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Arthroscopic Distal Clavicle Resection: A Comparison of Bursal and Direct Approaches
Arthroscopic Distal Clavicle Resection: A Comparison of Bursal and Direct Approaches William N. Levine, M.D., Maximillian Soong, M.D., Christopher S. Ahmad, M.D., Theodore A. Blaine, M.D., and Louis U. Bigliani, M.D.
Purpose: To test the hypothesis that the direct (superior) approach to arthroscopic distal clavicle resection is as safe and effective as the bursal (subacromial) approach. Methods: All patients who had an arthroscopic distal clavicle resection in our institution between 1994 and 2002 were reviewed. Patients with a history of acromioclavicular joint (ACJ) instability, previous shoulder surgery, glenohumeral pathology, full-thickness rotator cuff tear, or other significant orthopaedic comorbidity were excluded. Outcome data were collected including the American Shoulder and Elbow Surgeons (ASES) score as well as subjective ratings of pain and instability. Results: Follow-up was completed on 66 shoulders of 60 patients. Twenty-four shoulders had a bursal approach (group I) and 42 had a direct approach (group II). There were 45 men and 15 women with an average age of 46 years (range, 21 to 78 years). Follow-up averaged 6.0 years (range, 2 to 11.5 years). The average ASES score was 90 (range, 53-100) in group I and 94 (range, 55-100) in group II. Four patients (10%) in group II required reoperation: 2 patients required ACJ stabilization at 6 and 9 months postoperatively because of anteroposterior instability, and 2 patients required resection again at 5 years because of recurrent symptoms. Conclusions: Both the direct and bursal approaches lead to satisfactory outcomes in the majority of patients with ACJ arthrosis. However, the direct approach to the ACJ may damage the superior capsular ligaments, potentially leading to distal clavicle instability. Care should be taken when performing the direct ACJ resection to avoid disrupting the capsular restraints. Level of Evidence: Level IV therapeutic case series. Key Words: Arthroscopic—Bursal—Direct— Distal clavicle—Resection.
T
he contribution of acromioclavicular joint (ACJ) arthritis to subacromial impingement has been noted by many authors1-4 and the deterioration of this joint with advancing age has been well documented.5 Anterosuperior shoulder pain is a complex problem, often caused not only by subacromial impingement but by ACJ arthritis as well. Thus, procedures that fail to address all potential sources of pain may result in
From the Center for Shoulder, Elbow and Sports Medicine, Columbia University, Columbia University Medical Center, New York, New York, U.S.A. Address correspondence and reprint requests to William N. Levine, M.D., 622 W 168th St, PH-1117, New York, NY 10032, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2205-4362$32.00/0 doi:10.1016/j.arthro.2006.01.013
516
failure to alleviate the symptoms and continued disability. The prevalence of arthroscopic ACJ resection has increased over the last decade with a high success rate.6-19 In a cadaveric study, Gartsman et al.20 showed that arthroscopic distal clavicle resection could reliably be performed and that bony resection was comparable to open techniques. Using quantitative radiographic analysis, Flatow et al.10 documented comparable bone resection with arthroscopic and open techniques. Subsequent clinical studies have shown that the results are excellent and reliable.6-19 This procedure is not without risk, however, and may lead to excessive anteroposterior translational instability of the distal clavicle and continued pain after surgery.21-25 Most investigators have reported their results with the indirect or bursal approach to the ACJ. A direct
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 5 (May), 2006: pp 516-520
ARTHROSCOPIC DISTAL CLAVICLE RESECTION
517
approach to the ACJ can also be used, but it has been reported much less frequently.10,11 The direct approach allows improved visualization of the entire joint, direct access to the ACJ, and decreased bony debris in the subacromial space. Therefore, the purpose of this retrospective study was to compare the results of arthroscopic distal clavicle resection by the bursal and direct approaches, and our hypothesis is that both approaches are safe and effective. METHODS Sixty-four patients (70 shoulders) who underwent an arthroscopic distal clavicle resection by the senior investigator (L.U.B.) between 1994 and 2002 were retrospectively reviewed. Patients were excluded from the study if they had a history of shoulder surgery, associated glenohumeral pathology (i.e., SLAP tear), full-thickness rotator cuff tear, ACJ dislocation, or other significant orthopaedic comorbidity (e.g., reflex sympathetic dystrophy, congenital anomaly). All patients presented with anterosuperior shoulder pain localized to the ACJ, with or without other complaints including impingement symptoms. Physical examination showed tenderness to palpation of the ACJ, pain with passive cross-body adduction of the arm, and pain with extension and internal rotation of the arm. All patients had standard radiographic evaluation including an anteroposterior view in the plane of the scapula with the humerus in internal, external, and neutral rotation; a supraspinatus outlet view; an axillary view; and a Zanca view (10° cephalic tilt) of the ACJ. Before surgery, all patients had failed a 6-month course of nonoperative treatment including nonsteroidal anti-inflammatory drugs’ physical therapy, and activity modification. Those with coexisting subacromial impingement received a similar regimen that also addressed the rotator cuff. An injection of lidocaine and steroid resulting in temporary relief helped to verify the ACJ as a source of pain. Four patients were lost to follow-up, leaving 60 patients (66 shoulders) for the final cohort. Arthroscopic distal clavicle resection was performed through a bursal approach in 24 shoulders (group I) and through a direct, superior approach in 42 shoulders (group II). All 24 patients in group I also underwent subacromial decompression, compared with 13 of 42 patients in group II. All patients were evaluated postoperatively by physical examination, review of office charts, and supplemental telephone interview. Outcome measures included the American Society of Shoulder and Elbow Surgeons (ASES) score, subjec-
FIGURE 1. Bursal approach: The arthroscope is in midlateral portal and the burr is brought in from the anterosuperior portal.
tive pain and instability (each rated on a visual analog scale of 1 to 10), patient satisfaction, and patient recommendation of the procedure (Yes or No for each), as well as any failures. Postoperative radiographs were not routinely obtained. Statistical Analysis Quantitative data (ASES scores, pain rating, instability rating, and range of motion) were analyzed with the use of the Student t test. Nonquantitative data (patient satisfaction, recommendation, and reoperation) were analyzed with the Fisher exact test. Significance was set at P ⬍ .05. Operative Techniques Regional interscalene anesthesia was routinely used and the patient was placed in the modified beach-chair position. The portal sites were injected with 1% lidocaine with epinephrine to reduce skin bleeding. Bursal Approach: In the bursal approach (Fig 1), we used standard arthroscopic portals (posterior, anterior, and midlateral). A subacromial decompression was performed based on physical findings of impingement in the preoperative evaluation and intraoperative findings in the subacromial space (e.g., prominent acromion, inflamed bursa). Regardless, some subacromial soft tissues must be cleared before the ACJ can be visualized. Localization of the ACJ was facilitated by placing a 22-gauge needle into the joint from above. We used electrocautery to incise the inferior capsule and the distal clavicle was demarcated from anterior to posterior. Great care was taken to avoid
518
W. N. LEVINE ET AL. RESULTS
FIGURE 2. Direct approach: Two 18-gauge needles are used to establish anterosuperior and posterosuperior portals. When fluid flows freely between the needles, confirmation of the needles being in the ACJ is made.
disturbance of the superior ACJ capsule and ligaments. A 5-mm burr was used to resect the clavicle beginning inferiorly. Approximately 5 to 8 mm of bone was resected and this was confirmed by viewing from the anterior portal as well. A 70° arthroscope can facilitate visualization of the ACJ while viewing from the midlateral portal. In addition, a minimal resection of the medial acromion (4 to 5 mm) can also assist in visualization of the ACJ. Direct Approach: For the direct approach (Fig 2) two 22-gauge 1.5-inch needles were used to determine the location and orientation of the ACJ to allow precise introduction of the instruments. Variation in the inclination makes this step critical to facilitate the procedure. The 4.0-mm 30° arthroscope was then placed through the anterosuperior portal and a posterosuperior portal was made under direct vision. In cases with significant narrowing of the ACJ, a 2.7-mm arthroscope may be necessary initially. The distal clavicle was then carefully exposed subperiosteally using electrocautery. Care was taken to avoid disruption of the superior capsule as described in the bursal approach above. Approximately 5 to 8 mm of distal clavicle was then evenly resected from anterior to posterior. Both anterosuperior and posterosuperior portals were used to confirm an even resection. Diagnostic glenohumeral and subacromial arthroscopic examinations were not performed in cases of isolated ACJ pathology (as determined on preoperative evaluation). Thus, only if warranted, subacromial decompression was then performed in the same manner as described above from the bursal approach.
In the final cohort there were 45 men and 15 women with an average age of 46 years (range, 21 to 78 years). The dominant extremity was involved in 75% of patients. The indication for distal clavicle resection was isolated ACJ arthritis in 58 patients (88%), isolated distal clavicle osteolysis in 5 patients (8%), or both conditions in 3 patients (4%). Subacromial impingement syndrome was also found in 37 patients (56%). Follow-up averaged 6.1 years (range, 2.4 to 10.1 years) in group I and 5.9 years (range, 1.1 to 11.5 years) in group II. Individual ASES scores were classified as excellent (91-100 points), good (81-90 points), fair (61-80 points), and poor (ⱕ60 points). The outcomes are shown in Tables 1 and 2. In group I (n ⫽ 24), the average ASES score was 90 points (range, 53-100). These included 16 excellent, 2 good, 4 fair, and 2 poor. The average pain score was 1.0 (range, 0-6), and the average instability rating was 0.7 (range, 0-5). All 24 patients (100%) reported that they were satisfied and 23 (96%) would recommend the procedure. In group II (n ⫽ 42), the average ASES score was 94 points (range, 55-100). These included 36 excellent, 3 good, and 2 fair, and 1 poor. The average pain score was 0.5 (range, 0-5) and the average instability rating was 0.6 (range, 0-6). All 42 patients (100%) reported that they were satisfied and 41 (98%) would recommend the procedure. Four patients in group II (10%) required a second procedure. Two patients developed ACJ instability 6 and 9 months after the index procedure. Both were young active men (including 1 weightlifter) and complained of pain and excessive movement at the ACJ, which was confirmed by physical examination. Neither had any history of ACJ instability and both underwent stabilization by transfer of the acromial end of the coracoacromial ligament to the remaining distal clavicle. At most recent follow-up, 1 patient had no pain or instability and an ASES score of 100 and the other had a pain score of 3, no instability, and an ASES score of 78. Two other patients developed recurrence of symptoms 5 years after initially respond-
TABLE 1.
Group I, bursal Group II, direct
ASES Scores
Excellent (%)
Good (%)
Fair (%)
Poor (%)
16 (67) 36 (86)
2 (8) 3 (7)
4 (17) 2 (5)
2 (8) 1 (2)
ARTHROSCOPIC DISTAL CLAVICLE RESECTION TABLE 2.
Group I, bursal Group II, direct
519
Visual Analog Scale Pain Scores
0
1
2
3
4
5
6
15 (63) 33 (79)
2 (8) 5 (12)
4 (17) 1 (2)
1 (4) 2 (5)
0 (0) 0 (0)
0 (0) 1 (2)
2 (8) 0 (0)
ing well to direct distal clavicle resection with subacromial decompression. Both underwent repeat resection. At the most recent follow-up, 1 patient had no pain, no instability, and an ASES score of 100, and the other had no pain or instability, and an ASES score of 95. Both cases were assumed to involve bony regrowth because of the initial success followed by late recurrence, although this is not definite because there were no radiographs taken immediately after the index procedures to document adequate initial resection. There were no significant differences between the 2 groups with respect to ASES score (P ⬎ .1), pain (P ⬎ .1), subjective instability (P ⬎ .5), satisfaction (P ⫽ 1), recommendation (P ⬎ .1), and failure (P ⬎ .1).
Arthroscopic distal clavicle resection from either the bursal or direct approach yields predictable, reliable results in the majority of patients. Care should be taken to resect an even amount of bone and preserve the supporting capsular and ligamentous structures of the ACJ to maintain stability.
DISCUSSION
REFERENCES
The current study compares the outcomes of the bursal and direct approaches to arthroscopic distal clavicle resection. The principal findings are that both approaches are effective in treating ACJ arthrosis, although the direct approach may put the important superior capsular structures at risk. The 2 patients in the direct group who required subsequent ACJ stabilization had no history of ACJ sprain, and it is likely, therefore, that the superior capsular ligaments were violated during the procedure. If disruption of these ligaments is noted at the time of arthroscopic distal clavicle resection, open repair of the ACJ capsule may be necessary to avoid later failure of the procedure. Although superior capsular injury can lead to early failure with either approach, we have not seen this complication after the bursal procedure. Later failure (after several years) may result from bony regrowth, which may be treated by repeat resection. The direct approach may help avoid uneven resection by virtue of improved visualization, but both cases of presumed regrowth occurred in the direct group, for which we do not have an explanation. The major limitation of this study is the nonrandomized retrospective design that allows for selection bias because the surgeon determined which approach to use in each case. Another limitation is lack of power because there were no statistically significant
1. Kessel L, Watson M. The painful arc syndrome. Clinical classification as a guide to management. J Bone Joint Surg Br 1977;59:166-172. 2. Neer CS II. Impingement lesions. Clin Orthop 1983;173:7077. 3. Neviaser TJ, Neviaser RJ, Neviaser JS. The four-in-one arthroplasty for the painful arc syndrome. Clin Orthop 1982; 163:107-112. 4. Petersson CJ, Gentz CF. Ruptures of the supraspinatus tendon. The significance of distally pointing acromioclavicular osteophytes. Clin Orthop 1983;174:143-148. 5. DePalma A. Degenerative changes of the sternoclavicular and acromioclavicular joints in various decades. Springfield, IL: CC Thomas, 1957. 6. Barber FA. Coplaning of the acromioclavicular joint. Arthroscopy 2001;17:913-917. 7. Bell RH. Arthroscopic distal clavicle resection. Instr Course Lect 1998;47:35-41. 8. Bigliani LU, Nicholson GP, Flatow EL. Arthroscopic resection of the distal clavicle. Orthop Clin North Am 1993;24:133-141. 9. Caspari RB, Thal R. A technique for arthroscopic subacromial decompression. Arthroscopy 1992;8:23-30. 10. Flatow EL, Cordasco FA, Bigliani LU. Arthroscopic resection of the outer end of the clavicle from a superior approach: A critical, quantitative, radiographic assessment of bone removal. Arthroscopy 1992;8:55-64. 11. Flatow EL, Duralde XA, Nicholson GP, et al. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg 1995;4(1 Pt 1):41-50. 12. Gartsman GM. Arthroscopic resection of the acromioclavicular joint. Am J Sports Med 1993;21:71-77. 13. Jerosch J, Steinbeck J, Schroder M, et al. Arthroscopic resection of the acromioclavicular joint (ARAC). Knee Surg Sports Traumatol Arthrosc 1993;1:209-215. 14. Kay SP, Ellman H, Harris E. Arthroscopic distal clavicle
differences, despite the fact that all 4 reoperations were in the direct group. Finally, coexisting impingement is a highly prevalent confounding factor that reflects the clinical reality of degenerative shoulder disease.
CONCLUSIONS
520
15. 16.
17. 18. 19. 20.
W. N. LEVINE ET AL.
excision. Technique and early results. Clin Orthop 1994;301:181-184. Levine WN, Barron OA, Yamaguchi K, et al. Arthroscopic distal clavicle resection from a bursal approach. Arthroscopy 1998;14:52-56. Martin SD, Baumgarten TE, Andrews JR. Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression. J Bone Joint Surg Am 2001; 83:328-335. Snyder SJ, Banas MP, Karzel RP. The arthroscopic Mumford procedure: An analysis of results. Arthroscopy 1995;11:157164. Tolin BS, Snyder SJ. Our technique for the arthroscopic Mumford procedure. Orthop Clin North Am 1993;24:143-151. Zawadsky M, Marra G, Wiater JM, et al. Osteolysis of the distal clavicle: long-term results of arthroscopic resection. Arthroscopy 2000;16:600-605. Gartsman GM, Combs AH, Davis PF, et al. Arthroscopic
21. 22. 23. 24.
25.
acromioclavicular joint resection. An anatomical study. Am J Sports Med 1991;19:2-5. Blazar PE, Iannotti JP, Williams GR. Anteroposterior instability of the distal clavicle after distal clavicle resection. Clin Orthop 1998;348:114-120. Costic RS, Jari R, Rodosky MW, et al. Joint compression alters the kinematics and loading patterns of the intact and capsule-transected ACJ. J Orthop Res 2003;21:379-385. Fischer BW, Gross RM, McCarthy JA, et al. Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression. Arthroscopy, 1999;15:241-248. Klimkiewicz JJ, Williams GR, Sher JS, et al. The acromioclavicular capsule as a restraint to posterior translation of the clavicle: A biomechanical analysis. J Shoulder Elbow Surg 1999;8:119-124. Nuber GW, Bowen MK. Arthroscopic treatment of acromioclavicular joint injuries and results. Clin Sports Med 2003;22: 301-317.
Purpose: To test the hypothesis that the direct (superior) approach to arthroscopic distal clavicle resection is as safe and effective as the bursal (subacromial) approach. Methods: All patients who had an arthroscopic distal clavicle resection in our institution between 1994 and 2002 were reviewed. Patients with a history of acromioclavicular joint (ACJ) instability, previous shoulder surgery, glenohumeral pathology, full-thickness rotator cuff tear, or other significant orthopaedic comorbidity were excluded. Outcome data were collected including the American Shoulder and Elbow Surgeons (ASES) score as well as subjective ratings of pain and instability. Results: Follow-up was completed on 66 shoulders of 60 patients. Twenty-four shoulders had a bursal approach (group I) and 42 had a direct approach (group II). There were 45 men and 15 women with an average age of 46 years (range, 21 to 78 years). Follow-up averaged 6.0 years (range, 2 to 11.5 years). The average ASES score was 90 (range, 53-100) in group I and 94 (range, 55-100) in group II. Four patients (10%) in group II required reoperation: 2 patients required ACJ stabilization at 6 and 9 months postoperatively because of anteroposterior instability, and 2 patients required resection again at 5 years because of recurrent symptoms. Conclusions: Both the direct and bursal approaches lead to satisfactory outcomes in the majority of patients with ACJ arthrosis. However, the direct approach to the ACJ may damage the superior capsular ligaments, potentially leading to distal clavicle instability. Care should be taken when performing the direct ACJ resection to avoid disrupting the capsular restraints. Level of Evidence: Level IV therapeutic case series. Key Words: Arthroscopic—Bursal—Direct— Distal clavicle—Resection.
T
he contribution of acromioclavicular joint (ACJ) arthritis to subacromial impingement has been noted by many authors1-4 and the deterioration of this joint with advancing age has been well documented.5 Anterosuperior shoulder pain is a complex problem, often caused not only by subacromial impingement but by ACJ arthritis as well. Thus, procedures that fail to address all potential sources of pain may result in
From the Center for Shoulder, Elbow and Sports Medicine, Columbia University, Columbia University Medical Center, New York, New York, U.S.A. Address correspondence and reprint requests to William N. Levine, M.D., 622 W 168th St, PH-1117, New York, NY 10032, U.S.A. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2205-4362$32.00/0 doi:10.1016/j.arthro.2006.01.013
516
failure to alleviate the symptoms and continued disability. The prevalence of arthroscopic ACJ resection has increased over the last decade with a high success rate.6-19 In a cadaveric study, Gartsman et al.20 showed that arthroscopic distal clavicle resection could reliably be performed and that bony resection was comparable to open techniques. Using quantitative radiographic analysis, Flatow et al.10 documented comparable bone resection with arthroscopic and open techniques. Subsequent clinical studies have shown that the results are excellent and reliable.6-19 This procedure is not without risk, however, and may lead to excessive anteroposterior translational instability of the distal clavicle and continued pain after surgery.21-25 Most investigators have reported their results with the indirect or bursal approach to the ACJ. A direct
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 5 (May), 2006: pp 516-520
ARTHROSCOPIC DISTAL CLAVICLE RESECTION
517
approach to the ACJ can also be used, but it has been reported much less frequently.10,11 The direct approach allows improved visualization of the entire joint, direct access to the ACJ, and decreased bony debris in the subacromial space. Therefore, the purpose of this retrospective study was to compare the results of arthroscopic distal clavicle resection by the bursal and direct approaches, and our hypothesis is that both approaches are safe and effective. METHODS Sixty-four patients (70 shoulders) who underwent an arthroscopic distal clavicle resection by the senior investigator (L.U.B.) between 1994 and 2002 were retrospectively reviewed. Patients were excluded from the study if they had a history of shoulder surgery, associated glenohumeral pathology (i.e., SLAP tear), full-thickness rotator cuff tear, ACJ dislocation, or other significant orthopaedic comorbidity (e.g., reflex sympathetic dystrophy, congenital anomaly). All patients presented with anterosuperior shoulder pain localized to the ACJ, with or without other complaints including impingement symptoms. Physical examination showed tenderness to palpation of the ACJ, pain with passive cross-body adduction of the arm, and pain with extension and internal rotation of the arm. All patients had standard radiographic evaluation including an anteroposterior view in the plane of the scapula with the humerus in internal, external, and neutral rotation; a supraspinatus outlet view; an axillary view; and a Zanca view (10° cephalic tilt) of the ACJ. Before surgery, all patients had failed a 6-month course of nonoperative treatment including nonsteroidal anti-inflammatory drugs’ physical therapy, and activity modification. Those with coexisting subacromial impingement received a similar regimen that also addressed the rotator cuff. An injection of lidocaine and steroid resulting in temporary relief helped to verify the ACJ as a source of pain. Four patients were lost to follow-up, leaving 60 patients (66 shoulders) for the final cohort. Arthroscopic distal clavicle resection was performed through a bursal approach in 24 shoulders (group I) and through a direct, superior approach in 42 shoulders (group II). All 24 patients in group I also underwent subacromial decompression, compared with 13 of 42 patients in group II. All patients were evaluated postoperatively by physical examination, review of office charts, and supplemental telephone interview. Outcome measures included the American Society of Shoulder and Elbow Surgeons (ASES) score, subjec-
FIGURE 1. Bursal approach: The arthroscope is in midlateral portal and the burr is brought in from the anterosuperior portal.
tive pain and instability (each rated on a visual analog scale of 1 to 10), patient satisfaction, and patient recommendation of the procedure (Yes or No for each), as well as any failures. Postoperative radiographs were not routinely obtained. Statistical Analysis Quantitative data (ASES scores, pain rating, instability rating, and range of motion) were analyzed with the use of the Student t test. Nonquantitative data (patient satisfaction, recommendation, and reoperation) were analyzed with the Fisher exact test. Significance was set at P ⬍ .05. Operative Techniques Regional interscalene anesthesia was routinely used and the patient was placed in the modified beach-chair position. The portal sites were injected with 1% lidocaine with epinephrine to reduce skin bleeding. Bursal Approach: In the bursal approach (Fig 1), we used standard arthroscopic portals (posterior, anterior, and midlateral). A subacromial decompression was performed based on physical findings of impingement in the preoperative evaluation and intraoperative findings in the subacromial space (e.g., prominent acromion, inflamed bursa). Regardless, some subacromial soft tissues must be cleared before the ACJ can be visualized. Localization of the ACJ was facilitated by placing a 22-gauge needle into the joint from above. We used electrocautery to incise the inferior capsule and the distal clavicle was demarcated from anterior to posterior. Great care was taken to avoid
518
W. N. LEVINE ET AL. RESULTS
FIGURE 2. Direct approach: Two 18-gauge needles are used to establish anterosuperior and posterosuperior portals. When fluid flows freely between the needles, confirmation of the needles being in the ACJ is made.
disturbance of the superior ACJ capsule and ligaments. A 5-mm burr was used to resect the clavicle beginning inferiorly. Approximately 5 to 8 mm of bone was resected and this was confirmed by viewing from the anterior portal as well. A 70° arthroscope can facilitate visualization of the ACJ while viewing from the midlateral portal. In addition, a minimal resection of the medial acromion (4 to 5 mm) can also assist in visualization of the ACJ. Direct Approach: For the direct approach (Fig 2) two 22-gauge 1.5-inch needles were used to determine the location and orientation of the ACJ to allow precise introduction of the instruments. Variation in the inclination makes this step critical to facilitate the procedure. The 4.0-mm 30° arthroscope was then placed through the anterosuperior portal and a posterosuperior portal was made under direct vision. In cases with significant narrowing of the ACJ, a 2.7-mm arthroscope may be necessary initially. The distal clavicle was then carefully exposed subperiosteally using electrocautery. Care was taken to avoid disruption of the superior capsule as described in the bursal approach above. Approximately 5 to 8 mm of distal clavicle was then evenly resected from anterior to posterior. Both anterosuperior and posterosuperior portals were used to confirm an even resection. Diagnostic glenohumeral and subacromial arthroscopic examinations were not performed in cases of isolated ACJ pathology (as determined on preoperative evaluation). Thus, only if warranted, subacromial decompression was then performed in the same manner as described above from the bursal approach.
In the final cohort there were 45 men and 15 women with an average age of 46 years (range, 21 to 78 years). The dominant extremity was involved in 75% of patients. The indication for distal clavicle resection was isolated ACJ arthritis in 58 patients (88%), isolated distal clavicle osteolysis in 5 patients (8%), or both conditions in 3 patients (4%). Subacromial impingement syndrome was also found in 37 patients (56%). Follow-up averaged 6.1 years (range, 2.4 to 10.1 years) in group I and 5.9 years (range, 1.1 to 11.5 years) in group II. Individual ASES scores were classified as excellent (91-100 points), good (81-90 points), fair (61-80 points), and poor (ⱕ60 points). The outcomes are shown in Tables 1 and 2. In group I (n ⫽ 24), the average ASES score was 90 points (range, 53-100). These included 16 excellent, 2 good, 4 fair, and 2 poor. The average pain score was 1.0 (range, 0-6), and the average instability rating was 0.7 (range, 0-5). All 24 patients (100%) reported that they were satisfied and 23 (96%) would recommend the procedure. In group II (n ⫽ 42), the average ASES score was 94 points (range, 55-100). These included 36 excellent, 3 good, and 2 fair, and 1 poor. The average pain score was 0.5 (range, 0-5) and the average instability rating was 0.6 (range, 0-6). All 42 patients (100%) reported that they were satisfied and 41 (98%) would recommend the procedure. Four patients in group II (10%) required a second procedure. Two patients developed ACJ instability 6 and 9 months after the index procedure. Both were young active men (including 1 weightlifter) and complained of pain and excessive movement at the ACJ, which was confirmed by physical examination. Neither had any history of ACJ instability and both underwent stabilization by transfer of the acromial end of the coracoacromial ligament to the remaining distal clavicle. At most recent follow-up, 1 patient had no pain or instability and an ASES score of 100 and the other had a pain score of 3, no instability, and an ASES score of 78. Two other patients developed recurrence of symptoms 5 years after initially respond-
TABLE 1.
Group I, bursal Group II, direct
ASES Scores
Excellent (%)
Good (%)
Fair (%)
Poor (%)
16 (67) 36 (86)
2 (8) 3 (7)
4 (17) 2 (5)
2 (8) 1 (2)
ARTHROSCOPIC DISTAL CLAVICLE RESECTION TABLE 2.
Group I, bursal Group II, direct
519
Visual Analog Scale Pain Scores
0
1
2
3
4
5
6
15 (63) 33 (79)
2 (8) 5 (12)
4 (17) 1 (2)
1 (4) 2 (5)
0 (0) 0 (0)
0 (0) 1 (2)
2 (8) 0 (0)
ing well to direct distal clavicle resection with subacromial decompression. Both underwent repeat resection. At the most recent follow-up, 1 patient had no pain, no instability, and an ASES score of 100, and the other had no pain or instability, and an ASES score of 95. Both cases were assumed to involve bony regrowth because of the initial success followed by late recurrence, although this is not definite because there were no radiographs taken immediately after the index procedures to document adequate initial resection. There were no significant differences between the 2 groups with respect to ASES score (P ⬎ .1), pain (P ⬎ .1), subjective instability (P ⬎ .5), satisfaction (P ⫽ 1), recommendation (P ⬎ .1), and failure (P ⬎ .1).
Arthroscopic distal clavicle resection from either the bursal or direct approach yields predictable, reliable results in the majority of patients. Care should be taken to resect an even amount of bone and preserve the supporting capsular and ligamentous structures of the ACJ to maintain stability.
DISCUSSION
REFERENCES
The current study compares the outcomes of the bursal and direct approaches to arthroscopic distal clavicle resection. The principal findings are that both approaches are effective in treating ACJ arthrosis, although the direct approach may put the important superior capsular structures at risk. The 2 patients in the direct group who required subsequent ACJ stabilization had no history of ACJ sprain, and it is likely, therefore, that the superior capsular ligaments were violated during the procedure. If disruption of these ligaments is noted at the time of arthroscopic distal clavicle resection, open repair of the ACJ capsule may be necessary to avoid later failure of the procedure. Although superior capsular injury can lead to early failure with either approach, we have not seen this complication after the bursal procedure. Later failure (after several years) may result from bony regrowth, which may be treated by repeat resection. The direct approach may help avoid uneven resection by virtue of improved visualization, but both cases of presumed regrowth occurred in the direct group, for which we do not have an explanation. The major limitation of this study is the nonrandomized retrospective design that allows for selection bias because the surgeon determined which approach to use in each case. Another limitation is lack of power because there were no statistically significant
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CONCLUSIONS
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