Distal Clavicle Resection Research Articles

Arthroscopic Resection of Acromioclavicular Joint Cysts and Distal Clavicle: A Report of 3 Cases.

This case report describes 3 patients who developed acromioclavicular joint cysts secondary to rotator cuff arthropathy. The patients underwent arthroscopic cyst decompression and distal clavicle resection, resulting in successful excision of the cyst and minimal cyst recurrence. Based on these cases, arthroscopic cyst decompression with concomitant distal clavicle resection should be considered as an effective alternative to serial aspirations or open cyst excision and distal clavicle resection.

Arthroscopic distal clavicle resection versus conservation in patients with combined rotator cuff tears and acromioclavicular joint osteoarthritis.

The most common cause of shoulder pain originating from the acromioclavicular (AC) joint is osteoarthritis, causing pain and disability. Operative Management of AC arthritis includes arthroscopic distal clavicle resection (DCR) and open clavicle resection. This study was conducted to evaluate the outcomes of isolated rotator cuff repair with conservative treatment of ACJ arthritis versus the combined resection of the distal clavicle with the repair of a rotator cuff tear, in cases with acromioclavicular arthritis. A total of 46 patients with unilateral or bilateral combined rotator cuff tear and acromioclavicular arthritis were included, they were classified into 2 independent groups: Conservative group (23 patients), and DCR group (23 patients). All patients were subjected to full history taking, examination, pre and post-operative University of California at Los Angeles shoulder scoring scale (UCLA), Antero-Posterior and Zanca X-rays views, early and late complications. Mean age was (51 ± 9) years, males were predominant (56.5%). The average post-operative UCLA score was (31.1 ± 4.9), and the average time to return to work was (214 ± 22). (2.2%) of patients had early complications, (19.6%) had late complications, (32.6%) had > 24h till 1st post-operative analgesia, and (87%) needed MgSO4 Injection. We found a highly significant increase in UCLA score measurements in the Conservative group, and a highly significant increase in UCLA score measurements in the DCR group (p < 0.01). But there was no difference between the 2 groups. Conventional conservative approach with arthroscopic rotator cuff repair and subacromial decompression has proven to be as effective as arthroscopic rotator cuff repair and subacromial decompression with DCR, in terms of efficacy and safety profiles in short term, but with more risks of potential hazards and cost with the DCR.

Diagnostic value of a preoperative acromioclavicular injection for symptomatic acromioclavicular osteoarthritis: a retrospective study of cross-sectional midterm outcomes.

It is essential to distinguish between symptomatic- and asymptomatic radiographic acromioclavicular (AC) osteoarthritis (OA) because AC-targeted physical examinations are dubious. This study aimed to determine the diagnostic value of a preoperative AC injection in discriminating between symptomatic- and asymptomatic radiographic AC OA based on patient arthroscopic distal clavicle resection (aDCR) outcomes. Forty-eight patients who underwent aDCR for AC OA were included. Their satisfaction was objectified using a 5-point Likert scale and patient willingness to repeat the surgery. The Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), and the Numerical Rating Scale (NRS) were used to assess postoperative shoulder function and pain. Patients were subdivided into groups based on their good or minimal reaction to an AC injection (good reaction: ≥7 consecutive days of pain reduction, Minimal reaction: <7 consecutive days of pain reduction). Twenty-seven patients had a good reaction and 21 patients had a minimal reaction to the AC injection (median follow-up, 45.0 months; range, 31.0-52.8 months). No significant differences were found in level of satisfaction (P=0.234) or willingness to repeat the surgery (P=0.861). No significant differences were found in OSS (P=0.612), SSV (P=0.641), NRS at rest (P=0.684) or during activity (P=0.422). This study found no significant differences between patients with a good reaction or a minimal reaction to an AC injection after aDCR surgery. The outcomes of this study seem to suggest that a distinction between symptomatic and asymptomatic radiographic AC OA is unnecessary, as all patients were equally satisfied with the outcome. Level of evidence: IV.

Bone marrow edema in the acromioclavicular joint after arthroscopic rotator cuff repair

BackgroundBone marrow edema (BME) in the acromioclavicular joint (ACj) may occur after arthroscopic rotator cuff repair (ARCR), resulting in persistent postoperative ACj pain. We investigated the incidence and clinical characteristics of BME in ACj after ARCR. MethodsPatients exhibiting ACj-related symptoms prior to ARCR surgery, no BME in the ACj on MRI, and an ability to undergo 2-year postoperative physical and MRI examinations of the ACj were included. Patients who underwent distal clavicle resection or osteophyte resection below the ACj and those unable to achieve primary repair of the rotator cuff were excluded. MRI evaluation was performed preoperatively and at 3, 6, 12, and 24 months postoperatively. Patients who showed BME in ACj on fat-suppressed T2 MRI at 24 months postoperatively were classified into the BME + group, and those with no BME were classified into the BME− group. Patient background, operation time, Japanese Orthopedic Association (JOA) score, re-tear rate, ACj tenderness, and cross-body adduction test were compared between groups. In addition, we examined the time of occurrence of BME. ResultsA total of 345 ARCRs were performed during the study period. After the exclusion of 114 shoulders, the remaining 231 shoulders were included in this study. There were 208 cases in the BME− group and 23 cases in the BME + group. The incidence of BME was 9.96 %. Although the JOA scores of both groups showed a significant improvement postoperatively compared to preoperatively, there was no significant difference between the two groups. In terms of re-tear, there was 1 case in the BME + group and 7 in the BME− group. Positive ACj tenderness and cross-body adduction test were significantly higher in the BME + group (P < 0.001). BME occurred in 6 cases at 3 months, 9 cases at 6 months, and 8 cases at 1 year postoperatively. None of the patients developed BME at more than 1 year postoperatively. BME was observed on MRI in all cases at 2 years postoperatively. ConclusionsThe rate of occurrence of BME in the ACj after ARCR was 9.96 %. Patients with BME were significantly more likely to have ACj tenderness and positive cross-body adduction test. BME in the ACj often occurs within 6 months to 1 year after ARCR of small-to-medium rotator cuff tears, suggesting a relationship with postoperative functional improvement of the shoulder joint. The ACj should be considered as a potential site of persistent pain after ARCR for small-to-medium rotator cuff tears.

Insufficient evidence to confirm benefit of adjuvant distal clavicle resection during rotator cuff repair: a systematic review and meta-analysis.

The aim of this study is to determine whether adjuvant Distal Clavicle Resection (DCR) improves outcomes of Rotator Cuff Repair (RCR) in terms of ROM, clinical scores as well as reducing complications and/or reoperations. This systematic review conforms to the PRISMA guidelines. Studies were included if they compared outcomes of RCR with and without adjuvant DCR and reported on postoperative ROM, clinical scores, complications, and/or reoperations. Seven studies that comprised 1572 shoulders which underwent RCR at a follow-up ranged 8-54 months: 398 with adjuvant DCR and 1174 without DCR. No significant differences were found between patients that had DCR versus those that did not have DCR, in terms of postoperative clinical scores (ASES, Constant, pVAS), postoperative ROM (AFE, external and internal rotation), retear rate and reoperation rate. There were no significant differences in ROM, clinical scores, or rates of retears and reoperations between patients that underwent RCR with or without adjuvant DCR. There is insufficient evidence to support routine DCR during RCR; the incidence of new or residual acromioclavicular joint (ACJ) pain after RCR with adjuvant DCR is higher than following isolated RCR, which could in fact induce iatrogenic morbidity and therefore does not justify the additional surgery time and costs of routine adjuvant DCR.

Reversed total shoulder arthroplasty after acromioclavicular joint resection yields equivalent clinical results compared to a matched control group.

Reverse total shoulder arthroplasty (RTSA) is a well-establish procedure with increasing incidence. Depending on the medical history, many patients undergo multiple soft-tissue procedures before RTSA. The role of acromioclavicular pathology as well as the consequences of a distal clavicle resection (DCR) before RTSA has not been evaluated yet. A retrospective single-center review was performed on all patients undergoing primary RTSA with or without DCR with a minimum follow-up of 2years. We compared patient-reported outcome measures (Constant score (CS), subjective shoulder values (SSV), and range of motion (ROM)) with a matched control group. The control group consisted of patients treated with a RTSA without DCR and matching was performed for age, sex, operating side, American Society of Anesthesiologists (ASA), body mass index (BMI), and indication. Surgical time and complication rate were recorded. Thirty-nine patients with a mean follow-up of 63months (SD 33) were enrolled in the study group. Mean age was 67years (SD 7) with 44% male patients for both groups. The mean relative CS improved from 43% (SD 17) to 73% (SD 20) in the study group, and from 43% (18) to 73% (22) in the control group. The SSV improved from 29% (SD 17) to 63% (SD 29) in the study group, and from 28% (SD 16) to 69% (SD 26) in the control group (both n.s.). The postoperative ROM did not significantly differ between the two groups. Five patients in the study group and six in the control group had reoperations. Patients who received a DCR before RTSA showed equivalent clinical outcomes compared to a match-control group with RTSA only. Surgical time was not different, and no complication related to the open DCR was observed in the study group. Therefore, we conclude that a prior DCR does not influence the postoperative outcome after RTSA. Level III: Retrospective comparative study.

Outcomes of Secondary Arthroscopic Distal Clavicle Resection for Shoulders With Symptomatic Acromioclavicular Joint Arthropathy After Isolated Rotator Cuff Repair With Complete Tendon Healing.

Recent meta-analyses have advised against distal clavicle resection (DCR) as an adjuvant procedure during rotator cuff repair (RCR), whether performed routinely or in shoulders diagnosed with symptomatic acromioclavicular joint (ACJ) arthropathy. However, the efficacy of DCR as a secondary procedure in patients with persistent pain attributed to symptomatic ACJ arthropathy remains unknown. To evaluate outcomes of secondary DCR in patients with failed nonoperative treatment of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing. Case series; Level of evidence, 4. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥12 months after the index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR, as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included the Subjective Shoulder Value (SSV) and pain at rest. Clinical assessment at >12 months after DCR included the SSV, pain at rest, Constant-Murley score, range of motion, and satisfaction. Pre- and post-DCR SSV and pain scores were compared. Of the initial cohort, 5 patients did not consent to the use of their data, leaving 18 patients aged 53.3 ± 7.6 years (mean ± SD; range, 39-68 years) for outcome assessment. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV significantly improved from 58.7 ± 17.2 to 76.1 ± 20.2 (P < .001), and the pain at rest significantly decreased from 4.7 ± 1.5 to 2.8 ± 1.9 (P < .001). At final follow-up, the Constant-Murley score was 70.2 ± 21.0. Of 18 patients, 15 had none or mild residual pain (0-2; 83%), while 3 had substantial residual pain (5 or 6; 17%). Only 1 of the 3 patients with substantial residual pain had a poor SSV score (20 points) and was against opting for DCR in retrospect. No patient had infections or gross ACJ instability after DCR. Secondary DCR for cases of symptomatic ACJ arthropathy after isolated RCR with complete tendon healing reduced pain in 83% of patients, and 94% were satisfied and would undergo secondary DCR again.

Coracoid process transfer and distal clavicle resection for chronic acromioclavicular separation.

Dewar's procedure for transferring the coracoid process with the short head of biceps and coracobrachialis was reported in 1965 for treatment of both acute and chronic acromioclavicular (AC) joint separation, but little contemporary literature exists around the procedure. We report the clinical results of coracoid process transfer with excision of the lateral end of the clavicle for chronic AC joint separation. Fifty-one patients (39 men and 12 women, mean age 46±16 years) were included in the study. Clinical outcomes were evaluated using the American Shoulder and Elbow Surgeons and the Japanese Orthopaedic Association scores, as well as by measuring active range of motion in the shoulder, before-after (minimum follow-up time of 24 months [27±3 months]) surgery. Plain radiographs were used to examine stability of the AC joint and bone union of the graft. The mean American Shoulder and Elbow Surgeons and Japanese Orthopaedic Association scores increased (from 61±14 to 91±6, and from 54±9 to 89±8, respectively) at the time of final follow-up. There were no differences in active elevation and external rotation between before-after operation. Six patients whose grafts were fractured or displaced showed complete or partial loss of reduction of the AC joint. By transferring the coracoid process, the AC joint regained stability after chronic joint separation. Although potential complications related to the graft still need to be addressed, Dewar's procedure and lateral clavicle resection could be a reliable treatment of chronic AC joint separation.

Unusual-massive acromioclavicular joint cyst associated with complete reabsorption of the humeral head and outcomes of long-standing surgical stabilization for recurrent dislocations: a case report

Introduction. Acromioclavicular joint cysts (AJC) are rare findings associated with acromioclavicular (AC) joint arthritis or rotator cuff tear arthropathy. AJC type 1 are very rare and caused by an advanced degenerative arthritic process of the AC joint alone, without a rotator cuff tear; AJC Type 2 cysts are associated with a massive rotator cuff tear. Surgical excision represents the treatment of choice, since the aspiration of the cyst and the contextual injection of corticosteroid is burdened by a high rate of recurrence. We report the case of an unusual-massive acromioclavicular joint cyst associated with complete reabsorption of the humeral head and outcomes of long-standing surgical stabilization for recurrent dislocations. Case presentation. An 83-year-old man presented to our outpatient clinic complaining of a large cystic mass over the right shoulder region. Clinical examination revealed a mass over the right AC Joint, tender on palpation with normal overlying skin. Active range of motion (ROM) was limited but did not cause any discomfort to the patient. Imaging revealed complete reabsorption of the humeral head, and advanced shoulder degenerative arthropathy with loosening of the implanted hardware. Magnetic resonance imaging (MRI) revealed a ganglion cyst with the pathognomonic Geyser sign. The patient underwent surgical excision of the mass and an excision of 1 cm of the distal clavicle was performed to reduce the risk of recurrence. After one year of follow-up the patient is asymptomatic with no signs of recurrence. Discussion. Acromion-clavicular joint cysts are a rare consequence of advanced AC joint arthritis or chronic rotator cuff tear. The case presented is particularly interesting since it describes an AJC associated with an end stage shoulder arthropathy as a result of a surgical treatment for shoulder instability of only historical interest and certainly very rare to encounter in current clinical practice. Complete reabsorption of the humeral head associated with the mobilization of the implanted pins resulted in the formation of a fibrous cystic mass that replaced the head of the humerus; a complete cuff tear and a defect in the inferior capsule of the AC joint led to leakage of the synovial fluid through the AC joint which formed a cyst that appeared to be communicating through an isthmus with the previous described subacromion cyst. For the aforementioned reasoning, we believe that the formation of the acromioclavicular cyst is strictly related to the outcome of the previous surgery and represents the novelty of the case presented. Because of age, low demands and few symptoms lamented by the patient, we considered to perform only excision of the mass and resection of distal clavicle; patient satisfaction and no recurrence of the cyst after one year of follow-up rendered the therapeutic choice satisfying. Clinical presentation, instrumental diagnosis, and therapeutic possibilities on AJC are not discussed in detail as they do not represent the specific interest of the case and are debated in several other case reports. Conclusions. Although rare findings, AJC can be encountered in clinical practice in patients affected by degenerative shoulder arthropaties. Surgical excision associated with lateral end clavicle resection is a viable therapeutic option to treat an AJC in the elderly, which resulted in an appropriate treatment of the mass with no sign of recurrence after one year of follow up in the case presented.

Fistula of acromioclavicular cyst treated with a staged reverse total shoulder arthroplasty: a case report

BackgroundAcromioclavicular (AC) joint cysts are relatively rare. There are two distinct etiologies of AC cysts. Type 1 is isolated to the AC joint, while type 2, is related to a tear or rupture of the rotator cuff (RC). The disease is usually a rare result of advanced AC joint arthritis or RC-tear arthropathy. Patients may present with signs and symptoms of RC impingement and tear. Conservative management may be used initially in asymptomatic individuals who are also not concerned with cosmesis. Aspiration and steroid injection of the cyst has been reported as one method of non-surgical management of these lesions, however, there is a high rate of recurrence.Case PresentationWe report a case of A 72-year-old right-handed female with past medical history of type two diabetes mellitus, chronic smoking, and a prior right RC repair with distal clavicle resection who presented with an AC joint cyst complicated by a draining fistula as a result of cyst aspiration and steroid injection. Due to the persistent drainage of the cyst and concern for infection, the patient was treated with a staged reverse shoulder arthroplasty given the setting of an irreparable rotator cuff tear and end-stage cuff-tear arthropathy.ConclusionThis case demonstrates an important complication of persistent draining fistula resulting from AC joint cyst aspiration and steroid injection in the setting of advanced RC-tear arthropathy. In immunocompromised patients, staged reverse shoulder arthroplasty should be considered for treatment of these draining fistulas especially when the concern for periprosthetic infection is high.

Interest of arthroscopic distal clavicular resection in shoulder pain after rotator cuff repair and healing

To evaluate outcomes of secondary distal clavicle resection (DCR) in patients that had failed conservative treatment of symptomatic ACJ arthropathy following isolated rotator cuff repair (RCR) with complete tendon healing. Between 2008 and 2018, the senior surgeon performed isolated RCR in 1935 patients, of which 23 (1.2%) presented with ACJ pain and discomfort at ≥ 6 m following index RCR, despite complete healing of repaired tendons. Those 23 patients underwent secondary DCR as ACJ arthropathy was confirmed clinically and radiographically. Clinical assessment before DCR included subjective shoulder value (SSV) and pain at rest. Clinical assessment at > 12 months after DCR included SSV, pain at rest, Constant-Murley score and range of motion. Study design: case series, level III. Of the initial cohort of 23 patients, 5 were lost to follow-up, leaving 18 patients aged 53.3 ± 7.6 years (range, 39–68) for outcome assessment. None of the patients had complications or ACJ instability following DCR. At a mean follow-up of 7.0 ± 3.1 years after DCR, the SSV improved to 76.1 ± 20.2, the pain at rest decreased to 2.8 ± 1.9. At final follow-up, the Constant-Murley score was 64.7 ± 20.5. Secondary DCR for symptomatic ACJ arthropathy following isolated RCR reduced pain in only 67% of patients, though 94% were satisfied and would undergo secondary DCR again. It is worth noting that residual pain is common following RCR, which does not always restore normal shoulder function.

Rate and time to return to shooting following arthroscopic and open shoulder surgery

There is limited information on return to shooting following shoulder surgery. The purpose of this study is to determine the rate and timing for resuming shooting a rifle following shoulder surgery. We performed a retrospective review of prospectively collected data. The study included patients undergoing arthroscopic and open shoulder stabilization for unidirectional shoulder instability, and arthroscopic surgery for rotator cuff tears, SLAP lesions, biceps tendinopathy, and acromioclavicular pathology. Data collected included the laterality of surgery, shooting dominance, and patient-reported outcome measures at the preoperative and postoperative visits. Starting at the 4.5-month clinic visit, patients were asked if they could shoot a military rifle. One hundred patients were identified with arthroscopic and open shoulder surgery with a mean age of 30 years (range, 18-45) and a mean follow-up of 24 months (range, 12-32). The cohort consisted of patients undergoing arthroscopic Bankart repair (n=23), arthroscopic posterior labral repair (n=18), open Latarjet (n=16), mini-open subpectoral biceps tenodesis (OBT) (n=25), OBT with open distal clavicle resection (DCR) (n=10), open DCR (n=4), and arthroscopic rotator cuff repair with concomitant OBT (n=4). Significant improvement in SSV, VAS, ASES, and WOSI was shown at 1-year postoperative, SSV 85, VAS 2, ASES 85, WOSI 239, P=.001. The percentage of patients reporting the ability to shoot a military rifle postoperatively were 47%, 63%, 85%, and 94% at 4.5 months, 6 months, 1 year, and 2 years, respectively. At 4.5 months postoperatively, patients who underwent surgery ipsilateral to their shooting dominance (n=59) had a rate of return to shooting (33%) versus shoulder surgery on the contralateral side of shooting dominance (n=41) (60%), P=.04. However, there was no significant difference in the groups at 6 months and 1 year. Additionally, there was a significant difference in the rate of return to shooting at 6 months in patients undergoing arthroscopic posterior labral repair versus the remainder of the cohort (posterior instability (33%) vs. (69%), P=.016), and a significant difference between posterior shoulder stabilization and anterior shoulder stabilization (70%), P=.03. Patients undergoing arthroscopic and open shoulder surgery have a high rate of return to shooting. Approximately 60% of patients resume shooting at 6 months postoperatively and 85% return at 1 year. Patients undergoing shoulder surgery on the contralateral side of their shooting dominance return to shooting significantly faster than those with shoulder surgery ipsilateral to their shooting dominance. Additionally, those undergoing arthroscopic posterior shoulder stabilization return to shooting at a slower rate than anterior stabilization surgery.

Patient-reported outcomes for arthroscopic resection of the distal clavicle with concomitant arthroscopic subacromial decompression at a 2-year follow-up: a prospective study of 131 consecutive patients.

Arthroscopic distal clavicle resection (DCR) can be offered to patients with persistent acromioclavicular (AC) joint pain who do not benefit from conservative treatment. The aim of this study was to evaluate the outcome of combined arthroscopic DCR and concomitant arthroscopic subacromial decompression in a large consecutive and prospective cohort using patient-reported outcomes. Consecutive patients were identified from our online database and included based on their primary treatment code. All patients had a diagnosis of shoulder impingement syndrome and persistent AC joint pain resistant to at least six months of conservative treatment. The outcomes from the combined intervention were evaluated by patients through the Oxford Shoulder Score (OSS) questionnaire and EuroQol 5-Dimension 3-Level questionnaire, including a EuroQol visual analog scale score collected preoperatively and at a 2-year follow-up. Patient-reported satisfaction with the procedure was reported at the follow-up. Subgroups were formed to further evaluate outcome based on preoperative OSS (low, moderate, high) and age. 131 patients (75%) were available for analysis at the 2-year follow-up. Sixty seven patients (51%) were female and the mean age was 51 years (range 19-82). A mean OSS change of 12.1 (95% confidence interval, 10.3-14.0; P<.001) was observed within the entire study group. In both the low and moderate preoperative-OSS (pre-OSS) groups, a mean change of 14 was found with no difference between groups (P=.971). A mean change of 7 was found in the high pre-OSS group, which differed from both the moderate (P<.001) and low (P=.036) pre-OSS groups. A significant change in EuroQol 5-Dimension and EuroQol visual analog scale was observed within all the pre-OSS groups, and 107 patients (82%) replied that they were satisfied or very satisfied with their outcome of surgery at the follow-up. Patients who suffer from persistent AC joint pain largely benefit from arthroscopic DCR with arthroscopic subacromial decompression through relief of symptoms and improved quality of life, including those with a high self-reported and preoperative level of shoulder function.

Effectiveness of arthroscopic distal clavicle resection for symptomatic acromioclavicular joint arthritis

To investigate the effectiveness of arthroscopic distal clavicle resection for the symptomatic acromioclavicular joint arthritis. The clinical data of 14 patients with symptomatic acromioclavicular joint arthritis treated by arthroscopic indirect distal clavicle resection between January 2020 and March 2021 were retrospectively analyzed. There were 5 males and 9 females with an average age of 46.3 years (range, 18-57 years). The 4 cases of left shoulder and 10 cases of right shoulder were accompanied with acromial impingement, without the history of shoulder trauma. The average disease duration was 20.4 months (range, 9-48 months), and the average visual analogue scale (VAS) score was 7.6 (range, 5-9) preoperatively. The results were evaluated using the University of California Los Angeles (UCLA) shoulder rating score before and after operation, further, the patient satisfaction rate was also calculated. All 14 patients were followed up 5-18 months, with an average of 13 months. There was no postoperative pain of acromioclavicular joint in 12 patients; 1 case had occasional mild pain, which could be controlled by painkillers. Moreover, there was only 1 acromioclavicular joint subluxation due to early fitness training at 2 weeks postoperatively, and the symptoms gradually relieved after 1 month of conservative treatments. The UCLA score was 22.1±6.2 preoperatively, which improved to 30.2±3.4 at last follow-up, showing significant difference ( t=5.359, P<0.001). The patient satisfaction rate was 92.9%, with 12 excellent cases, 1 good case, and 1 fair case. Arthroscopic distal clavicle resection for symptomatic acromioclavicular arthritis is a safe, reliable, and repeatable procedure.

Co-occurring Acromioclavicular Joint Cyst and Hemarthrosis of the Shoulder Associated With Rotator Cuff Tear Arthropathy

Both acromioclavicular joint (ACJ) cysts and hemarthrosis of the shoulder are rare conditions of massive rotator cuff tear that eventually lead to cuff tear arthropathy. We herein report the first case of a patient with co-occurring ACJ cyst and hemarthrosis of the shoulder. An 80-year-old right-hand-dominant man presented to our outpatient department with a six-month history of repeatable right shoulder pain and swelling. Clinical examination revealed a 5 x 5 x 5 cm elastic hard or hard shoulder lump overlying the ACJ on skin with subcutaneous bleeding and swelling of the shoulder. Shoulder pain at rest and a fully reduced active range of motion (ROM), particularly in flexion and abduction, were also noted. Radiographs demonstrated moderate degeneration of the glenohumeral joint including a bone cyst of the humeral head. Magnetic resonance imaging (MRI) revealed a massive rotator cuff tear with atrophy of the supraspinatus, infraspinatus, and subscapularis muscles. The T2-weighted MRI images showed that the cyst was in direct contact with the markedly degenerated glenohumeral joint. Based on these findings, the patient was diagnosed with massive rotator cuff tear with ACJ cyst and hemarthrosis of the shoulder. The patient underwent distal clavicle resection and reverse total shoulder arthroplasty (RSA). At 12-month follow-up, the patient showed no pain symptoms, no recurrence of the cyst, and excellent ROM. We experienced a very rare case of ACJ cyst and hemarthrosis of the shoulder occurring simultaneously with rotator cuff tear arthropathy. This report is very valuable in that it suggests that RSA is useful for both ACJ cysts and hemarthrosis of the shoulders associated with rotator cuff tear arthropathy.

Nanoscopic Distal Clavicle Resection

Acromioclavicular joint pathology such as osteoarthritis has historically been treated with either an open or arthroscopic distal clavicle resection. Over the years the trend has been toward more minimally invasive treatment options with the arthroscope. In this article we highlight the use of the nanoscope to visualize the resection which can be performed through a small percutaneous incision. The advantages of this technique include the use of smaller portals, which should lead to improved earlier outcomes, and less iatrogenic damage to the shoulder.

The reverse coracoacromial ligament transfer for “horizontal” acromioclavicular joint instability

Acromioclavicular (AC) horizontal instability is a problem affecting not only young athletic patients after a trauma to the AC joint but also older patients who have undergone distal clavicle resection. It may cause pain and poor functional outcomes unless the reconstruction technique specifically addresses the horizontal instability of the clavicle, in addition to the well-known superior instability. Three cadaveric specimens underwent dissection of the AC joint capsule to determine the superior attachments of the AC joint capsule. These shoulders subsequently underwent distal clavicle resection and were loaded to a 7-kg weight in the horizontal plane. The horizontal displacement of the clavicle was measured and resection continued to the point of horizontal instability of the clavicle. Thereafter, the reverse coracoacromial ligament reconstruction technique was performed and recreation of horizontal stability assessed. Utilization of the reverse coracoacromial ligament transfer in two clinical cases will also be presented. The AC joint capsule is continuous with trapezius and deltoid insertions. The average distance between the articular surface and insertion of the capsule on the clavicle is 10 mm and on the acromion is 14.8 mm. Horizontal clavicular translation increased from 2.3 mm when intact to 3.3 mm with capsular transection, 8.7 mm with 5 mm clavicle resection, and finally 15 mm with a 10-mm clavicle resection. Horizontal instability of the clavicle was demonstrated with a 10-mm clavicle resection. Horizontal instability of the clavicle is evident with distal clavicle resection of greater than 10 mm. A reverse coracoacromial ligament transfer may be a reasonable technique to address horizontal stability of the clavicle during AC joint reconstruction in the context of painful instability.

Indirect Arthroscopic Distal Clavicle Resection: an Institutional Experience with Midterm Functional Outcome

Acromioclavicular joint arthritis is a relatively common source of shoulder pain. The treatment options consist of conservative management and operative intervention depending on the severity and duration of the disease. Distal clavicle excision is the standard operative treatment and can be performed through either open or arthroscopic techniques. The purpose of this study was to evaluate the functional outcome of arthroscopic resection of the distal clavicle. This was a prospective study, conducted in a group of 50 patients in the Post-Gra-duate Department of Orthopaedics, Govt. Medical College Srinagar, from July 2015 to July 2019 with cases followed for a minimum of 3 years. The mean UCLA score improved from 13.2 preoperatively to 29.56 at final follow-up. An excellent result was seen in 10 patients (20%), good in 34 (68%), fair in 3 (6%) and poor in 3 (6%) patients. Overall 88% of the patients achieved excellent or good results and 94% were satisfied. Persistent pain and excessive intraoperative bleeding were the most common complications in our study. 1. Distal clavicle excision through an indirect or subacromial approach is a safe and effective procedure with very few complications. 2. The subacromial approach gives the added advantage of evaluating any glenohumeral joint and subacromial pathology. 3. This procedure is associated with less pain and improved cosmesis in comparison to open procedures.

Modified technique of Indirect arthroscopic distal clavicle resection

Distal clavicle resection is an accepted surgical treatment option for unremitting acromioclavicular joint arthritis. Indirect arthroscopic approach is preferred when an additional subacromial or glenohumeral diagnostic or therapeutic procedure is contemplated. However, concomitant subacromial decompression and acromial overhang removal, which is integral to indirect approach vis-a-vis direct approach, have additional risks of stiffness and acromial fracture. A modification in indirect approach technique is demonstrated which not only reduces these risks but also improves accuracy and safety of distal clavicle resection. The pros and cons are discussed in detail with reference to relevant literature.

Arthroscopic Distal Clavicle Resection Through the Supraspinatus Fossa Portal

Disorders of the acromioclavicular (AC) joint quite often necessitate distal clavicle resection (DCR). Arthroscopic DCR is favored because of it is mini-invasive and convenient to treat concomitant intraarticular or subacromial lesions. In previous reports, arthroscopic DCR was performed through the anterior portal with the patient in beach chair position. However, when the patient is in the lateral decubitus position, it is inconvenient to perform DCR through the anterior portal. Thus, we introduce a special DCR technique through the supraspinatus fossa (SSF) portal. The critical point of this technique is viewing the acromioclavicular joint through the routine posterior portal, creating the SSF portal at the anterior edge of the scapular spine and the same medial-to-lateral level to the AC joint, and enough removal of the posterior edge of the distal clavicle. We believe the introduction of this technique will provide a special technical option when DCR is needed.