The evaluation and management of failed 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.

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.

Acromioclavicular joint arthritis is not an indication for routine distal clavicle excision in arthroscopic rotator cuff repair

PURPOSE

To evaluate the significance of untreated primary acromioclavicular joint (ACJ) osteoarthritis, encountered during arthroscopic rotator cuff repair (RCR), as a cause of persistent symptomatology and need for revision surgery.

METHODS

In a cohort of 811 consecutive patients older than 55 years who underwent RCR, the effect of primary ACJ osteoarthritis presence was prospectively examined. A total of 497 patients with mild/moderate and severe ACJ osteoarthritis based on preoperative MRI evaluation were allocated to Group A (n = 185, symptomatic ACJ) and Group B (n = 312, asymptomatic ACJ). Distal clavicle excision was not performed regardless of the presence of pain. The minimum follow-up was 28 months (28-46). The visual analogue scale (VAS) pain scores were assessed for ACJ pain on palpation, the cross body adduction test, the Constant-Murley, and the American Shoulder and Elbow Surgeons (ASES).

RESULTS

The overall loss to follow-up rate was 3.82% (19 patients: 11 in Group A and eight in Group B). The mean ASES score at the latest follow-up was 91.16 ± 9.3 and 92.37 ± 10.44 in Groups A and B, respectively, and the mean Constant-Murley score was 96.36 ± 5.7 and 95.76 ± 4.6 in Groups A and B, respectively. There was no statistical significance between regarding both scores. Localised ACJ pain on palpation and pain on cross body adduction were diminished in both the symptomatic and asymptomatic group. There were five cases (1%: two in Group A and three in Group B) with persistent ACJ pain who had failed the conservative treatment, and ACJ excision was necessary to alleviate the symptoms. All revision operations were uncomplicated with symptom resolution.

CONCLUSION

Untreated ACJ osteoarthritis, symptomatic or not, encountered during arthroscopic RCR is associated with a low percentage of failure. Routine distal clavicle excision is not absolutely necessary, even in patients with symptomatic ACJ osteoarthritis.

LEVEL OF EVIDENCE

II, Prospective cohort study.

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.

Benefits of distal clavicle resection during rotator cuff repair: Prospective randomized single-blind study

INTRODUCTION

Rotator cuff tears often occur in combination with acromioclavicular (AC) arthropathy. But it can be difficult to separate pain caused by the rotator cuff tear from pain caused by the AC joint, despite clinical and other examinations. Distal clavicle resection (DCR) is increasingly being done at the same time as arthroscopic rotator cuff repair. The aim of this study was to compare the functional outcomes 1 year after arthroscopic rotator cuff repair between patients who simultaneously undergo DCR and patients who do not. The primary hypothesis was that DCR improves the clinical outcomes.

MATERIAL AND METHODS

This was a prospective, multicenter, randomized, single-blind study of 200 patients who underwent isolated supraspinatus repair using the same technique. The patients were randomized into two groups: 97 patients who also underwent DCR and 103 patients who did not. The patients were followed until 1 year postoperative according to a standardized radiological and clinical review protocol.

RESULTS

At 1 year postoperative, all the clinical outcomes were worse in the DCR group, although only external rotation with elbow at side (53° vs. 59°, p=0.04) and the SSV (86.5 vs. 90.1, p=0.04) were statistically different. Overall shoulder pain was higher in the DCR group during the first 3 months postoperative (p=0.04). At 1 year, the DCR group had more residual pain; this pain was mainly located on the superior side of the shoulder (p=0.03), especially when more than 11 mm was resected (p=0.01). More of the shoulders in the DCR group had failures in rotator cuff healing based on ultrasonography (p=0.5).

CONCLUSION

Our hypothesis was not confirmed. We do not recommend doing routine DCR with arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

I, prospective randomized simple blind study.

New possibilities: the LockDown device for distal clavicle fractures

Background and hypothesis

The majority of distal clavicle fractures are displaced fractures and constitute a treatment challenge because they have a 30% chance of delayed union or nonunion. Although several options for surgical reconstruction have been described, in patients with a comminuted and/or small distal fragment, these reconstructive options have proved to be prone to failure. Moreover, secondary surgery for removal is necessary in most cases. We hypothesized that the LockDown device, a braided synthetic ligament device, combined with resection of the distal fracture fragment is a suitable alternative in specified patients with distal clavicle fractures.

Methods

Eleven patients with distal clavicle fractures were treated with distal fracture resection and the LockDown procedure. All patients underwent regular follow-up with data collection; additionally, 7 were assessed at 1-year follow-up according to the study protocol. On the basis of radiography, these patients had a clear coracoclavicular ligament disruption and subsequent cranial dislocation of the medial fragment. Regular follow-up was performed at 6 weeks, 3 months, and 6 months. Control radiographs were taken at 3 and 6 months. Furthermore, the 7 enrolled patients were assessed at 1 year, when the Disabilities of the Arm, Shoulder and Hand score, Constant shoulder score, Nottingham Clavicle Score, and range of motion were recorded. Residual pain was ascertained by a visual analog scale score.

Results

In total, 11 patients were treated with distal clavicle resection and the LockDown procedure. Eight patients underwent surgery within 3 weeks after presentation at the emergency department. The other 3 patients were operated on after a trial of conservative treatment (due to persisting pain and delayed union). None of the patients had postoperative complications. At 3 months, 9 of the 11 patients had made a full recovery.

Discussion

All 11 patients had good short-term clinical outcomes. None showed acromioclavicular instability. Furthermore, secondary surgery was avoided, and hardware complications did not occur. In low-demand patients or patients with a high risk of nonunion, this technique may be a favorable alternative to other known techniques.

Minimum 10-Year Outcomes After Revision Anatomic Coracoclavicular Ligament Reconstruction for Acromioclavicular Joint Instability

Background:

Revision surgery in cases of previously failed primary acromioclavicular (AC) joint stabilization remains challenging mainly because of anatomic alterations or technical difficulties. However, anatomic coracoclavicular ligament reconstruction (ACCR) has been shown to achieve encouraging biomechanical, clinical, and radiographic short-term to midterm results.

Purpose:

To evaluate the clinical and radiographic long-term outcomes of patients undergoing revision ACCR after failed operative treatment for type III through V AC joint injuries with a minimum 10-year follow-up.

Study Design:

Case series; Level of evidence, 4.

Methods:

A retrospective chart review was performed on prospectively collected data within an institutional shoulder registry. Patients who underwent revision ACCR for type III through V AC joint injuries between January 2003 and December 2009 were analyzed. Clinical outcome measures included the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE). The coracoclavicular distance (CCD) was measured for radiographic analysis immediately postoperatively and at last postoperative follow-up.

Results:

A total of 8 patients with a mean age at the time of surgery of 44.6 ± 10.6 years and a mean follow-up of 135.0 ± 17.4 months (range, 120-167 months) were eligible for inclusion in the study. The time from initial AC joint stabilization until revision surgery was 10.2 ± 12.4 months (range, 0.5-36 months); 62.5% of the patients had undergone more than 2 previous AC joint surgical procedures. The ASES score improved from 43.9 ± 22.4 preoperatively to 80.6 ± 28.8 postoperatively (P = .012), the SST score improved from 4.4 ± 3.6 preoperatively to 11.0 ± 2.2 postoperatively (P = .017), and the SANE score improved from 31.4 ± 27.3 preoperatively to 86.9 ± 24.1 postoperatively (P = .018) at final follow-up. There was no significant difference in the CCD (P = .08) between the first (7.6 ± 3.0 mm) and final (10.6 ± 2.8 mm) radiographic follow-up (mean, 50.5 ± 32.7 months [range, 18-98 months]).

Conclusion:

Patients undergoing revision ACCR after failed operative treatment for type III through V AC joint injuries maintained significant improvement in clinical outcomes at a minimum 10-year follow-up.

Surgical techniques for management of acromioclavicular joint separations: review and update for radiologists

Imaging plays a central role in the postoperative management of acromioclavicular (AC) joint separations. There are more than 150 described techniques for the surgical management of AC joint injuries. These procedures can be categorized as varying combinations of the following basic techniques: a) soft-tissue repair, b) trans-articular AC joint fixation, c) coracoclavicular (CC) fixation, d) non-anatomic reconstruction of the CC ligaments, e) anatomic reconstruction of the CC ligaments, f) distal clavicle resection, and g) dynamic muscle transfer. The goals of this article are to describe the basic techniques for the surgical management of AC joint separations with an emphasis on technique-specific complications and postoperative imaging assessment.

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.

Trends in the Surgical Management of Acromioclavicular Joint Arthritis Among Board-Eligible US Orthopaedic Surgeons

PURPOSE

(1) Define the epidemiologic trend of distal clavicle excision (DCE) for acromioclavicular (AC) joint arthritis among board-eligible orthopaedic surgeons in the United States, (2) describe the rates and types of reported complications of open and arthroscopic DCE, and (3) evaluate the effect of fellowship training on preferred technique and reported complication rates.

METHODS

The American Board of Orthopaedic Surgery (ABOS) database was used to identify DCE cases submitted by ABOS Part II Board Certification examination candidates. Inclusion criteria were predetermined using a combination of ICD-9 and CPT codes. Cases were dichotomized into 2 groups: open or arthroscopic DCE. The 2 groups were then analyzed to determine trends in annual incidence, complication rates, and surgeon fellowship training.

RESULTS

From April 2004 to September 2013, there were 3,229 open and 12,782 arthroscopic DCE procedures performed and submitted by ABOS Part II Board Eligible candidates. Overall, the annual incidence of open DCE decreased (78-37 cases per 10,000 submitted cases, P = .023). Although the annual number of arthroscopic DCE remained steady (1160-1125, P = .622), the percentage of DCE cases performed arthroscopically increased (65%-79%, P = .033). Surgeons without fellowship training were most likely to perform a DCE via an open approach (31%) whereas surgeons with sports medicine training were more likely to perform DCE arthroscopically compared with other fellowship groups (88%, P < .001). Open DCE was associated with a higher surgical complication rate overall when compared with arthroscopic DCE (9.4% vs 7.6%, respectively; P < .001). When compared with other fellowship-trained surgeons, sports medicine surgeons maintained a lower reported surgical complication rate whether performing open or arthroscopic DCE (5.5%, P = .027).

CONCLUSIONS

In recent years, open management of AC joint arthritis has declined among newly trained, board-eligible orthopaedic surgeons, possibly because of an increased complication rate associated with open treatment. Fellowship training was significantly associated with the type of treatment (open vs arthroscopic) rendered and complication rates.

LEVEL OF EVIDENCE

Level IV, case series.

Functional outcome of open acromioclavicular joint stabilization for instability following distal clavicle resection

Background

Acromioclavicular joint instability following distal clavicle resection can result in considerable pain and dysfunction.

Method

We present a review of 13 patients who underwent ACJ stabilization following one or more distal clavicle resection procedures.

Results

The mean Quick DASH and CM scores were 26(0-57) and 73(46-100) respectively. All but one patient reported an improvement in the pain component of their CM score and in the work component of the Quick DASH score.

Discussion

Open ACJ stabilization to treat instability following distal clavicle resection resulted in improved functional scores, pain scores and facilitated return to work in most patients.Level of evidence IV.

Distal Clavicular Osteochondral Autograft Augmentation for Glenoid Bone Loss: A Comparison of Radius of Restoration Versus Latarjet Graft

BACKGROUND

Bone loss in shoulder instability is a well-recognized cause of failure after stabilization surgery. Many approaches have been described to address glenoid bone loss, including coracoid transfer. This transfer can be technically difficult and has been associated with high complication rates. An ideal alternative to coracoid transfer would be an autologous source of fresh osteochondral graft with enough surface area to replace significant glenoid bone loss. The distal clavicle potentially provides such a graft source that is readily available and low-cost.

PURPOSE

To evaluate distal clavicular autograft reconstruction for instability-related glenoid bone loss, specifically comparing the width of the clavicular autograft with the width of an ipsilateral coracoid graft as prepared for a Latarjet procedure. Further, we sought to compare the articular cartilage thickness of the distal clavicle graft with that of the native glenoid.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-seven fresh-frozen cadaver specimens were dissected, and an open distal clavicle excision was performed. The coracoid process in each specimen was prepared as has been described for a classic Latarjet coracoid transfer. In each specimen, the distal clavicle graft was compared with the coracoid graft for size and potential of glenoid articular radius of restoration. The distal clavicle graft was also compared with the native glenoid for cartilage thickness.

RESULTS

In all specimens, the distal clavicle grafts provided a greater radius of glenoid restoration than the coracoid grafts ( P < .0001). On average, the clavicular graft was able to reconstruct 44% of the glenoid diameter, compared with 33% for the coracoid graft ( P < .0001). The articular cartilage of the glenoid was significantly thicker (1.4 mm thicker, P < .0001) than that of the distal clavicular autograft (average ± SD, 3.5 ± 0.6 mm vs 2.1 ± 0.8 mm, respectively). When specimens with osteoarthritis were excluded, this difference decreased to 0.97 mm when compared with the clavicular cartilage ( P = .0026).

CONCLUSION

The distal clavicle autograft can restore a significantly greater glenoid bone deficit than the Latarjet procedure and has the additional benefit of restoring articular cartilage to the glenoid. The articular cartilage thickness of the distal clavicle is within 1.4 mm of that of the native glenoid.

CLINICAL RELEVANCE

The distal clavicular autograft may be a suitable option for reconstruction of instability-related glenoid bone loss. This graft provides a structural osteochondral autograft with a broader radius of reconstruction than that of a coracoid graft, is locally available, has minimal donor site morbidity, is anatomic, and provides articular cartilage.

Arthroscopic Distal Clavicle and Medial Border of Acromion Resection for Symptomatic Acromioclavicular Joint Osteoarthritis

Acromioclavicular joint osteoarthritis can lead to persistent shoulder pain. Distal clavicle excision is the most common operative procedure in patients with failed, conservative symptomatic acromioclavicular joint osteoarthritis treatment, with some reports of complications. This report describes an alternative procedure that can be used to excise the distal clavicle together with the medial border of the acromion. This technique is a simple procedure because the standard distal clavicle excision can preserve the acromioclavicular ligament, as well as the joint capsule, and achieve an adequate resection length.

Limited distal clavicle excision of acromioclavicular joint osteoarthritis

INTRODUCTION

Resection of the distal aspect of clavicle has a well-documented treatment modality in case of acromioclavicular joint osteoarthritis resistant to conservative treatment.

HYPOTHESIS

Limited (mean ∼0.5cm distal end of clavicle resection) distal clavicle excision of A-C joint arthritis in cases resistant to conservative treatment may reduce the pain and improve the shoulder function.

MATERIAL AND METHODS

In this study, we retrospectively evaluated the results of limited distal clavicle excision of acromioclavicular joint osteoarthritis resistant to conservative treatment. All patients were evaluated by using the Visual Analogue Scale (VAS) and UCLA shoulder rating scale (University of California Los Angeles), either before surgery or final follow-up period for pain and functional results, respectively.

RESULTS

A total of 110 patients (48 male, 62 female) with AC joint arthritis, treated between the years of 2008-2012, were retrospectively analyzed. A total of 30 patients (12 male, 18 female) who failed to show improvement with conservative treatment underwent limited surgical open excision of distal clavicle. The mean age of the study population was 52.5±1.2 years. The mean follow-up period was 27±1.3 months. The mean preoperative VAS score was 83.6±5.58 (range, 70-90) while mean VAS was 26.6±9.3 (range, 10-50) at the final follow-up. There was a statistically significant difference between pre- and postoperative VAS scores in patients who had treated by surgical approach (P<0.001). The mean UCLA score of the patients increased postoperatively from 11.5 (range, 9-14) to 29.2 (range, 27-32) at the final follow-up. There was a statistically significant difference between the two time periods with respect to UCLA scores (P<0.001).

DISCUSSION AND CONCLUSION

In patients with AC osteoarthritis resistant to conservative therapy, the hypothesized limited clavicle excision (mean ∼0.5cm distal end of clavicle resection with preserving coracoclavicular ligaments and inferior capsule) reduced the pain and improved the shoulder function.

CONCLUSION

Our midterm follow-up (mean 27 months) results showed that limited distal clavicle excision of patients with AC joint osteoarthritis resistant to conservative treatment (0.5cm distal end of clavicle resection with preserving inferior capsule, and coracoclavicular ligaments) reduced the pain and improved the shoulder function.

LEVEL OF EVIDENCE

IV (Retrospective study).

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

[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.

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.

Biomechanical analysis of distal clavicle excision with acromioclavicular joint reconstruction

BACKGROUND

Acromioclavicular (AC) joint separation is a common injury, usually affecting young adults. Controversy exists regarding whether to excise the distal clavicle when surgical intervention is required.

PURPOSE

To evaluate the biomechanical strength of AC and coracoclavicular (CC) ligament reconstruction with and without concurrent distal clavicle excision.

STUDY DESIGN

Controlled laboratory study.

METHODS

Nine matched pairs of cadaver shoulders were used. All shoulders were tested with intact CC and AC ligaments, and the ligaments were sectioned. For 1 shoulder in each pair, a 7-mm distal clavicle excision was performed. The contralateral distal clavicle was left intact. Single-tunnel CC ligament reconstruction was performed, and excess graft length was extended and secured across the AC joint to reconstruct the superior AC joint ligaments in all specimens. Specimens were then potted and cyclically loaded for 500 cycles in the anterior-posterior and superior-inferior planes using an MTS Minibionix load frame to evaluate displacement across the AC joint.

RESULTS

Regarding the clavicle-intact reconstructed versus the intact state, there was significantly greater AC joint translation in the reconstructed state in the anterior-posterior (20.2 ± 7.0 mm vs 6.0 ± 1.5 mm; P < .001) and superior-inferior directions (12.3 ± 3.3 mm vs 4.2 ± 1.2 mm; P < .001). In the clavicle-excised reconstructed versus the intact state, there was also significantly greater translation in the reconstructed state in the anterior-posterior (21.7 ± 5.1 mm vs 8.9 ± 4.3 mm; P < .001) and superior-inferior directions (12.3 ± 6.1 mm vs 5.8 ± 3.1 mm; P < .001). When the difference in translation between the reconstructed and intact groups in the clavicle-intact versus the clavicle-excised group was compared, no statistically significant difference was noted in anterior-posterior (14.2 ± 7.8 mm vs 12.8 ± 5.0 mm; P = .67) or superior-inferior translation (8.1 ± 2.9 mm vs 6.6 ± 3.9 mm; P = .39).

CONCLUSION

Excision of the distal clavicle did not have a significant effect on anterior-posterior or superior-inferior motion at the AC joint following single-tunnel CC and AC ligament reconstruction.

CLINICAL RELEVANCE

The study suggests that excision of the distal clavicle in this procedure is not associated with increased anterior-posterior or superior-inferior instability in this model.

The biomechanical stability of distal clavicle excision versus symmetric acromioclavicular joint resection

BACKGROUND

Treatment for acromioclavicular (AC) joint pain may include distal clavicle excision (DCE). It is possible that DCE can disrupt the surrounding ligaments, leading to increased AC joint laxity.

PURPOSE

To determine the load to failure and stiffness of the AC joint after DCE and symmetric acromioclavicular joint resection (ACJR).

STUDY DESIGN

Controlled laboratory study.

METHODS

Specimens were randomly assigned to 1 of 2 groups: 1-cm DCE (n = 10) or symmetric (5-mm excision of acromion and distal clavicle) ACJR (n = 10). The specimens were loaded intact in the anterior-posterior plane to determine anteroposterior translation. This was repeated after surgery and compared. The specimens were loaded at 2 mm/s until clinical failure. Force and displacement were recorded, and stiffness was calculated.

RESULTS

The peak load to failure for the DCE group was 387.8 N (standard error of the mean [SEM], 31.4 N) and for the ACJR group was 468.5 N (SEM, 30.9 N) (P = .035). The average stiffness for the DCE group was 35.2 N/mm (SEM, 2.5 N/mm) and for the ACJR group was 37.4 N/mm (SEM, 2.3 N/mm) (P = .11). There was no significant difference in the anteroposterior translation before and after resection for either group (P > .05).

CONCLUSION

This cadaveric study demonstrates that the anterior-posterior load to clinical failure of the AC joint after 5 mm of resection from the distal clavicle and medial acromion is significantly greater than 1 cm of the resected distal clavicle alone.

CLINICAL RELEVANCE

Performing ACJR may improve joint stability, leading to fewer complications when compared with DCE.

Acromioclavicular joint injuries and reconstructions: a review of expected imaging findings and potential complications

Shoulder injuries, including acromioclavicular (AC) joint separations, remain a common reason for presentation to the emergency room. Although the diagnosis can be made apparent through proper history and physical examination by the emergency medicine physician, ascertaining the degree of injury can be difficult on the basis of clinical evaluation alone. While there is consensus in the literature that low-grade AC joint injuries can be treated with conservative management, high-grade injuries will generally require surgical intervention. Furthermore, the treatment of grade 3 injuries remains controversial, making it incumbent upon the radiologist to become comfortable with distinguishing this diagnosis from lower or higher grade injuries. Imaging of AC joint injuries after clinical evaluation is generally initiated in the emergency room setting with plain film radiography; however, on occasion, an alternative modality may be presented to the emergency room radiologist for interpretation. As such, it remains important to be familiar with the appearance of AC joint separations on a variety of modalities. Another possible patient presentation in both the emergent and nonemergent setting includes new onset of pain or instability in the postsurgical shoulder. In this scenario, the onus is often placed on the radiologist to determine whether the pain or instability represents the sequelae of reinjury versus a complication of surgery. The purpose of this review is to present an anatomically based discussion of imaging findings associated with AC joint separations as seen on multiple modalities, as well as to describe and elucidate a variety of potential complications which may present to the emergency room radiologist.

Arthroscopic stabilization for Neer type 2 fracture of the distal clavicle fracture

The distal clavicle fractures are divided into three types according to Neer's classification. Types 1 and 3 fractures are treated with a sling to immobilize the upper extremity. However, the treatment of type 2 fractures is controversial. We paid attention to the anatomic basis of type 2 fractures that the disruptions of the conoid ligament lead to the distraction between the two bony fragments. In this study, we describe the arthroscopic procedure to reconstruct the disrupted ligament and stabilize the fracture as a minimally invasive method. The subjects were seven patients with the distal clavicle fractures. According to Neer's or Rockwood's classification on plain radiographs, all seven patients were evaluated as type 2 or 2B, respectively. Our surgical procedure was performed with the patient in the beach chair position. We have used the artificial ligament with an EndoButton (Smith & Nephew Endoscopy, Andover, MA) as the substitute ligament to reconstruct the disrupted conoid ligament. The mean duration of postoperative follow-up was 2 years and 5 months. The bony union was achieved in all patients at a final follow-up. When concerning the range of motion at final examinations, mean forward flexion was 171°, mean abduction was 165°, mean internal rotation was Th11, and mean horizontal adduction was 132°. It is possible to treat the distal clavicle fractures by a minimally invasive arthroscopic procedure without opening the fracture site of clavicle.

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.