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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