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Distal Clavicle Excision: Clinical and Radiographic Findings:

- Clinical Findings:
      - patients may note pain with activities that occur in adduction (golf back swing);
      - local tenderness to palpation and to hyper-adduction;
      - trapezial spasm;
      - patients will often note pain located posterior to the AC joint;
      - steroid-lidocaine injection:
            - remember that AC joint injections are often a difficult "stick" and are often painful;
            - if dx is in question, consider a subacromial lidocaine-steroid injection;
            - if the patient does not receive relief from the subacromial injection, then AC joint arthrosis is a more likely diagnosis; 
            - references:
                  - Diagnostic value of physical tests for isolated chronic acromioclavicular lesions
                  - Diagnostic values of tests for acromioclavicular joint pain.
                  - Therapeutic efficacy of corticosteroid injections in the acromioclavicular joint.
                  - The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. 
                  - Intra-Articular Versus Periarticular Acromioclavicular Joint Injection: A Multicenter, Prospective, Randomized, Controlled Trial

- cautions:
       -
be sure to consider a slap tear or biceps tendonitis in the differential diagnosis;
       - reference: The SLAP lesion: A cause of failure after distal clavicle resection

- Radiographs: (Zanca view):
        - AC joint subluxation;
        - narrowing of the joint space w/ sclerosis of distal end of the clavicle;
        - inferior osteophytes;
        - in some cases distal clavicular resorption may be present, which might indicate RA, scleroderma, or which may occur in weight lifters); 

- MRI:
        - reactive bone edema on MRI is most reliable predictor of symptomatic AC pathology than degenerative changes seen on MRI
        - other findings include caudal osteophytes, capsular hypertrophy, and subchondral cysts;
        - in the study by Stein et al, the authors sought to detection of AC joint pathology in asymptomatic shoulders with magnetic resonance imaging;
        - ACJ arthritic changes were graded on a scale from 1 to 4 (none, mild, moderate, and severe), based on the amount of subacromial fat effacement,
                  joint space narrowing, irregularity, capsular distension, and osteophyte formation;
        - 41 (82%) of 50 shoulders had abnormalities consistent with arthritis on MRI;
        - references:
                -
A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients. 
                - Atraumatic osteolysis of the distal clavicle: MR findings
                - Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging.
                - A comparison of magnetic resonance imaging findings of the acromioclavicular joint in symptomatic versus asymptomatic patients.
                - Increased T2 signal intensity in the distal clavicle: incidence and clinical implications.
                - MRI features of the acromioclavicular joint that predict pain relief from intraarticular injection.
                - The MRI geyser sign: acromioclavicular joint cysts in the setting of a chronic rotator cuff tear

- Indications For Excision:
         - pts w/ incomplete AC separation (type I & II) who develop degenerative changes & persistant symptoms may require excision of distal clavicle;
         - references:
                 - The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty.
                 - The management of acromioclavicular joint osteoarthrosis: débride, resect, or leave it alone.

- Contra-indications:
          - it is inappropriate to excise the distal clavicle in chronic type III, IV, V or VI AC separations;
          - this may increase the patients symptoms, by converting a displaced long clavicle, into a short displaced clavicle; 

- references:
        - Arthroscopic resection of the distal clavicle with a superior approach
        - Sequential Resection of the Distal Clavicle and Its Effects on Horizontal Acromioclavicular Joint Translation