Open and arthroscopic distal clavicle excision technique

OVERVIEW

Chapter synopsis

This chapter aims to outline the anatomy, pathology, and clinical evaluation of acromioclavicular (AC) joint pain. We describe the surgical management of AC joint pathology via three different techniques: arthroscopic indirect, direct, and open surgical excision of the distal clavicle. The clinical outcomes as they pertain to the different techniques are reported along with possible postoperative complications.

Important points

Indications (with or without concomitant shoulder pathology)

AC joint arthritis
AC joint osteolysis

Relative contraindications

AC joint instability

Surgical technique

Arthroscopic indirect excision
Arthroscopic direct excision
Open surgical excision

Clinical/surgical pearls

Correct diagnosis and evaluation
Patient positioning and anesthesia concerns
Establishment of surface anatomy, portals, or incision location
8 mm of distal clavicle excision
Retention or repair of AC joint capsule

Clinical/surgical pitfalls

Under resection of the distal clavicle
Over resection of the distal clavicle
Retained superior bone
Untreated concomitant shoulder pathology

Introduction

Acromioclavicular (AC) joint pain due to primary or secondary osteoarthritis and osteolysis may exist alone or in combination with other shoulder pathology. When AC joint arthritis exists in isolation, there are currently three described surgical techniques that can be utilized to address the condition if the patient fails conservative measures. These include the indirect arthroscopic approach, direct arthroscopic approach, and open resection. Open distal clavicle resection was first described by Mumford in 1941 to treat AC instability and was later adapted for the treatment of AC joint osteoarthritis and osteolysis. Arthroscopic techniques are more commonly utilized and have been hypothesized to minimize trauma and decrease soft tissue damage. Interestingly, the most recent meta-analyses on the subject suggest patients obtain similar functional and clinical outcomes following distal clavicle excision irrespective of the surgical approach. Regardless of which approach is attempted, excellent outcomes depend on proper evaluation, diagnosis, and surgical technique.

Preoperative considerations

Anatomy and pathology

The AC joint, which is formed by the acromion process and lateral clavicle, is part of the shoulder complex and contributes to shoulder girdle and scapular motion. Ligaments and a dense fibrous capsule surround the AC joint and provide multi-directional stability. ^, The AC joint capsular ligaments resist 50% of anterior displacement and 90% of posterior displacement of the joint. ^, Cadaveric studies have most reliably identified posterosuperior and anteroinferior ligaments, with the former being the most important contributor to stability. ^, The coracoclavicular ligaments, the trapezoid and conoid, respectively from lateral to medial, prevent vertical displacement of the clavicle and axial translation. ^, The anterior deltoid, trapezius, and serratus anterior also contribute to this dynamic soft tissue stabilization. ^, The vascular supply to the joint comes from the suprascapular and thoracoacromial arteries. Sensory innervation is provided from branches of the suprascapular and lateral pectoral nerve that can be injured during an open approach to the AC joint. The AC joint is a diarthrodial joint containing an intra-articular disc, which undergoes rapid degeneration and is effectively non-functional by the second decade of life. This rapid degeneration in combination with high energy loading patterns transferred over a small surface area contribute to the prevalence of osteoarthritis, osteolysis, and pain at the AC joint.

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