A Sports Medicine Clinician's Guide to the Diagnosis and Management of Distal Clavicular Osteolysis

ABSTRACT

Weightlifting associated shoulder injuries have seen a dramatic rise in the last 20 years. Distal clavicular osteolysis, coined weightlifter's shoulder, is one such condition caused by repetitive microtrauma to the distal clavicle with subsequent, painful development of bony erosions and resorption of the distal clavicle. Diagnosis, treatment, and prevention of this condition can be challenging. In this article, we highlight evidence-based clinical recommendations for the diagnosis and management of distal clavicular osteolysis, including specific considerations for atraumatic and posttraumatic etiologies, to help clinicians better care for their patients. Activity modification and rehabilitation are the mainstays of the initial treatment. Adjuvant treatments, such as injections or surgery, may be required in refractory cases or in certain patient populations. Early recognition and treatment of weightlifter's shoulder is essential to prevent progression to acromioclavicular joint pathology or instability and to allow for continued participation in sport-specific activities.

Fractured coracoid process with acromioclavicular joint dislocation: A case report

RATIONALE

Coracoid processes (CPs) fracture with acromioclavicular (AC) joint dislocation are extremely rare. This combined injury has brought many challenges to surgeons, and the mechanism underlying the injury is still not fully understood. There is no clear consensus on its treatment.

PATIENT CONCERNS

Here, we describe a CP fracture with AC joint dislocation in a middle-aged manual worker.

DIAGNOSIS

Radiographs showed a fracture of the base of the CP and a third-degree AC joint separation.

INTERVENTIONS

The patient was treated surgically with open reduction and internal fixation of the AC joint by LCP clavicle hook plate, and the CP was fixed with a 3.5 mm diameter cannulated screw.

OUTCOMES

Three months after the operation, shoulder function was completely restored, and the affected shoulder had full mobility with no tenderness. Plain film radiography showed anatomical indications of the healing of these combined injuries.

LESSONS

Although AC joint dislocation with CP fractures is extremely rare in adults, it is important to remind and remember that this possibility exists. In unclear cases, special radiographic films and CT are necessary. Surgical treatment of AC joint dislocation with CP fractures can provide solid stability and restore normal shoulder function with an excellent prognosis.

Unusual case of lipoma arborescens in the subacromial-subdeltoid bursa

A 38-year-old female presented with a 10-month history of right shoulder pain with impingement symptoms. She was diagnosed on magnetic resonance (MR) imaging to have supraspinatus tendon tear and degenerative changes contributing to subacromial impingement. She also had lipoma arborescens of the subacromial-subdeltoid bursa, an uncommon condition in a particularly rare location. Lipoma arborescens is a benign intra-articular condition characterized by lipomatous proliferation of synovium with replacement of subsynovial tissue by mature adipocytes. It is typically a monoarticular process affecting the knee. Due to the presence of pathognomonic fat, diagnosis is usually straightforward with MR as the preferred imaging modality.

A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review

OBJECTIVES

The clinical examination of the shoulder joint is an undervalued diagnostic tool for evaluating acromioclavicular (AC) joint pathology. Applying evidence-based clinical tests enables providers to make an accurate diagnosis and minimize costly imaging procedures and potential delays in care. The purpose of this study was to create a decision tree analysis enabling simple and accurate diagnosis of AC joint pathology.

METHODS

A systematic review of the Medline, Ovid and Cochrane Review databases was performed to identify level one and two diagnostic studies evaluating clinical tests for AC joint pathology. Individual test characteristics were combined in series and in parallel to improve sensitivities and specificities. A secondary analysis utilized subjective pre-test probabilities to create a clinical decision tree algorithm with post-test probabilities.

RESULTS

The optimal special test combination to screen and confirm AC joint pathology combined Paxinos sign and O'Brien's Test, with a specificity of 95.8% when performed in series; whereas, Paxinos sign and Hawkins-Kennedy Test demonstrated a sensitivity of 93.7% when performed in parallel. Paxinos sign and O'Brien's Test demonstrated the greatest positive likelihood ratio (2.71); whereas, Paxinos sign and Hawkins-Kennedy Test reported the lowest negative likelihood ratio (0.35).

CONCLUSION

No combination of special tests performed in series or in parallel creates more than a small impact on post-test probabilities to screen or confirm AC joint pathology. Paxinos sign and O'Brien's Test is the only special test combination that has a small and sometimes important impact when used both in series and in parallel. Physical examination testing is not beneficial for diagnosis of AC joint pathology when pretest probability is unequivocal. In these instances, it is of benefit to proceed with procedural tests to evaluate AC joint pathology. Ultrasound-guided corticosteroid injections are diagnostic and therapeutic. An ultrasound-guided AC joint corticosteroid injection may be an appropriate new standard for treatment and surgical decision-making.

LEVEL OF EVIDENCE

II - Systematic Review.

A Case Report of an Acromioclavicular Joint Ganglion Associated with a Rotator Cuff Tear

We report a case of subcutaneous ganglion adjacent to the acromioclavicular joint with massive rotator cuff tear [1-7]. An 81-year-old woman presented with a ganglion adjacent to the acromioclavicular joint that had first been identified 9 months earlier. The ganglion had recurred after having been aspirated by her local physician, so she was referred to our hospital. The puncture fluid was yellowish, clear and viscous. Magnetic resonance imaging identified a massive rotator cuff tear with multi- lobular cystic lesions continuous to the acromioclavicular joint, presenting the "geyser sign". During arthroscopy, distal clavicular resection and excision of the ganglion were performed together with joint debridement. At present, the ganglion has not recurred and the patient has returned to normal daily activity. In this case, the ganglion may have developed subsequent to the concomitant massive cuff tear, due to subcutaneous fluid flow through the damaged acromioclavicular joint.

Bilateral weighted radiographs are required for accurate classification of acromioclavicular separation: an observational study of 59 cases

INTRODUCTION

Misinterpretation of the Rockwood classification system for acromioclavicular joint (ACJ) separations has resulted in a trend towards using unilateral radiographs for grading. Further, the use of weighted views to 'unmask' a grade III injury has fallen out of favour. Recent evidence suggests that many radiographic grade III injuries represent only a partial injury to the stabilising ligaments. This study aimed to determine (1) whether accurate classification is possible on unilateral radiographs and (2) the efficacy of weighted bilateral radiographs in unmasking higher-grade injuries.

METHODS

Complete bilateral non-weighted and weighted sets of radiographs for patients presenting with an acromioclavicular separation over a 10-year period were analysed retrospectively, and they were graded I-VI according to Rockwood's criteria. Comparison was made between grading based on (1) a single antero-posterior (AP) view of the injured side, (2) bilateral non-weighted views and (3) bilateral weighted views. Radiographic measurements for cases that changed grade after weighted views were statistically compared to see if this could have been predicted beforehand.

RESULTS

Fifty-nine sets of radiographs on 59 patients (48 male, mean age of 33 years) were included. Compared with unilateral radiographs, non-weighted bilateral comparison films resulted in a grade change for 44 patients (74.5%). Twenty-eight of 56 patients initially graded as I, II or III were upgraded to grade V and two of three initial grade V patients were downgraded to grade III. The addition of a weighted view further upgraded 10 patients to grade V. No grade II injury was changed to grade III and no injury of any severity was downgraded by a weighted view. Grade III injuries upgraded on weighted views had a significantly greater baseline median percentage coracoclavicular distance increase than those that were not upgraded (80.7% vs. 55.4%, p=0.015). However, no cut-off point for this value could be identified to predict an upgrade.

CONCLUSIONS

The accurate classification of ACJ separation requires weighted bilateral comparative views. Attempts to predict grade on a single AP radiograph result in a gross underestimation of severity. The value of bilateral weighted views is to 'unmask' a grade V injury, and it is recommended as a first-line investigation.

Quantitative and qualitative analyses of subacromial impingement by kinematic open MRI

PURPOSE

Quantitative and qualitative kinematic analyses of subacromial impingement by 1.2T open MRI were performed to determine the location of impingement and the involvement of the acromioclavicular joint.

METHODS

In 20 healthy shoulders, 10 sequential images in the scapular plane were taken in a 10-s pause at equal intervals from 30° to maximum abduction in neutral and internal rotation. The distances between the rotator cuff (RC) and the acromion and the acromioclavicular joint were measured. To comprehend the positional relationships, cadaveric specimens were also observed.

RESULTS

Although asymptomatic, the RC came into contact with the acromion and the acromioclavicular joint in six and five cases, respectively. The superior RC acted as a depressor for the humeral head against the acromion as the shoulder elevated. The mean elevation angle and distance at the closest position between the RC and the acromion in neutral rotation were 93.5° and 1.6 mm, respectively, while those between the RC and the acromioclavicular joint were 86.7° and 2.0 mm. When comparing this distance and angle, there was no significant difference between the RC to the acromion and to the acromioclavicular joint. The minimum distance between the RC and the acromion was significantly shorter than that between the greater tuberosity and the acromion. The location of RC closest to the acromion and the acromioclavicular joint differed significantly.

CONCLUSION

Although asymptomatic, contact was found between the RC and the acromion and the acromioclavicular joint. The important role of the RC to prevent impingement was observed, and hence, dysfunction of the RC could lead to impingement that could result in a RC lesion. The RC lesions may differ when they are caused by impingement from either the acromion or the acromioclavicular joint.

[Treatment of chronic acromioclavicular joint instability]

The purpose of this paper is to assess the results obtained with the arthroscopy-assisted surgical technique for the treatment of chronic acromioclavicular joint instability (CACJI), based on non-rigid coracoclavicular (CC) fixation and anatomical CC reconstruction with a tendinous allograft. Patients with CACJI who underwent surgery between 2008 and 2012 were included in the study. Clinical assessments included SF36, VAS and DASH, applied at the preoperative visit (POV) and at the last follow-up visit (LFUV). The Constant score and the General Satisfaction Score (0-10) were applied at the last follow-up visit. Occurrence of secondary subluxations was assessed. Ten patients were included; mean age was 41 years (range 33-55). Mean follow-up was 25.50 months (range 24-30). Surgical treatment was indicated in all patients after failure of conservative treatment. Questionnaires applied at the POV and the LFUV showed the following results: 1. SF36: physical, POV = 29.60 ± 3.41 and LFUV = 59.58 ± 1.98 (p = 0.000); 2. SF36 mental, POV = 46.57 ± 3.80 and LFUV = 56.62 ± 1.89 (p = 0.000); 3. VAS: POV = 5.17 ± 2.40 and LFUV: 1.67 ± 2.07 (p = 0.022); and 4. DASH: POV = 63.33 ± 23.56 and LFUV = 2.61 ± 1.79 (p = 0.000). The Constant score and the general satisfaction at the LFUV were 95.56 ± 3.28 and 9.22 ± 0.67, respectively. There were no secondary subluxations. Treatment of CACJI with a CC suspension device and arthroscopically-assisted anatomical reconstruction of CC ligaments may provide a significant quality of life improvement to patients. It is a strategy that, upon considering primary mechanical CC fixation, may minimize the chance of failure and occurrence of secondary subluxations.

Mycobacterium avium-intracellulare: a rare cause of subacromial bursitis

Septic subacromial bursitis is an uncommon disorder with only a few reported cases in the literature. The most common causative organism is Staphylococcus aureus. We report the case of a 61-year-old female with a septic subacromial bursitis where the causative organism was found to be Mycobacterium avium-intracellulare (MAI). The diagnosis was only made following a biopsy, and we use this case to highlight the importance of recognising the need to consider a biopsy and aspiration in atypical situations.

Complex shoulder injuries in sports

A 26-year-old Olympic wrestling athlete presented with a pectoralis major muscle injury, glenohumeral instability and acromioclavicular joint dislocation separately. The patient underwent surgical treatment to repair these injuries. The pectoralis major muscle was reconstructed with a semitendinosus tendon graft using the endobutton technique, as described by Pochini et al. Treatment of the traumatic anterior instability was performed using the technique described by Bristow-Latarjet, and the acromioclavicular joint dislocation was repaired using the modified technique of Weaver-Dunn with the aid of an anchor. The athlete exhibited a rapid recovery and could return to normal activities 6 months after surgery. At present, 18 months postoperatively, the patient is asymptomatic.

[Quality of life of patients with acromioclavicular dislocation]

OBJECTIVE

To compare quality of life in patients with Tossy type Ill acromioclavicular dislocation treated with the hook-plate ORIF technique, the Weaver & Dunn technique and the Bosworth technique.

MATERIAL AND METHODS

A cross-sectional analytical survey was conducted from January 2012 to April 2013 in patients with a diagnosis of Tossy type III acromioclavicular dislocation treated surgically with the hook-plate ORIF technique, the Weaver & Dunn technique, and the Bosworth technique. We included patients ages 18 to 70 years old, operated within three weeks after the diagnosis. Quality of life was assessed using the hetero-administered DASH questionnaire once the informed consent was obtained.

RESULTS

Forty-seven patients were operated on. They were divided into 3 groups: hook-plate ORIF technique, with 26 patients: Weaver & Dunn technique, 11 patients; and Bosworth technique, 10 patients. Sex and age distribution were similar in all 3 groups, with p =0.137 and p = 0.252, respectively. Time elapsed after surgery was similar in all 3 groups, with p = 0.051. The hook-plate ORIF technique was the most frequently used one, in 26 surgeries. 96.4% of patients had mild disability and symptoms with the hook-plate ORIF technique, and 100% with the Bosworth and Weaver & Dunn techniques.

CONCLUSIONS

Quality of life was similar with all 3 surgical techniques and involved mild disability and symptoms. The hook-plate ORIF technique was the most frequently used technique.

[A women with a swelling on the shoulder]

A 52-year-old women with diffuse cutaneous systemic sclerosis was examined because of a swollen right acromioclavicular joint after surgery 3 years earlier. Joint aspiration showed serosanguinolent fluid with white amorph material. Polarized microscopy revealed calcium deposits. The diagnosis 'calcinosis cutis' was made.

[Triple endobutton technique for repair of chronic complete acromioclavicular joint dislocations]

OBJECTIVE

To evaluate the early result of triple Endobutton technique for reconstructing coracoclavicular ligament of chronic complete acromioclavicular joint dislocations.

METHODS

Between January 2009 and June 2010, 14 patients with chronic complete acromioclavicular joint dislocations were treated with triple Endobutton technique for reconstructing coracoclavicular ligament. There were 10 males and 4 females with a mean age of 38.5 years (range, 26-52 years). Injury was caused by traffic accident in 7 cases, by falling in 5 cases, and by bruise in 2 cases. The average time was 47 days from injury to the operation (range, 29-75 days). All patients had pain and activity restriction. The X-ray films showed complete dislocation of acromioclavicular joint. According to Allman's type, all cases were classified as III degree complete dislocations.

RESULTS

At postoperation, wound healed by first intention with no early complication of infection or neurovascular injury. All patients were followed up 18.3 months on average (range, 13-30 months). Acromioclavicular joint subluxation occurred in 1 patient at 1 week after operation, and no redislocation or other complication occurred in the other patients. American Shoulder and Elbow Surgeons (ASES) score was 90.8 +/- 4.1 at last follow-up, showing significant difference when compared with the preoperative score (65.3 +/- 4.4) (t = -17.57, P = 0.00); Constant-Murley score was 91.7 +/- 3.9, showing significant difference when compared with preoperative one (71.5 +/- 4.6) (t = -75.02, P = 0.00). The definite answer in Simple Shoulder Test (SST) averaged 9.7 (range, 7-12).

CONCLUSION

The triple Endobutton technique for reconstructing coracoclavicular ligament is an effective method in treatment of chronic complete acromioclavicular joint dislocations. The short-term results are satisfactory.

The MRI geyser sign: acromioclavicular joint cysts in the setting of a chronic rotator cuff tear

We present the case of a 71-year-old man with a large acromioclavicular (AC) joint cyst successfully managed with surgical excision. AC joint cysts are soft tissue masses generally signifying underlying rotator cuff pathology. Traditionally, these cysts were identified with shoulder arthrography as a "geyser" of fluid escaping through the AC joint. Magnetic resonance imaging (MRI) is today's preferred imaging modality; we describe the MRI equivalent of the "geyser sign," signifying synovial fluid escaping through the cuff defect, across the subacromial bursa, and decompressing superiorly through a degenerated AC joint. Surgical management is preferred for symptomatic cysts. Based on a review of limited retrospective case series, recommendations for management of these lesions are as follows. Repair of the rotator cuff is preferable whenever possible. In the case of an irreparable defect, good results can be achieved through excisional AC joint arthroplasty and resection of the cyst base. Aspiration of these cysts should not be attempted, due to the high recurrence rate and potential for a draining sinus. Hemiarthroplasty also may be effective in indirectly decompressing these cysts; but given the invasive nature of this procedure, it should be reserved for patients who are also symptomatic from cuff arthropathy.

Coracoid process fracture with acromioclavicular joint separation in an American football player: a case report and literature review

Coracoid process fractures are rare and few cases have been reported in the orthopedic literature. In this article, we report the case of an American football player with a coracoid process fracture in the setting of acromioclavicular separation and describe incidence, mechanism of injury, and treatment. Although rare, coracoid process fracture should be considered in the differential diagnosis for shoulder pain. Treatment varies according to fracture type. Based on our literature review, we recommend that clinicians initially treat nondisplaced coracoid fractures nonoperatively.

Imaging in shoulder disorders

Clinical assessment of the patient with shoulder symptoms can usually localize the cause to one of a few syndromes, each associated with specific imaging questions. MRI is used as the primary form of investigation for recurrent dislocation, SLAP lesions and PSI, as well as articular cartilage, synovial disease, tumours and infection. Ultrasound plays the leading role in impingement, acromioclavicular disease, dynamic assessment and guided therapy. Both techniques are reported to play a role in adhesive capsulitis. In our hospital, approximately four times as many shoulder ultrasound examinations as shoulder MRI are carried out, but elsewhere these proportions will vary according to the prevalence of clinical syndromes in the population being treated.

Acromioclavicular joint disorders

The acromioclavicular (AC) joint is a highly used, versatile, and complex joint that provides stability and increases function. Acute and chronic dysfunction at the AC joint can have debilitating effects that should be treated appropriately and expediently to preserve function. The historical, physical examination, and radiographic findings are generally very consistent and lead to both diagnosis and well-established treatment protocols. With few exceptions, injuries can be treated nonoperatively with a high degree of success. When indicated, surgical outcomes are also successful but have an overall higher rate of complications. A physician should be well versed in both acute and chronic conditions to ensure the patient has the best opportunity to reclaim function, return to sport, and avoid pain, restriction in range of motion, and need for further surgery.

Experimental and clinical evaluation of acromioclavicular joint structures with new scan orientations in MRI

The objective of the study was to evaluate MRI for visualization of acromioclavicular (ac) joint structures in cadaveric shoulders, asymptomatic volunteers and symptomatic patients with trauma of the ac-joint. Three cadaveric shoulders were examined to find adequate planes and sequences for MRI. Afterwards, MR images were correlated to corresponding anatomical sections. Six asymptomatic volunteers and 13 patients were scanned in a 1.5 T Magnetom Vision with three sequences in the following planes: (1) parallel to the clavicle; (2) orthogonal to the ac joint, each time a fat-suppressed proton density-weighted + T2-sequence (TR/TE 4,000/15 ms) was performed; (3) parallel to the clavicle, T1-SE (TR/TE 817/20 ms). The parameters were: slice thickness 3 mm, field-of-view 180 mm, matrix 210x256 pixels. Standard of reference in the patients was clinical examination and conventional X-rays. Classification was by Rockwood grades I-VI. MRI allowed excellent visualization and diagnoses of ac-joint structures in volunteers and patients (n=6 normal, n=1 Rockwood I, n=5 Rockwood II, n=3 Rockwood III, n=4 Rockwood V). On MRI, in one lesion type II and III each, a lower lesion type was suspected clinically and by X-ray. In one patient additional information by MRI led to surgery. MRI allows excellent anatomical display of ac-joint structures and can give clinically relevant information on type and extension of ac-joint trauma, which may influence therapy.

[Isolated synovial chondromatosis of the subacromial bursa: report of a new case and review of the literature]

Synovial chondromatosis is a rare metaplasia of the synovium of unknown etiology that may involve occasionally the subacromial bursa. We report a new case diagnosed by ultrasound in a 30-year-old man and we present pathogenetic, diagnostic and therapeutic features of this disease with a literature review.

Coracoclavicular joint degeneration, an unusual cause of painful shoulder: a case report

A case of painful shoulder in a 42-year old right-hand dominant Caucasian female due to degeneration of the coracoclavicular joint is described. The pain was aggravated by weight lifting. The diagnosis was confirmed radiographically with simple plain films and clinically by the injection of local anaesthetic (xylocaine 2%) that lead to the exclusion of any other concomitant pathology of the acromioclavicular joint and the anterior subacromial space. The patient was treated successfully with an intraarticular steroid injection, and 30 months later she remains free of symptoms.

A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients

The purpose of this study was to compare acromioclavicular (AC) joint magnetic resonance imaging (MRI) findings in asymptomatic patients with those in symptomatic patients. The MRI scans of 25 patients with symptomatic AC joints were compared with 50 asymptomatic control subjects by use of the same grading scale. In the symptomatic group, AC joint arthritis grading was normal in 0%, mild in 20%, moderate in 52%, and severe in 28%. In the asymptomatic group, grading was normal in 18%, mild in 66%, moderate in 12%, and severe in 4%; there was a statistically higher grade of AC arthritis in the symptomatic group (P < .05). Of the symptomatic individuals, 80% demonstrated reactive bone edema in either the distal clavicle (6), the acromion (3), or both sides of the AC joint (11), whereas no individual in the asymptomatic group had this finding (P < .05). Reactive bone edema on MRI is a more reliable predictor of symptomatic AC pathology than degenerative changes seen on MRI and, when correlated with clinical examination, is reproducible.

The short term effects of a single corticosteroid injection on the range of motion of the shoulder in patients with isolated acromioclavicular joint arthropathy

This study is aimed at evaluating the short-term effects of a single corticosteroid injection of the acromioclavicular joint on the range of motion of the shoulder joint using a three dimensional electromagnetic tracking system (FASTRAK) in patients with isolated unilateral acromioclavicular joint (ACJ) arthropathy. Eighteen patients (16 male, 2 female; mean age: 47.53 years), with isolated unilateral ACJ arthropathy were included in the study. Injection of the symptomatic ACJ with local anaesthetic and corticosteroid was performed under image intensifier guidance. Bilateral shoulder FASTRAK assessment before and two weeks after injection of the symptomatic ACJ was performed, measuring flexion/extension, anatomical abduction, scapular abduction and horizontal cross body adduction. Pain was measured using a visual analogue scale. There was a significant difference in the range of movement between the symptomatic and asymptomatic shoulder before the injection (p < 0.01). Range of extension and pain score of the symptomatic shoulder improved significantly (p < 0.05 and p < 0.001, respectively) after the injection. In patients with radiographical evidence of degenerative ACJ disease, there was also significant improvement in the range of horizontal flexion (p < 0.05). Injection of the ACJ with local anaesthetic and corticosteroid was found to produce short-term pain relief and partial improvement in the range of movement. FASTRAK is useful in the measurement and documentation of range of motion, and can be used to assess the treatment outcome in patients with isolated ACJ arthropathy.

Acromial spur: relationship to aging and morphologic changes in the rotator cuff

This study's objective is to elucidate the relationship between acromial spur formation and rotator cuff pathology or aging. The subjects comprised 1029 shoulders in control, cadaveric, and operative groups. A radiograph in the supraspinatus outlet view was taken in all subjects. The lengths of the incident spurs were measured and classified into 3 sizes (small, <5 mm; medium, <10 mm; and large, > or =10 mm). The rotator cuff was macroscopically classified as normal or as having bursal-side fraying, joint-side tear, intratendinous tear, bursal-side tear, complete tear limited to the supraspinatus tendon, or massive tear. In the control group, the overall incidence of spurs and spur size increased with advancing age (P < .001), but the majority of spurs were small (<5 mm). In the cadaveric group, the overall incidence did not correlate with advancing age (P > .05). However, spur size increased with age in subjects aged 50 years or older (P < .001). The incidence of spurs in rotator cuffs with bursal-side tears was highest and was significantly higher than that in normal cuffs and cuffs with bursal-side fraying and intratendinous tears. We observed 40% of medium spurs and 69% of large spurs in cases with bursal-side tears, complete tears limited to the supraspinatus tendon, and massive tears. In the operative group, the overall incidence correlated to advancing age (P < .001), reaching 80% or more in subjects aged 30 years or older. In addition, the size of spurs was larger than that in the other 2 groups in all age groups with few exceptions (P < .05). Small spurs were associated with advancing age. Morphologic change to the bursal side of the rotator cuff may enhance spur growth. The presence of a small spur has no diagnostic value for rotator cuff tears. Spurs measuring 5 mm or more, however, are of diagnostic value because of their high rate of association with bursal-side tear, complete tears limited to the supraspinatus tendon, or massive tears.

Septic arthritis of the acromioclavicular joint

Septic arthritis of the acromioclavicular (AC) joint is a rare but rapidly destructive etiology of acute shoulder pain. We report a case of septic AC joint in the absence of trauma or intravenous drug use. A diabetic man presented with severe right shoulder pain and was later diagnosed with septic arthritis of the AC joint by magnetic resonance imaging (MRI) and positive blood cultures. Chronic diabetic foot ulcers were the source of the patient's group B streptococcus bacteremia.

Acromioclavicular joint osteoarthritis

The purpose of this study was to determine the correlation between routine radiography and magnetic resonance (MR) imaging in the analysis of the acromioclavicular (AC) joint osteoarthritis (OA). MR imaging studies of the shoulder in 50 patients performed over a 1-year period at a single institution with corresponding conventional radiographic examinations performed within 1 month of the MR imaging study were restrospectively evaluated by the consensus of two musculoskeletal radiologists with special attention to the AC joint. As conclusion, information provided by conventional radiography in the analysis of AC joint OA does not correlate with that provided by MR imaging. AC joint OA is more frequently detected with MR imaging than with radiography. MR imaging provides better assessment of the full extent of AC joint OA and its effect on the underlying RC.

Correlation of ultrasonographic findings to Tossy's and Rockwood's classification of acromioclavicular joint injuries

The aim of this study was to examine the value of ultrasonography to assess high-graded acromioclavicular (AC) joint injuries. We propose a new sonographic technique to evaluate the state of the soft tissues, specifically the deltoid and trapezoid muscles and their common fascia. Radiologic findings graded by Tossy's and Rockwood's classification were compared with sonographic findings for 92 patients with high-grade injuries of the AC joint. Of the 92 patients, 39 underwent operative treatment. A total of 36 patients were radiographically classified as type II and 56 with type III injuries, according to Tossy. In 4 cases, ultrasonography displayed disrupted insertions of the deltoid and, in 30 patients, of the trapezius muscle. All patients classified as type V, eight of 18 patients classified as type IV, nine of 31 patients classified as type III and two of 28 patients classified as type II injuries, according to Rockwood's classification, displayed a disrupted deltoid and trapezius insertion and common fascia on ultrasound (US). Comparison between sonographic and intraoperative findings revealed a sensitivity for diagnosing delta muscle detachment and fascial disruption of 100%. No true-negative results occurred. For trapezius muscle detachment, 24 of 30 patients were diagnosed correctly and nine true-negative results occurred. False-positive results were not encountered. The sensitivity was 80%. The specificity was 100%. We conclude that US provides additional information concerning soft tissues and that it may be useful to delineate type III injuries, in which nonoperative vs. operative treatment is still being debated. Diagnosis based only on sagittal X-ray examination may under- or over-estimate the soft tissue injury involved. Additional transaxillary X-ray as well as an US evaluation may need to be included in the diagnostic process. We propose this new sonographic technique for future studies.

Acromioclavicular joint cyst: nine cases of a pseudotumor of the shoulder

OBJECTIVE

(1) To analyse the imaging appearances of nine patients with acromioclavicular joint cysts presenting as shoulder masses for tumor staging with operative, histopathological and joint aspiration findings.

DESIGN AND PATIENTS

Retrospective review of imaging and correlation with clinical, operative and surgical notes. Images were reviewed by two musculoskeletal radiologists by consensus. Nine patients who presented clinically with a shoulder mass were evaluated by radiographs (n=9), ultrasound (n=1), conventional arthrography (n=3), MRI (n=6; with direct MR arthrography n=2, indirect MR arthrography n=4).

RESULTS

All patients had a focal mass superior to the AC joint, with a size ranging from 1.5 cm to 6 cm and a mean of 3.27 cm. Correlation was available with surgery (n=7), histopathology (n=2) and cyst aspiration (n=2). Two patients were managed conservatively. Geyser sign was positive in all three arthrograms. All MRIs revealed extensive rotator cuff tears with a column of fluid extending from the glenohumeral joint through the rotator cuff tear into the acromioclavicular joint and acromioclavicular cyst. Chondrocalcinosis was seen in the acromioclavicular joint cyst (n=2) and in the glenohumeral joint (n=1). Aspirate in two patients contained calcium pyrophosphate dihydrate crystals.

CONCLUSION

Acromioclavicular joint cysts may present as a tumor mass. They are associated with extensive rotator cuff tears and there is usually communication of the cyst with the joint space. This feature excludes a diagnosis of tumor. AC joint cysts may be associated with calcium pyrophosphate dihydrate deposition disease.

The causes of pain in benign solitary enchondromas of the proximal humerus

Patients with benign solitary enchondromas of the proximal humerus frequently present to the diagnosing physician with shoulder pain. Once the lesion is considered benign, emphasis can be placed on identifying the etiology for the pain. We reviewed our experience with these patients to identify the cause of the presenting pain. A retrospective review of clinical records and radiographic studies (radiographs, magnetic resonance images, and bone scans) was done for all patients presenting to an orthopaedic oncology unit with solitary enchondroma of the proximal humerus. Attention was focused on diagnostic evidence of additional disease in the shoulder. Fifty-seven patients (mean age, 53.6 years) met the criteria of the study and were included for evaluation. Of patients presenting with pain, 82% (47 of 57 patients) had findings seen on magnetic resonance imaging scans that correlated with the initial clinical diagnostic impression, suggesting that other disease was present that could explain the pain. Solitary enchondromas of the proximal humerus often are found incidentally during the initial evaluation of patients with shoulder pain. This study showed that additional treatable disease usually is present in patients with enchondromas of the proximal humerus.

Direct arthroscopic distal clavicle resection: a technical review

Degenerative change involving the acromioclavicular (AC) is frequently seen as part of a normal aging process. Occasionally, this results in a painful clinical condition. Although AC joint symptoms commonly occur in conjunction with other shoulder pathology, they may occur in isolation. Treatment of isolated AC joint osteoarthritis is initially non-surgical. When such treatment fails to provide lasting relief, surgical treatment is warranted. Direct (superior) arthroscopic resection of the distal (lateral) end of the clavicle is a successful method of treating the condition, as well as other isolated conditions of the AC joint. The following article reviews appropriate patient evaluation, surgical indications and technique.

The acromioclavicular joint

Acute injuries of the AC joint have a limited differential diagnosis. A thorough examination and appropriate radiographs can identify nearly all problems while ruling out tumors as a causal factor. AC injury frequently occurs with other fractures, dislocations, or soft tissue injury around the shoulder. The single unifying diagnosis one searches for in medical conditions is frequently absent in musculoskeletal injury. For effective management of AC separations, the primary care physician need only distinguish type I, II, and III injuries from surgically treated type IV, V, and VI injuries. Types I, II, and III injuries should be treated with pain control and progressive rehabilitation as described previously. Patients who have types IV, V, and VI injuries should be referred to an orthopedic surgeon. Chronic injuries of the AC joint are also clearly diagnosed by appropriate physical examination and radiographs. Steroid injections can aid in the diagnosis and management of these conditions. Injury to one shoulder component predisposes to other shoulder injuries. A thorough examination will reveal these other associated abnormalities that may not be part of the presenting complaint. With practice in the examination of the shoulder and intra-articular injections, the primary care physician can effectively treat most common AC conditions. Only after conservative measures fail is it necessary to refer the patient for surgical management.

Synovial chondromatosis of the acromioclavicular joint

A 53-year-old woman presented with swelling of 3 years' duration on the right anterior chest wall. A radiograph showed coarse calcifications around the subclavicular region and erosion of the ipsilateral acromioclavicular joint. Computed tomography also showed calcifications in soft tissue. Magnetic resonance imaging revealed a tumor around the clavicle extending to the anterior aspect of chest wall, which had low signal intensity on T1-weighted imaging and high signal intensity on T2-weighted imaging. The histologic findings were of a hyaline cartilage-like mass consisting of mature chondrocytes and an extracellular matrix. The histologic diagnosis of synovial chondromatosis was made. The present case is unusual in respect of the location and size of the tumor.

A serial comparison of arthroscopic repairs for partial- and full-thickness rotator cuff tears

PURPOSE

To compare the outcome of arthroscopic rotator cuff repair and subacromial decompression in partial-thickness rotator cuff tears (PTRCT) with those in full-thickness rotator cuff tears (FTRCT).

TYPE OF STUDY

Prospective serial follow-up study.

METHODS

Of 46 consecutive patients who were treated with arthroscopic rotator cuff repair, 42 patients who were followed-up serially for 2 years were enrolled as study subjects. The average age of the patients at the time of the operation was 55 years, and the mean duration of follow-up was 34 months. The subjects included 22 cases of PTRCT and 20 cases of FTRCT.

RESULTS

At the final follow-up, the PTRCT group showed changes in scores from 7.2 to 0.9 for average pain and from 34 to 91 for the shoulder functional evaluation score of the American Shoulder and Elbow Society (ASES score). The FTRCT group showed changes in scores from 7.6 to 1.2 for pain and from 29 to 88 for the ASES score. There were no significant differences between the 2 groups ( P >.05). The average range of shoulder motion was significantly improved in both groups at the final follow-up versus their preoperative values. Evaluation at the final follow-up showed that 93% of the total subjects showed good or excellent results, and 95% showed satisfactory results with regard to pain reduction and functional outcomes. The 2 fair results were the result of acromioclavicular arthritis.

CONCLUSIONS

It may be anticipated that arthroscopic rotator cuff repair and subacromial decompression will give satisfactory postoperative outcomes in both PTRCT and FTRCT in terms of pain relief and functional recovery. However, careful preoperative examination of the acromioclavicular joint is critical to avoid procedural failure.

LEVEL OF EVIDENCE

Level IV.

Shoulder arthroscopy: principles and practice

Shoulder arthroscopy has an expanding role in the diagnostic and therapeutic management of shoulder disorders. This article describes the principles of shoulder arthroscopy, including basic technique,indications, and complications. The clinical applications to several shoulder pathologies, such as rotator cuff disorders, glenohumeral instability, and biceps anchor superior lesions, ar reviewed.

Isolated Acromioclavicular Joint Pathology in the Symptomatic Shoulder on Magnetic Resonance Imaging

The acromioclavicular (AC) joint is a synovial joint that is predisposed to painful syndromes because of mechanical stress or developmental variation. It is often overlooked in the evaluation of patients with shoulder pain, however. Isolated AC joint pathology was studied on magnetic resonance imaging scans of patients with symptoms suggesting rotator cuff pathology. The conditions identified included osteoarthritis, distal clavicle osteolysis, and os acromiale syndrome.

Magnetic resonance imaging of the coracoclavicular ligaments: its role in defining pathoanatomy at the acromioclavicular joint

Four patients with acromioclavicular joint injuries (one type II, two type III, one type V), two patients without acromioclavicular joint injury, and a fresh-frozen cadaver underwent magnetic resonance imaging (MRI) and plain radiographs. The normal conoid and trapezoid ligaments were easily identified in the cadaver and the two uninjured patients. Magnetic resonance imaging revealed disruption of both coraclavicular ligaments in the three patients with type II and type III injuries. However, the patient with the type V injury had disruption of the trapezoid ligament alone. Thus, the grade of injury, as determined by the change in the coracoclavicular interval onplain radiography and defined by the Rockwood classification system, failed to correlate with the pathoanatomy seen on MRI in two of the four injured patients. These findings suggest that improvements in the classification of these injuries may be necessary.

Vascular endothelial growth factor 121 and 165 in the subacromial bursa are involved in shoulder joint contracture in type II diabetics with rotator cuff disease

Vascular endothelial growth factor (VEGF) is a glycoprotein that plays an important role in neovascularization and increases vascular permeability. We reported that VEGF is involved in motion pain of patients with rotator cuff disease by causing synovial proliferation in the subacromial bursa (SAB). The present study investigates whether VEGF is also involved in the development of shoulder contracture in diabetics with rotator cuff disease. We examined 67 patients with rotator cuff disease, including 36 with complete cuff tears, 20 with incomplete tears, and 11 without apparent tears (subacromial bursitis). The patients were into groups according to the presence or absence of diabetes (14 type II diabetics and 53 non-diabetics). Specimens of the synovium of the SAB were obtained from all patients during surgery. Expression of the VEGF gene in the synovium of the subacromial bursa was evaluated by using the reverse transcriptase polymerase chain reaction. The VEGF protein was localized by immunohistochemistry, and the number of vessels was evaluated based on CD34 immunoreactivity. The results showed that VEGF mRNA was expressed in significantly more diabetics (100%, 14/14) than in non-diabetics (70%, 37/53) (P=0.0159, Fisher's test). Investigation of VEGF isoform expression revealed VEGF121 in all 14 diabetics and in 37 of the 53 non-diabetics, VEGF165 in 12 of the 14 diabetics and in 21 of the 53 non-diabetics, and VEGF189 in 1 of the 14 diabetics and in 2 of the 53 non-diabetics. No VEGF206 was expressed in either group. VEGF protein was localized in both vascular endothelial cells and synovial lining cells. The mean number of VEGF-positive vessels and the vessel area were also significantly greater in the diabetics (p<0.015, Mann-Whitney U test). Synovial proliferation and shoulder joint contracture were more common in the diabetics (P=0.0329 and P=0.073, respectively; Fisher's test). The mean preoperative range of shoulder motion significantly differed in terms of elevation between two groups: 103.8 degrees in diabetics and 124.9 degrees in no diabetics (p=0.0039 Mann-Whitney U test). In contrast, external rotation did not significantly differ: 44 degrees in diabetics and 49 degrees in non-diabetics (p=0.4957, Mann-Whitney U test). These results suggest that VEGF121 and VEGF165 expression in the SAB is responsible for the development of shoulder joint contracture, especially in elevation, among type II diabetic patients with rotator cuff disease.

Prevalence of osteophytes associated with the acromion and acromioclavicular joint

Osteophytes as a stigma for shoulder impingement syndrome and osteoarthritis of the acromioclavicular (AC) joint were studied on the acromions and AC joints in 346 skeletons (230 males; 116 females), ranging in age from 15-100 years. Osteophytes were found on 28.9% (200/692) of the acromions, mostly on the anteroinferior aspect (54%; 108/200). Of these 28.9%, 87% (174/200) were of the traction type and 13% (26/200) of the claw type. Regarding the clavicles, 11.6% (80/692) had osteophytes on the articular facets of their lateral ends; all were of the traction type. There were statistically more osteophytes on the right than on the left side of both acromion and clavicle (P < 0.05). The occurrence of osteophytes and increasing age were significantly correlated (r = 0.65, P < 0.001). No gender differences were noted in the frequency of osteophytes on acromions or clavicles. These data should prove beneficial to clinicians in planning a proper course of treatment for patients suffering from painful conditions of the shoulder.

MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection

OBJECTIVE

Our objective was to evaluate the predictive value of various MRI findings in the acromioclavicular joint for pain relief after intraarticular injection.

MATERIALS AND METHODS

The acromioclavicular joint of 50 patients (20 women, 30 men; mean age, 51 years; range, 25-75 years) was evaluated on MRIs of the shoulder. Osteophytes, subchondral cysts and irregularities, bone marrow edema, joint effusion, and joint capsule hypertrophy were assessed by two musculoskeletal radiologists in consensus. Local anesthetics were injected into the acromioclavicular joint with fluoroscopic guidance. Patients graded pain relief on a visual analogue scale (0-100%) after 15 min. The relationship between pain relief and MRI findings was assessed with the Mann-Whitney U test. Pain relief equal to or greater than 70% was rated as a positive response to the injection. This cutoff value was used to calculate sensitivity, specificity, accuracy, and predictive values of the various MRI findings in determining which acromioclavicular joints were responsive to joint injections.

RESULTS

Mean pain relief after injection was 38%. Pain relief was significantly related to capsular hypertrophy (p = 0.007) and was equal to or greater than 70% in 11 patients. The sensitivity in diagnosing a successful injection (range, 9-82%) was highest for caudal osteophytes (82%) and capsular hypertrophy (73%). The specificity (range, 51-97%) was highest for subchondral cysts (97%), subchondral bone marrow edema (95%), and joint effusion (92%).

CONCLUSION

Pain relief after intraarticular injection is significantly related to capsular hypertrophy diagnosed on MRI. MRI findings have a reasonable sensitivity and a high specificity in predicting relevant short-term pain relief after intraarticular injection.

Clinical testing for tears of the glenoid labrum

PURPOSE

With the increasing use of shoulder arthroscopy, diagnosis of glenoid labral lesions has become increasingly common. However, a physical examination maneuver that would allow a definitive clinical diagnosis of a glenoid labral tear, and more specifically a SLAP lesion, has been elusive. This study correlated the results of commonly used examination maneuvers with findings at shoulder arthroscopy. The working hypothesis was that 7 commonly used clinical tests, alone or in logical combinations, would provide diagnoses with reliability greater than the accepted standards for magnetic resonance imaging arthrography; i.e., greater than 95% sensitivity and specificity.

TYPE OF STUDY

Consecutive sample, sensitivity-specificity study.

METHODS

Sixty shoulders undergoing arthroscopy for a variety of pathologies were examined before surgery. All subjects submitted to the Speed test, an anterior apprehension maneuver, Yergason test, O'Brien test, Jobe relocation test, the crank test, and a test for tenderness of the bicipital groove. The examination results were compared with surgical findings and analyzed for sensitivity and specificity in the diagnosis of SLAP lesions and other glenoid labral tears.

RESULTS

The results of the O'Brien test (63% sensitive, 73% specific) and Jobe relocation test (44% sensitive, 87% specific) were statistically correlated with presence of a tear in the labrum and the apprehension test approached statistical significance. Performing all 3 tests and accepting a positive result for any of them increased the statistical value, although the sensitivity and specificity were still disappointingly low (72% and 73%, respectively). The other 4 tests were not found to be useful for labral tears, and none of the tests or combinations were statistically valid for specific detection of a SLAP lesion.

CONCLUSIONS

Clinical testing is useful in strengthening a diagnosis of a glenoid labral lesion, but the sensitivity and specificity are relatively low. Thus a decision to proceed with surgery should not be based on clinical examination alone.