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Open Excision of Distal Clavicle

This is a useful technique to be able to offer to patients with a acromioclavicular joint pain secondary to degenerative change.  Isolated acromioclavicular joint pain is quite common and can vary in severity, from being either a minor inconvenience to interfering significantly with work, sport and leisure activities and in particular sleep. 

The clavicle is one of the last bones to fully ossify in the human skeleton and almost as soon as it has done so there is propensity for it to degenerate at either the medial sternoclavicular joint or more commonly at the lateral acromioclavicular joint.  The onset of pain in the acromioclavicular joint can be insidious or maybe as a result of minor trauma such as a grade 1 or a grade 2 sprain, which comes about as a fall directly on to the point of the shoulder or a direct blow to the acromioclavicular joint.

It has been documented that approximately 30% of the population have an intra-articular disc of soft tissue similar to a knee meniscal cartilage within the acromioclavicular joint.  If this were to be damaged, then that can also be a cause of persistent pain and disability. 

Once a diagnosis of acromioclavicular joint pain has been established then simple conservative measures should be recommended in the first instance.  If non-operative measures have been exhausted and the patient has persistent pain, then consideration should be given to excision arthroplasty of the acromioclavicular joint with removal of the joint contents and resection of the distal clavicle articular facet. This is also known as the Mumford procedure after an early description published in 1941.  The cavity then fills with scar tissue and generally the patient’s symptoms are greatly improved quite quickly.  The open technique described here is relatively quick, straightforward and successful.

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- See: Distal Clavicle Excision - main discussion

Discussion:
     - consider excising only 1 cm of the distal clavicle;
- excision of the distal 1.5-2.0 cm of the clavicle ensures that impingement will not occur (excision of this fragment may cut trapezoid ligament);
- the remaining conoid ligament is sufficient to anchor the distal clavicle to the coracoid process;
- however, as pointed out by Eskola, et al (1996), excision of more than 1 cm of the distal clavicle was more often associated with pain;
- with the excision of only a small segment of the distal clavicle and with the time, the distal clavicle may develop a spur;
- in the report by Martin SD, et al, the authors evaluated the surgical results in 31 consecutive patients (32 shoulders) with AC pathology with concomitant subacromial impingement;
- mean age of the patients at the time of surgery was thirty-six years (range, 18 to 67 years).
- 25 patients, including four professional athletes, were actively involved in sports activities;
- mean duration of follow-up was four years and ten months (range, three to eight years).
- of 25 patients who participated in sports, 22 (including the four professional athletes) returned to their previous level of sports activity;
- 26 patients had no pain, three reported mild pain on strenuous repetitive overhead activity, two (both weight-lifters) had occasional pain in the AC joint and the lateral aspect of the shoulder with bench-pressing, and two (both baseball players) had mild pain in the posterior aspect of the shoulder with throwing;
- all of the patients were satisfied with the results;
- no patient had superior migration of the clavicle;
- amount of distal clavicular resection averaged 9 mm (range, 7 to 15 mm).
- 5 patients had calcification at the anterior deltoid insertion into the acromion that was asymptomatic, with no impingement on overhead activity and no pain on direct palpation;
- Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression.
           - The results of operative resection of the lateral end of the clavicle.


- Distal clavicular excision: a detailed functional assessment

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Resection of the lateral end of the clavicle. A 3 to 30-year follow-up