Distal Clavicle Resection Using a Combined Anterior and Posterior Arthroscopic Approach

Abstract

Background:

Distal clavicle resections are an effective treatment for subacromial impingement caused by clavicular pathologies. Causes include but are not limited to degenerative osteoarthritis, infection, malunion after trauma, and inflammatory arthritis. There are multiple variations of the procedure with different potential complications, including open and arthroscopic (direct, indirect).

Indications:

In the setting of isolated acromioclavicular (AC) joint arthrosis, patients often have pain at the anterosuperior shoulder. Patients should be examined for tenderness to palpation at the AC joint in comparison to the unaffected side. This pain may increase with specific maneuvers to stress the AC joint, such as cross-body adduction, active compression, or maximal internal rotation. In addition to the standard 3 views of the shoulder, a Zanca view radiograph allows for optimal visualization of the AC joint.

Technique Description:

The patient is placed upright in the beach-chair position, and the glenohumeral joint is accessed via the posterior and anterior portals. A soft tissue shaver and an ablation device are used to remove joint debris and capsule. Once the lateral clavicle is exposed, a bur is then introduced through the anterior portal. The proximal acromion and distal clavicle are then removed from anterior to posterior. A total of 6 to 7 mm of bone should be removed, which can be measured using the size of the bur. The camera is then switched to the anterior portal, and the resection can be completed with the bur in the posterior portal. This can accompany other subacromial decompression procedures or rotator cuff repair as needed.

Results:

The results of treating distal clavicle lesions via the above technique have been very successful in our patients. This is consistent with other studies in the literature, where patients with 20 years of follow-up were shown to have good outcomes after arthroscopic subacromial decompression. Patients who underwent arthroscopic rotator cuff repair with and without acromioplasty had a higher reoperation rate than those who did not undergo acromioplasty.

Discussion/Conclusion:

Distal clavicle resection is a safe and effective technique that can be easily employed as part of arthroscopic subacromial decompression.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we present the use of a direct posterior portal for arthroscopic distal clavicle resection.

These are our disclosures.

Background

The acromioclavicular (AC) joint is an important joint that connects the axial skeleton to the arm. It is a diarthrodial joint between the distal clavicle and anteromedial acromion. ² The fibrocartilaginous disc and the joint capsule and ligaments all function as stabilizers of the AC joint. ³

Indications

The AC joint can be damaged by acute traumatic injuries as well as chronic conditions such as degenerative osteoarthritis, infections, and inflammatory processes.

Our case is of a 55-year-old man who has had pain in his right shoulder for over a year, localized to the superior anterior aspect of the shoulder. It has been progressively worsening to the point where he was unable to perform pushups or raise his arm above his head, which he needed to do in order to work. He underwent a trial of physical therapy and anti-inflammatories, but his symptoms did not improve. He had a corticosteroid injection into the AC joint, which significantly relieved his pain for 10 days, after which he began to have discomfort again.

On examination, he has excellent range of motion in his shoulder and reports pain at terminal range of motion. His strength is preserved in all muscle groups. There is prominence and tenderness to palpation over the AC joint, but he is nontender in other areas of the shoulder. ⁶ There is also pain with cross-body adduction. ⁸

Here you can see the patient's initial radiograph, which is taken with the beam 10° to 15° cephalad for optimal visualization of the AC joint. ¹⁰ Compared to the unaffected left side, you can see evidence of hypertrophy and osteolysis at the right acromion. There also appears to be formation of a small cyst in the distal clavicle.

We obtained magnetic resonance imaging (MRI) for further evaluation and to rule out other pathologies, which were not present. You can once again notice the AC joint pathology in greater detail. There is significant edema at the AC joint with the cyst at the distal clavicle. No frank cuff tear was noted on his MRI. At this point, a decision was made to proceed with arthroscopic distal clavicle resection.

Technique Description

For this procedure, the patient is placed upright in the beach-chair position in a standard fashion.

We begin the procedure by first entering the shoulder in the usual manner through posterior and anterior portals. Diagnostic arthroscopy of the glenohumeral joint shows no pathology. Now in the subacromial space, we are viewing from the standard lateral portal and working through an anterior portal.

We first introduce a soft tissue shaver into the anterior portal. We place a switching stick through the posterior portal to aid in holding tissue down, preventing bleeding. We use an arthroscopic ablation device to skeletonize the distal clavicle and the acromion, including the thickened capsule and the intra-articular disc. Here, a grabber can be used to remove redundant tissue.

We then start our bony resection with a 4-mm bur, first on the acromial side moving from the anterior to posterior direction, removing 1 to 2 mm for better visualization. Then we begin our distal clavicle excision using a cutting block technique, sweeping the cutter from anterior inferior to posterior superior. Typically, it takes 2 passes to remove 6 to 8 mm of bone.

At this point, we make our direct posterior portal with an outside-in technique, localizing first with a spinal needle. Once the spinal needle location is confirmed viewing from the anterior portal, we make a direct posterior portal and localize with a blunt trocar. The hole is enlarged with electrocautery, and hemostasis is achieved. We then use the bur to finish off our bony resection. Working from the direct posterior portal ensures that we can have adequate removal posteriorly and superiorly, which can be easily missed if just working from the anterior portal.

Finally, we go back to view through the lateral portal and clean up any remaining debris. Electrocautery is used as a probe to make sure no bone is missed.

The most common complication that can occur after this procedure is persistent pain due to inadequate resection. This is why we use multiple portals to complete the resection. It is also possible to cause an iatrogenic instability of the AC joint due to disruption of capsular attachment or medial coracoclavicular ligaments if the resection is overzealous. Thus, care must be taken not to go past 6 to 8 mm from the joint. Finally, bleeding can often be encountered as the bur moves medial, so care must be taken not to get into the arteries at the medial border of the coracoacromial ligament.

Results

For a postoperative protocol after an isolated distal clavicle excision/subacromial decompression, our patients can begin active range of motion immediately after surgery and use a sling just for comfort, as long as no other concomitant procedures are performed. Patients can progress to range of motion as tolerated at 4 weeks and typically to resumption of full activity at 8 to 12 weeks.

Discussion/Conclusion

We have had great success using this technique. This is also well supported in the literature, with reports of good outcomes and decreased reoperation rates in patients who underwent distal clavicle excision. ⁴ Leon et al ⁵ found a statistically significant improvement in active and passive range of motion, as well as visual analog scale pain scores in patients who underwent distal clavicle resection. Most of these patients were able to return to work. In the case series by Bismuth et al, ¹ patients who underwent isolated rotator cuff repair and continued to have pain experienced improvement after a subsequent distal clavicle resection. These studies and more demonstrate the effectiveness of distal clavicle resection in treating AC joint pathology.^7,9

These are our references.

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