Arthroscopic distal clavicle resection in athletes: a prospective comparison of the direct and indirect approach

Upper Extremity Stress Fractures

BACKGROUND

Stress injuries are often missed secondary to their insidious onset, milder symptoms, and subtle or initially absent findings when imaged.

MAIN BODY

This review aims to provide strategies for evaluating and treating upper extremity stress fractures. This article outlines the classic presentation of each fracture, the ages during which these injuries often occur, the relevant anatomy and biomechanics, and the mechanism of each injury. Diagnostic imaging and management principles are also discussed, including the use of conservative versus surgical management techniques.

SHORT CONCLUSION

Upper extremity stress fractures are often mild injuries that resolve with conservative management but can lead to more serious consequences if ignored. Given their increasing incidence, familiarity with diagnosis and management of these injuries is becoming increasingly pertinent.

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.

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.

Nanoscopic Distal Clavicle Resection

Acromioclavicular joint pathology such as osteoarthritis has historically been treated with either an open or arthroscopic distal clavicle resection. Over the years the trend has been toward more minimally invasive treatment options with the arthroscope. In this article we highlight the use of the nanoscope to visualize the resection which can be performed through a small percutaneous incision. The advantages of this technique include the use of smaller portals, which should lead to improved earlier outcomes, and less iatrogenic damage to the shoulder.

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.

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.

Open versus arthroscopic acromioclavicular joint resection: a systematic review and meta-analysis

INTRODUCTION

The purpose of this study was to perform a meta-analysis comparing open and arthroscopic surgical techniques for distal clavicle resection.

METHODS

A systematic review of Medline, Embase, Scopus, and Google Scholar identified relevant publications in the English and German literature between 1997 and 2017. All included studies were levels I-IV, describing both treatments, with a minimum of 12 month follow-up, had at least one validated outcome score and documented patient recruitment, study design, demographic details, and surgical technique. Studies were excluded if they were only abstracts or conference proceedings, involved revision procedures, or the loss to follow-up exceeded 20%. Publication bias and risk of bias were assessed using the Cochrane Collaboration tools, and heterogeneity was assessed using the I² statistic.

RESULTS

Four studies (n = 319 patients) met the criteria for inclusion. The pooled estimate for clinical outcomes (Constant, ASES) demonstrated no significant differences (SMD 0.323, I² = 0%, p = 0.065) between open and arthroscopic resection, although the analysis favored open resection. The pooled estimate for clinical outcomes (SST) also demonstrated no significant differences (SMD 0.744, I² = 49.82%, p = 0.144) between open and arthroscopic resection, but the analysis again favored open resection. The pooled estimate for VAS assessment of pain demonstrated no differences (SMD 0.217, I² = 58.96%; p = 0.404) between open and arthroscopic resection.

CONCLUSION

The results of this study suggest that similar functional and clinical outcomes can be achieved with either open or arthroscopic distal clavicle resection. The observed trend that open resection may have a more favorable outcome warrants further investigation.

LEVEL OF EVIDENCE

Level 3; systematic review and meta-analysis.

Ultrasound-Guided Prolotherapy for Acromial Enthesopathy and Acromioclavicular Joint Arthropathy: A Single-Arm Prospective Study

OBJECTIVES

Prolotherapy is an injection-based complementary treatment for various musculoskeletal diseases. The aim of this study was to evaluate the therapeutic efficacy of ultrasound-guided prolotherapy in the treatment of acromial enthesopathy and acromioclavicular joint arthropathy.

METHODS

Thirty-one patients with chronic moderate-to-severe shoulder pain were recruited from September 2015 to September 2017. Ultrasound-guided prolotherapy was performed by injecting 10 mL of a 15% dextrose solution into the acromial enthesis of the deltoid or acromioclavicular joint capsule aseptically. Prolotherapy was given in 2 sessions separated by a 1-month interval. The pretreatment-to-posttreatment change in the pain visual analog scale (VAS) score was recorded as the primary outcome. The mean follow-up duration was 61.8 days. A paired t test was used to assess the difference in pretreatment and posttreatment VAS scores. A univariate logistic regression analysis was conducted to identify the demographic variables associated with substantial pain reduction after the intervention. Substantial pain reduction was defined as a posttreatment VAS score of 3 or less.

RESULTS

Twenty of the 31 patients reported substantial pain reduction without adverse effects after the intervention. The mean VAS score reduction ± SD was 4.3 ± 2.6 (pretreatment, 6.8 ± 1.5; posttreatment, 2.5 ± 2.1; P < .01).

CONCLUSIONS

Ultrasound-guided prolotherapy with a 15% dextrose solution is an effective and safe therapeutic option for moderate-to-severe acromial enthesopathy and acromioclavicular joint arthropathy.

Does Distal Clavicle Resection Decrease Pain or Improve Shoulder Function in Patients With Acromioclavicular Joint Arthritis and Rotator Cuff Tears? A Meta-analysis

BACKGROUND

Acromioclavicular joint arthritis is a common, painful, and often missed diagnosis, and it often accompanies other shoulder conditions such as rotator cuff disease. Whether distal clavicle resection is important to perform in patients undergoing surgery for rotator cuff tears and concomitant acromioclavicular joint arthritis is controversial.

QUESTIONS/PURPOSES

The purpose of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of distal clavicle resection on (1) outcome scores; (2) shoulder ROM, joint pain or tenderness, and joint instability; and (3) risk of reoperation among patients treated surgically for rotator cuff tears who had concomitant acromioclavicular joint arthritis.

METHODS

We systematically searched the PubMed, EMBASE, and Cochrane databases to find RCTs that met our eligibility criteria, which, in summary, (1) compared rotator cuff repair plus distal clavicle resection with isolated rotator cuff repair for patients who sustained a full- or partial-thickness rotator cuff tear and concomitant acromioclavicular joint arthritis; and (2) the followup period was at least 2 years. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis. Statistical heterogeneity among studies was quantitatively evaluated with the I index. No heterogeneity was detected (I = 0%; p = 0.75) in terms of acromioclavicular joint pain or tenderness, Constant score, forward flexion, external rotation, and risk of reoperation, so fixed-effect models were used in these endpoints. Heterogeneity was moderate for the American Shoulder and Elbow Surgeons (ASES) score (I = 53%; p = 0.12) and low for the visual analog scale (VAS) score (I = 35%; p = 0.22), so random-effect models were used in these endpoints. Subgroup analysis was stratified by the symptom of acromioclavicular joint arthritis. Three RCTs with 208 patients were included. We evaluated the risk of bias using the Cochrane risk-of-bias tool; in aggregate, the three RCTs included showed low to intermediate risk, although not all parameters of the Cochrane tool could be assessed for all studies.

RESULTS

There was no difference between the distal clavicle resection plus rotator cuff repair group and the isolated rotator cuff repair group in ASES score (mean difference =1.41; 95% confidence interval [CI], -3.37 to 6.18; p = 0.56) nor in terms of the VAS score and Constant score. Likewise, we found no difference in ROM of the shoulder (forward flexion, internal rotation, and external rotation) or acromioclavicular joint pain or tenderness between the groups (pooled results of acromioclavicular joint pain or tenderness: risk ratio [RR], 1.59; 95% CI, 0.67-3.78; p = 0.30). Acromioclavicular joint instability was only detected in the rotator cuff repair plus distal clavicle resection group. Finally, we found no difference in the proportion of patients undergoing repeat surgery between the study groups (pooled results of risk of reoperation for the rotator cuff repair plus distal clavicle resection and isolated rotator cuff repair: one of 52 versus two of 78; RR, 0.86; 95% CI, 0.11-6.48; p = 0.88).

CONCLUSIONS

Distal clavicle resection in patients with rotator cuff tears did not result in better clinical outcome scores or shoulder ROM and was not associated with a lower risk of reoperation. Distal clavicle resection might cause acromioclavicular joint instability in patients with rotator cuff tears and concomitant asymptomatic acromioclavicular joint arthritis. Arthroscopic distal clavicle resection is not recommended in patients with rotator cuff tears and concomitant acromioclavicular joint arthritis. Additional well-designed RCTs with more participants, long-term followup, and data on patient-reported outcomes are needed.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Managing acromio-clavicular joint pain: a scoping review

BACKGROUND

Shoulder pain secondary to acromioclavicular joint pain is a common presentation in primary and secondary care but is often poorly managed as a result of uncertainty about optimal treatment strategies. Osteoarthritis is the commonest cause. Although acromioclavicular pain can be treated non-operatively and operatively, there appears to be no consensus on the best practice pathway of care for these patients, with variations in treatment being common place. The present study comprises a scoping review of the current published evidence for the management of isolated acromioclavicular pain (excluding acromioclavicular joint dislocation).

METHODS

A comprehensive search strategy was utilized in multiple medical databases to identify level 1 and 2 randomised controlled trials, nonrandomised controlled trials and systematic reviews for appraisal.

RESULTS

Four systematic reviews and two randomised controlled trials were identified. No direct studies have compared the benefits or risks of conservative versus surgical management in a controlled environment.

CONCLUSIONS

High-level studies on treatment modalities for acromioclavicular joint pain are limited. As such, there remains little evidence to support one intervention or treatment over another, making it difficult to develop any evidenced-based patient pathways of care for this condition.Level of evidence: 2A.

Diagnosis and Management of Distal Clavicle Osteolysis

Distal clavicle osteolysis is an uncommon condition that most commonly affects weight lifters and other athletes who perform repetitive overhead activity. Although this condition most commonly presents in young active men, it is becoming increasing more common in women with the rise in popularity of body building and extreme athletics. Distal clavicle osteolysis can be debilitating, especially in those with rigorous training regimens, preventing exercise because of pain with activities such as bench presses and chest flies. Aside from a careful history and physical examination, radiographic evaluation is essential in distinguishing isolated distal clavicle osteolysis from acromioclavicular joint pathology, despite a potentially similar presentation of the 2 conditions. Nonoperative therapy that includes activity modification, nonsteroidal anti-inflammatory drugs, and cortisone injections is the first-line management for this condition. Patients whose conditions are refractory to nonoperative modalities may benefit from distal clavicle resection via either open or arthroscopic techniques. Arthroscopic techniques typically are favored because of improved cosmesis and the added benefit of the ability to assess the glenohumeral joint during surgery to rule out concomitant pathology. There are varying operative techniques even within arthroscopic management, with pros and cons of a direct and an indirect surgical approach. Patients often do well after such procedures and are able to return to their preinjury level of participation in a relatively short period. [Orthopedics. 2017; 40(2):119-124.].

Distal clavicular osteolysis in adults: association with bench pressing intensity

OBJECTIVES

To investigate the association between distal clavicular osteolysis (DCO) and bench pressing intensity.

METHODS

From a retrospective review of MRI shoulder reports of individuals between 20 and 40 years of age, 262 male patients with DCO and 227 age-matched male patients without DCO were selected. All patients had completed a bench pressing questionnaire. The patients' bench pressing frequency (times per week), duration (years of bench pressing), bench pressing weight (maximum bench pressing weight with one repetition = 1RM) and the ratio of bench pressing weight to body weight were compared between both groups using Chi-square and Mann-Whitney tests.

RESULTS

The results showed that 56 % (146/262) of patients with DCO were high-intensity bench pressers (1RM more than 1.5 times the body weight) compared to 6 % (14/227) in patients without DCO. High-intensity bench pressing was a risk factor for DCO (OR = 19; 95 %CI = 11-35; p < 0.001). Low-intensity bench pressing (1RM less than 1.5 times the body weight) was not a risk factor for DCO (OR = 0.6; 95 % CI = 0.4-0.8). High frequency (>1×/week) and duration (>5 years) of bench pressing were risk factors. In bench pressers who suffered from DCO, the mean 1RM was 283 lbs (±SD 57) compared to 209 lbs (±SD 60) in bench pressers not affected by DCO (p < 0.001, Mann-Whitney).

CONCLUSIONS

High-intensity, but not low-intensity bench pressing is a risk factor for DCO.

Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: a resident's case problem

STUDY DESIGN

Resident's case problem.

BACKGROUND

Acromioclavicular joint pathology is reported to be present in up to 30% of all patients complaining of shoulder dysfunction. The operative approach to treating acromioclavicular joint disease often includes a distal clavicle excision and, in circumstances of acromioclavicular joint instability, reconstruction of the coracoclavicular and/or the acromioclavicular ligament. Surgical complications for these procedures are rare, but potentially include suprascapular neuropathy secondary to the course of the suprascapular nerve posterior to the clavicle prior to entering the supraspinatus fossa.

DIAGNOSIS

A 28-year-old Caucasian woman reported directly to an outpatient physical therapy clinic with a complaint of right shoulder weakness. Three years prior, the patient underwent a distal clavicle excision and coracoclavicular ligament reconstruction. A detailed examination, including diagnostic imaging, identified infraspinatus atrophy and weakness, increasing the suspicion for suprascapular nerve injury. Electromyography was ordered to confirm the clinical and imaging diagnosis of suprascapular neuropathy and to rule out other nerve lesions, especially considering the selective atrophy of the infraspinatus muscle without mechanical explanation.

DISCUSSION

The clinical decision making and systematic use of diagnostic testing resulted in identifying a rare case of suprascapular neuropathy, selective to the infraspinatus, in a patient who previously underwent a distal clavicle excision and coracoclavicular ligament reconstruction. Without a spinoglenoid cyst or other suprascapular nerve lesion identified on advanced imaging, it is likely that the suprascapular neuropathy identified in this case was related to the surgical procedure.

LEVEL OF EVIDENCE

Differential diagnosis, level 4.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

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

RESULTS

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

CONCLUSION

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

Is arthroscopic distal clavicle resection necessary for patients with radiological acromioclavicular joint arthritis and rotator cuff tears? A prospective randomized comparative study

BACKGROUND

The failure of subacromial decompression may be attributed to persistent symptoms of acromioclavicular joint (ACJ) arthritis, while inferior clavicular spurs of the ACJ may be associated with failed healing of repaired rotator cuffs.

PURPOSE

To evaluate the clinical effectiveness of arthroscopic distal clavicle resection (DCR) in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis who were scheduled for arthroscopic rotator cuff repair were prospectively randomized into 2 groups. Patients underwent arthroscopic rotator cuff repair with acromioplasty. Patients in group 1 (39 patients) underwent additional arthroscopic DCR, while patients in group 2 (39 patients) did not. Clinical outcomes of the 2 groups were compared using the visual analog scale (VAS) for pain, range of motion, Constant score, and American Shoulder and Elbow Surgeons (ASES) score up to at least 24 months. The structural integrity of repaired rotator cuffs was assessed using ultrasonography, computed tomography arthrography, or MRI at least 6 months after surgery. To evaluate ACJ instability, weighted stress radiography of the ACJ was studied at 6 and 12 months postoperatively.

RESULTS

Patients in both groups showed significant improvement in the VAS score and all functional scores at final follow-up (mean, 29.2 months; range, 24-46 months) without significant differences between the 2 groups (P > .05). Results (mean ± SD) for preoperative group 1/group 2 and postoperative group 1/group 2 were as follows, respectively: 7.2 ± 1.8/6.1 ± 1.9 (P = .02) and 0.6 ± 1.8/0.6 ± 0.9 (P = .97) for the VAS score, 74.1 ± 5.7/73.8 ± 8.0 (P = .87) and 96.3 ± 5.7/95.7 ± 4.6 (P = .77) for the Constant score, and 47.0 ± 10.3/50.8 ± 14.1 (P = .22) and 91.5 ± 15.5/94.5 ± 11.8 (P = .55) for the ASES score. Failed cuff healing occurred in 9 patients (23%) in group 1 and 10 patients (26%) in group 2, with no significant difference (P = .95). In group 1, there were 2 patients (5.0%) with ACJ subluxation on weighted stress radiography at 6 months postoperatively. These patients complained of gross protrusion and ACJ tenderness.

CONCLUSION

Preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and it did lead to symptomatic ACJ instability in some patients. Preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis. Further long-term follow-up is needed to confirm the development of symptoms in ACJ arthritis.

Degenerative joint disease of the acromioclavicular joint: a review

Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities. This most commonly occurs in middle-aged individuals because of degeneration to the fibrocartilaginous disk that cushions the articulations. Diagnosis relies on history, physical examination, imaging, and diagnostic local anesthetic injection. Diagnosis can be challenging given the lack of specificity with positive physical examination findings and the variable nature of AC joint pain. Of note, symptomatic AC osteoarthritis must be differentiated from instability and subtle instability, which may have similar symptoms. Although plain radiographs can reveal degeneration, diagnosis cannot be based on this alone because similar radiographic findings can be seen in asymptomatic individuals. Nonoperative therapy can provide symptomatic relief, whereas patients with persistent symptoms can be considered for resection arthroplasty by open or arthroscopic technique. Both techniques have proven to provide predictable pain relief; however, each has its own unique set of potential complications that may be minimized with an improved understanding of the anatomical and biomechanical characteristics of the joint along with meticulous surgical technique.

Arthroscopic anatomy of the subdeltoid space

From the first shoulder arthroscopy performed on a cadaver in 1931, shoulder arthroscopy has grown tremendously in its ability to diagnose and treat pathologic conditions about the shoulder. Despite improvements in arthroscopic techniques and instrumentation, it is only recently that arthroscopists have begun to explore precise anatomical structures within the subdeltoid space. By way of a thorough bursectomy of the subdeltoid region, meticulous hemostasis, and the reciprocal use of posterior and lateral viewing portals, one can identify a myriad of pertinent ligamentous, musculotendinous, osseous, and neurovascular structures. For the purposes of this review, the subdeltoid space has been compartmentalized into lateral, medial, anterior, and posterior regions. Being able to identify pertinent structures in the subdeltoid space will provide shoulder arthroscopists with the requisite foundation in core anatomy that will be required for challenging procedures such as arthroscopic subscapularis mobilization and repair, biceps tenodesis, subcoracoid decompression, suprascapular nerve decompression, quadrangular space decompression and repair of massive rotator cuff tears.

Manual physical therapy for injection-confirmed nonacute acromioclavicular joint pain

STUDY DESIGN

Prospective single-cohort study.

OBJECTIVES

To determine and document changes in pain and disability in patients with primary, nonacute acromioclavicular joint (ACJ) pain treated with a manual therapy approach.

BACKGROUND

To our knowledge, there are no published studies on the physical therapy management of nonacute ACJ pain. Manual physical therapy has been successful in the treatment of other shoulder conditions.

METHODS

The chief inclusion criterion was greater than 50% pain relief with an ACJ diagnostic injection. Patients were excluded if they had sustained an ACJ injury within the previous 12 months. Treatment was conducted utilizing a manual physical therapy approach that addressed all associated impairments in the shoulder girdle and cervicothoracic spine. The primary outcome measure was the Shoulder Pain and Disability Index. Secondary measures were the American Shoulder and Elbow Surgeon and global rating of change scales. Outcomes were collected at baseline, 4 weeks, and 6 months. The Shoulder Pain and Disability Index and American Shoulder and Elbow Surgeon scale values were analyzed with a repeated-measures analysis of variance.

RESULTS

Thirteen patients (11 male; mean ± SD age, 41.1 ± 9.6 years) completed treatment consisting of an average of 6.4 sessions. Compared to baseline, there was a statistically significant and clinically meaningful improvement for the Shoulder Pain and Disability Index at 4 weeks (P = .001; mean, 25.9 points; 95% confidence interval [CI]: 11.9, 39.8) and 6 months (P<.001; mean, 29.8 points; 95% CI: 16.5, 43.0), and the American Shoulder and Elbow Surgeon scale at 4 weeks (P<.001; mean, 27.9 points; 95% CI: 14.7, 41.1) and 6 months (P<.001; mean, 32.6 points; 95% CI: 21.2, 43.9).

CONCLUSION

Statistically significant and clinically meaningful improvements were observed in all outcome measures at 4 weeks and 6 months, following a short series of manual therapy interventions. These results, in a small cohort of patients, suggest the efficacy of this treatment approach but need to be verified by a randomized controlled trial.

LEVEL OF EVIDENCE

Therapy, level 4.

Arthroscopic versus open distal clavicle excision: a comparative assessment at intermediate-term follow-up

BACKGROUND

While few comparative studies exist, it has been suggested that open distal clavicle excisions (DCEs) provide inferior results when compared with the all-arthroscopic technique.

PURPOSE

The purpose of this study was to compare the intermediate-term (5-year follow-up) results of patients undergoing arthroscopic versus open DCE for the treatment of recalcitrant acromioclavicular joint pain.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients who underwent an arthroscopic or open DCE between January 1999 and September 2006 were reviewed. Forty-eight patients (49 shoulders; 32 arthroscopic, 17 open) following DCE without significant glenohumeral pathologic changes were included. The mean follow-up for group I (open) and group II (arthroscopic) was 5.3 years and 4.2 years, respectively. The American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, surgical time, and minimum radiographic acromioclavicular joint distance were calculated. Each patient completed a questionnaire assessing their scar satisfaction, percentage of normal shoulder function, and willingness to have the surgery again. Risk factors for poor outcomes were analyzed.

RESULTS

Arthroscopic patients had significantly less pain (P = .035) by VAS (0.61 ± 1.02) compared with open (1.59 ± 2.15) at final follow-up. There was no significant difference between group I and group II with regard to ASES (87.5 ± 17.6 vs 94.6 ± 8.6), percentage of normal shoulder function (89.7% ± 12.5 vs 92.9% ± 8.6), average operative time (53.1 minutes vs 48 minutes), or radiographic resection distance (12.8 ± 2.1 mm vs 9.5 ± 2.9 mm). In the open group, patients with 16 of 17 shoulders were satisfied with their scar and 100% would do it again. In the arthroscopic group, patients with 31 of 32 shoulders (97%) were both satisfied and would have the surgery again.

CONCLUSION

Open and arthroscopic DCE are both effective surgeries to treat recalcitrant acromioclavicular joint pain. At intermediate-term follow-up, they provide similarly good to excellent results with regard to patient satisfaction and shoulder function. Although both are effective treatments, less residual pain was found using the arthroscopic technique.

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.

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.

Injuries to the acromioclavicular joint

Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor subluxations are best managed conservatively, but there is debate concerning the treatment of complete dislocations and the more complex combined injuries in which other elements of the shoulder girdle are damaged. Confusion has been caused by existing systems for classification of these injuries, the plethora of available operative techniques and the lack of well-designed clinical trials comparing alternative methods of management. Recent advances in arthroscopic surgery have produced an even greater variety of surgical options for which, as yet, there are no objective data on outcome of high quality. We review the current concepts of the treatment of these injuries.

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.