint dislocation, particularly if follow-up radiographs are nonspecific, equivocal, or do not indicate the presence of secondary osteoarthritis.

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.

Acromioclavicular Joint Injuries and Distal Clavicle Fractures

The acromioclavicular joint is commonly affected by traumatic and degenerative conditions. Most injuries are due to direct trauma, such as a fall on the shoulder. Six types of acromioclavicular sprains and three types of distal clavicle fractures have been described in adults. Although there is general agreement on treatment of type I, II, IV, V, and VI acromioclavicular injuries, the treatment of type III injuries remains controversial. Studies have shown no distinct advantage for surgical reconstruction over nonoperative treatment. Because type II distal clavicle fractures are prone to nonunion, operative fixation may be advisable to avoid this complication.

Post-traumatic osteolysis of the distal clavicle

We report a case of post-traumatic osteolysis of the distal clavicle of a 25-year-old man. The diagnosis was missed for several months, and the patient continued to have pain in his right shoulder. The pain continued in spite of intensive physiotherapy. When he was seen for the first time in our clinic 6 months after the accident, the radiographs showed an osteolysis of the distal clavicle.

Surgical resection of the distal clavicle

Distal clavicle resection is frequently performed for persistent acromioclavicular pain. However, patient outcome after this procedure has not been well described. The results of subjective and objective retrospective analysis of 23 open distal clavicle resections in 21 patients are reported. Patients were evaluated with a questionnaire, roentgenographs, physical examination, and isokinetic muscle strength testing at an average of 30 months after surgery. Eighteen of 23 shoulders had good or excellent postoperative ratings. All patients had normal motion. No significant weakness of the operated shoulder was seen on objective muscle testing when compared with the unoperated shoulder. The average preoperative Hospital for Special Surgery score was 34, and the average postoperative score was 84. Age and hand dominance were unrelated to postoperative outcomes. Less predictable results were obtained in patients with workmen's compensation and in those patients involved in litigation. Open distal clavicle resection yields good to excellent results in properly selected patients and does not create significant subjective or objective weakness.

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.

Atraumatic osteolysis of the distal clavicle. Results of open surgical excision

A group of 14 patients underwent 17 consecutive open surgical excisions of the distal clavicle for atraumatic osteolysis after having failed conservative treatment. All patients were men involved in weight training or heavy-lifting occupations. The diagnosis was based on no history of shoulder trauma, positive plain radiographs, and positive joint scintigraphy. All 14 patients were available for followup at an average of 25 months postoperatively. The UCLA Shoulder Rating Scale was used for evaluation. All patients reported full return to sports and employment at a satisfactory level. All results were rated as excellent (8) or good (9). Eleven of the 14 patients had bilateral involvement to some extent. One patient had undergone open excision of the contralateral distal clavicle before the study and 3 patients presented with bilateral symptoms and underwent staged bilateral excisions during the study. Seven patients presented with contralateral symptoms and radiographic involvement at latest followup after return to weight-lifting activities.

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

The technique of arthroscopic resection of the outer end of the clavicle through a superior approach is evaluated to determine whether adequate bone removal can be achieved. Furthermore, the results are compared with open resection. Twelve patients with osteolysis of the outer end of the clavicle refractory to conservative treatment underwent resection: six open and six arthroscopically through a superior approach. The distances from the acromial side of the AC joint to the lateral edge of the clavicle at its superior and inferior cortices were measured before and after surgery on anteroposterior radiographs. Bone removal was assessed by the difference between pre- and postoperative measurements. Satisfactory bone removal was possible arthroscopically and averaged 17 mm. This compared favorably with 18-mm average bone removal in the open group. Comparable pain relief and function were achieved in both groups. However, pain relief was achieved on average 3.4 months earlier in the arthroscopic group. Hospital stay was significantly shortened because the arthroscopic resections were outpatient procedures, whereas the open procedures had an average hospital stay of 3 days.

Osteolysis of the pubic bone simulating malignancy. A case report and review of literature

A 78-year-old white female presented with groin pain of 3 months' duration. Radiographs revealed an osteolytic lesion in the pubic bone, simulating a malignancy or infection. A closed needle biopsy was performed and pathological findings were consistent with post-traumatic osteolysis, showing avascular necrotic tissues. A review of the literature found 16 previous cases presenting with groin pain and a radiographic lesion in the pubic bone that appeared malignant. All of the patients reported in the literature were postmenopausal women most with a recent history of trauma or increased physical activity. All of the lesions were benign and, when treated conservatively, usually resolved within 6 months.

Parasymphyseal and associated insufficiency fractures of the pelvis and sacrum

Eleven post-menopausal women presenting with a parasymphyseal insufficiency fracture of the pubis are reported. The plain radiographs showed delayed healing with a mixed lytic and sclerotic area developed at the fracture site simulating a malignant lesion. Aetiological factors included post-menopausal osteoporosis, rheumatoid arthritis and steroid therapy, previous hip replacement and pelvic radiotherapy. Ten patients had concomitant fractures of the pelvis, including nine with sacral fractures. These were all initially missed on presentation because of the subtle radiographic signs of a longitudinal band of sclerosis, usually bilaterally, in the sacral ala. Bone scanning was shown to be the most sensitive technique in detecting the sacral fractures by demonstrating increased uptake in the sacral ala as well as the other fractures of the pelvis. Computed tomography in three cases was helpful in confirming the presence of fractures and excluding the possibility of malignancy.

Atraumatic osteolysis of the distal clavicle: histologic evidence of synovial pathogenesis. A case report

Osteolysis of the distal clavicle was diagnosed in a young male athlete following many years as a baseball pitcher with a supplementary weightlifting program. There was no history of ligamentous injuries, contusions, fractures or separation of the acromioclavicular joint. As such, this case was categorized as "atraumatic" osteolysis. Non-decalcified histologic sections from the resected clavicle suggest that the pathogenesis of this atraumatic osteolysis arose from the synovium.

Resection of the lateral end of the clavicle. A 3 to 30-year follow-up

Fifty patients, operated on with resection of the clavicle, were evaluated postoperatively after an average of 9 years. There was no significant difference between the traumatic and non-traumatic group. The initial results did not alter significantly with time. Nearly half of the patients with poor outcome had psychiatric or alcoholic problems. Radiographic examination of 30 shoulders showed newly formed bone at the resected clavicle in one third and radio-opaque deposits in the resection gap in another third. These findings were consistent with good outcome.

Radiographic joint space in normal acromioclavicular joints

The acromioclavicular joint space in standard antero-posterior images of 151 normal subjects was measured. The joint space was significantly wider in men. There was a highly significant reduction of the joint space with age in both men and women and in persons past 60 a joint space of 0.5 mm or less is not pathological. A joint space wider than 7 mm in men and 6 mm in women is abnormal. The measuring technique described is useful in population studies. In individual cases a simple measurement with a ruler serves the same purpose.