Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Arthroscopic Distal Clavicle Excision

- Discussion:
    - general discussion: clinical and radiographic findings
    - in contrast to open excision, arthroscopic excision allows preservation of the superior AC capsular ligaments;
    - stability of the AC joint comes from capsular ligaments (anterior, posterior, superior, and inferior)
    - capsular ligaments provide anteroposterior (horizontal) stability of the distal clavicle;
    - superior AC ligament is the strongest and is confluent with the fascial attachments of the deltoid and trapezius muscles;
    - cautions:
            - higher incidence of failure has been demonstrated in patients with prior AC joint instability (i.e., previous type II AC separation).
    - ref: Open versus arthroscopic distal clavicle resection

    - Surgical Technique: Arthroscopic Excision:
acromioclavicular joint is identified with an 18-gauge spinal needle passed from above the joint
            - need to visualize the superior aspect of the joint because of the overhanging acromion (which is difficult even after acromioplasty)
            - anterior portal is modified to come in directly perpendicular to the AC joint;
            - soft-tissue shaverwas is used to remove all fibrous tissue from the medial border of the acromion and acromioclavicular joint region;
            - burr is used to gently remove the inferomedial edge of the acromion and the associated joint capsule;
            - it is helpful at this point to removal a small even row of distal clavicle (inferior edge) from front to back;
            - this helps arthroscopic orientation when the scope is switched to the lateral portal;
            - arthroscope is introduced into the bursa from the lateral portal (allows more direct view of the acromioclavicular joint region);
            - about 5 mm of resection is optimal;
                     - ref: Sequential Resection of the Distal Clavicle and Its Effects on Horizontal Acromioclavicular Joint Translation
            - manually depress distal aspect of clavicle during resection inorder to optimize exposure;
            - outline the tip of the clavicle frequently with a cautery device as the clavicle is being resected medially (to address periosteal vessels);
            - resection begins anterior and then works toward the posterior aspect of the joint
            - caution: common technical error is inadequate visualization and resection of the posterior clavicle  
                     - power burr can be introduced from the posterior portal to facilitate resection of posterior distal clavicle;
            - degree of distal clavicle excision - only requires 5-7 mm of distal excision (prevents bone to bone contact with rotation of the scapula)
                     - ref: Arthroscopic distal clavicle resection: a biomechanical analysis of resection length and joint compliance in a cadaveric model.
            - consider postoperative radiograph to document the intial postoperative appearance (due to the occurence of post op HO);
            - references:
                         - Arthroscopic distal clavicle excision. Technique and early results
                         - Our technique for the arthroscopic Mumford procedure
                         - Arthroscopic versus open acromioplasty: a prospective, randomized, blinded study
                         - Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression.
                         - Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial.
                         - Arthroscopic distal clavicle resection from a bursal approach.
                         - Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression.
                         - The Biomechanical Stability of Distal Clavicle Excision Versus Symmetric Acromioclavicular Joint Resection
                         - Sequential Resection of the Distal Clavicle and Its Effects on Horizontal Acromioclavicular Joint Translation 

    - Coplaning of the AC joint:
             - references:
                   - Coplaning of the acromioclavicular joint.
                   - Long-term results of acromioclavicular joint coplaning.
                   - Midterm results of arthroscopic co-planing of the acromioclavicular joint.
                   - Acromioclavicular stability: a biomechanical comparison of acromioplasty to acromioplasty with coplaning of the distal clavicle.

- Complications:
     - The evaluation and management of failed distal clavicle excision.
     - Incidence of acromioclavicular joint complications after arthroscopic subacromial decompression.  
     - Reossification and fusion across the acromioclavicular joint after arthroscopic acromioplasty and distal clavicle resection

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, January 15, 2013 10:23 am

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