Arthroscopic Acromioplasty and the Distal Clavicle, All in One’
Abstract & Commentary
Synopsis: A retrospective review of 31 consecutive patients undergoing simultaneous arthroscopic distal clavicle excision and concomitant acromioplasty shows remarkably good results with all patients satisfied with their surgery and 22 of 25 athletes returning to overhead sport activity.
Source: Martin SD, et al. Arthroscopic resection of the distal aspect of the clavicle with concomitant subacromial decompression. J Bone Joint Surg. 2001;83-A(3):328-335.
This study documents the functional outcome associated with the arthroscopic approach to the symptomatic AC joint in the presence of subacromial impingement. The patients were reviewed from 1988 to 1991 during which 241 subacromial decompressions were performed by Martin and colleagues. Thirty-nine (or 16%) of these 241 patients underwent a concomitant arthroscopic distal clavicle excision and made up the initial database for this study. Seven patients were lost to follow-up, leaving 32 patients to be included in the retrospective review. The study used only simplistic measures of shoulder symptomatology and patients were specifically asked whether they were satisfied with the result, whether shoulder function had returned to its previous level, and whether they would have the procedure again. Functional strength testing showed no difference in strength between the involved and uninvolved shoulders postsurgery, but time to testing was not clearly identified. No outcome-measurement tools were used, nor were numeric pain scales such as the visual analog scale used. Preoperative and postoperative radiographs were used and showed evidence of hypertrophic ossification in 1 patient with mild pain on direct palpation of the AC joint. No superior migration of the clavicle was noted in any of the patients. The mean amount of distal clavicular resection was 9 mm (range, 7-15) on radiographic evaluation.
Their technique for such a demanding arthroscopic procedure begins with a routine shoulder EUA and glenohumeral arthroscopy in the lateral decubitus position using an arthroscopic pump. Once glenohumeral pathology was corrected (10 partial cuff and 2 SLAP tears requiring debridement were noted), the subacromial space was entered with the 30° scope posteriorly. The lateral portal was used for acromial spur decompression to the coronal level of the anterior edge of the distal aspect of the clavicle. Once the undersurface of the distal clavicle was burred level with the subacromial decompression through the lateral portal, the 5.5 mm burr was then switched to the anterior portal, while a 70° scope was placed through the posterior portal to allow improved upward visualization of the AC joint. Exposure was enhanced by depressing the distal clavicle manually during resection and switching the scope to the lateral portal for a more direct view of the distal clavicle excision.
Comment by Robert C. Schenck, Jr., MD
Little controversy remains over clinical decision-making in the management of the AC joint in conjunction with symptoms of impingement. If the AC joint is asymptomatic, it should be left untouched, or as Martin et al recommend, only the osseous excrescences on the undersurface of the joint need be removed. In addition, exact delineation of symptoms attributable to the AC joint should be made with specific radiographs of the joint (50% underpenetrance with a 10° cephalic tilt on AP radiographs), tenderness on direct palpation, tenderness on cross arm adduction, and a diagnostic lidocaine injection (which was performed in 28 of the 29 patients treated by Martin et al and was positive in all 28). Routine treatment of an asymptomatic AC joint has been shown to decrease the overall success rate of an acromioplasty in the management of impingement syndrome. Once the decision is made to proceed with both the distal clavicle and anterior acromial pathology, the surgical approach is varied and ranges from all open to combined approaches (arthroscopic acromioplasty and open distal clavicle excision) to this reviewed technique (arthroscopic distal clavicle excision and concomitant arthroscopic acromioplasty). Nonetheless, one advantage of an open distal clavicle excision lies in the ability to test for impingement in the resected joint in cross-arm adduction, which also allows for palpation of the undersurface of the completed acromioplasty.
I found the technical aspects of the paper very useful and was pleasantly surprised to find it published in the Journal of Bone and Joint Surgery. Use of Martin et al’s stepwise technique can be applied to the beach chair position, which is more convenient for the routine shoulder arthroscopy. I would caution that the learning curve for this combined approach will be surgeon-dependent, and I would recommend having the patient in the beach chair position for a straightforward conversion to an open distal clavicle excision for the first 10-20 patients. The orthopaedic surgeon should monitor fluid extravasation and surgical time in determining the need for abandoning an all-arthroscopic approach while gaining experience. Certainly, this all-arthroscopic approach is the "next level," but the surgeon should be cautioned to ensure that an adequate decompression of the distal clavicle, especially posteriorly, is performed.
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