Arthrosis of the Bilateral Acromial Clavicular Joints Is Again Noted
Curr Rev Musculoskelet Med. 2008 Jun; one(2): 154–160.
Surgical handling for acromioclavicular joint osteoarthritis: patient pick, surgical options, complications, and result
Salvatore Docimo, Jr.
1Anatomy and Pathology Academic Medicine Young man, New York Higher of Osteopathic Medline, One-time Westbury, NY USA
2Section of Pathology, New York College of Osteopathic Medicine, Old Westbury, NY United states of america
Dellene Kornitsky
threeNew York Higher of Osteopathic Medicine, Old Westbury, NY United states of america
Bennett Futterman
4Department of Beefcake, New York College of Osteopathic Medicine, Old Westbury, NY United states
David Due east. Elkowitz
2Department of Pathology, New York College of Osteopathic Medicine, Old Westbury, NY USA
Abstract
Osteoarthritis is i of the about common causes of pain originating from the acromioclavicular (AC) joint. An awareness of appropriate diagnostic techniques is necessary in social club to localize clinical symptoms to the AC joint. Initial treatments for Ac articulation osteoarthritis, which include non-steroidal anti-inflammatory drugs (NSAIDS) and corticosteroids, are recommended prior to surgical interventions. Distal clavicle excision, the chief surgical treatment option, can exist performed by various surgical approaches, such as open up procedures, direct arthroscopic, and indirect arthroscopic techniques. When choosing the best surgical option, factors such as avoidance of Ac ligament damage, clavicular instability, and post-operative hurting must be considered. This article examines patient choice, complications, and outcomes of surgical treatment options for AC joint osteoarthritis.
Keywords: Acromioclavicular joint, Osteoarthritis, Arthritis, Surgery, Complications, Outcomes
Introduction
Shoulder hurting has become the third almost common cause of musculoskeletal consultation in chief intendance with a prevalence of cocky-reported shoulder pain estimated to be between 16% and 26% [1]. Ane of the underlying causes of these complaints is pathology of the acromioclavicular (Ac) joint, with a prevalence much college than generally realized [2]. An analysis of 1,000 patients with shoulder pain revealed Air conditioning joint abnormalities on standard radiographs to have a prevalence of 12.seven% [iii].
Osteoarthritis, the most common cause of shoulder pain originating from the AC joint, is a frequent finding in patients older than 50 years of historic period [4]. A report demonstrated 54–57% of elderly patients have radiographic evidence of degenerative arthritis of the AC joint [5]. Evaluation of MRIs amidst asymptomatic subjects demonstrated the prevalence of AC articulation osteoarthritis to be between 48% and 82% [half dozen, 7].
The treatment of Air-conditioning joint pathology tin be difficult considering non-invasive measures frequently only provide short-term benefits. Non-steroidal anti-inflammatory drugs (NSAIDS) and corticosteroid injections take shown to ameliorate pain and function temporarily, causing patients to seek surgical handling. One report institute injection provided on an average 20 days of pain relief, with eighteen of the 27 patients (67%) seeking surgical treatment following injections [8]. A diversity of surgical treatments exist, ranging from open distal clavicle resection to directly and indirect arthroscopic surgical resection. This commodity reviews advisable evaluation of patients presenting with AC joint pain, not-surgical interventions, surgical indications, and surgical techniques.
Beefcake and pathology
The Air-conditioning joint is a diarthrodial joint between the lateral portion of the clavicle and the acromion (Fig.1). Stability of the Ac joint is facilitated by the capsule, ligaments, and intra-articular disc [9]. Capsular ligaments surround the AC joint and provide stability superiorly, inferiorly, posteriorly, and anteriorly [x]. The conoid and trapezoid ligaments, which collectively comprise the coracoclavicular ligament, span the altitude between the superior surface of the coracoid to the conoid tuberosity and trapezoid ridge of the clavicle and prevent vertical deportation of the Ac joint [11, 12] (Fig.ii). The intra-articular disc varies in size and shape and undergoes rapid degeneration, rendering it functionally picayune by the 4th decade [9].
Zanca view radiograph demonstrating the anatomy of the acromioclavicular joint. ©1999 American Academy of Orthopaedic Surgeons. Reprinted from the Periodical of the American Academy of Orthopaedic Surgeons, Volume 7 (three), pp. 176–188 with permission
Bony and ligamentous structures of the acromioclavicular joint. Image courtesy of Medical Multimedia Group LLC, www.eOrthopod.com
Primary osteoarthritis more commonly affects the AC articulation than glenohumeral joint [thirteen], while postal service-traumatic AC joint arthritis is even more prevalent due to the high incidence of injury to the joint [14]. Arthritic symptoms accept been demonstrated in Grade I and II sprains of the AC articulation in 8% and 42% of patients, respectively [fifteen, sixteen].
Failure or absence of the intra-articular disc probable contributes to the high rate of early degenerative changes seen in the Air-conditioning joint [17]. The intra-articular disc is shown to begin its natural progression of degeneration as early as the second decade of life [xviii]. High centric loads transferred through the small surface area of the Air conditioning joint, which has an boilerplate articulation size of 9 × xix mm in an adult, may place high stresses on the articular surface causing failure, such as osteoarthritis or osteolysis, among weightlifters [eleven]. High axial loads, when compounded with a degenerated or absent intra-articular disc, are even more probable to crusade osteoarthritis.
Patient presentation and evaluation
A study of 21 male and 35 female patients with AC joint osteoarthritis found shoulder hurting presented during the ages of 53–55 years with less than fifty% of these patients reporting a history of trauma [19]. Patients frequently present with an intact range of motion with the exception of cross-body adduction, behind the back motions, and overhead reaching, which all produce pain localized to the Ac joint [xiii, 17, xx]. All the same, pain to the deltoid area upon cantankerous-body adduction has also been noted and is likely caused by irritation of the underlying subacromial bursa past inferiorly projecting osteophytes of the Air conditioning articulation [17] (Fig.three).
Schematic demonstration the presentation of acromioclavicular osteoarthritis and location of osteophytes. Image courtesy of Medical Multimedia Group LLC, world wide web.eOrthopod.com
In addition to osteoarthritis, the differential diagnosis of AC joint pain includes calcific tendonitis, glenohumeral arthritis, adhesive capsulitis, and rotator cuff impingement syndrome [17]. Authentic diagnosis and localization of pathology to the AC articulation is vital in determining the correct treatment protocol in order to avoid persistent shoulder hurting. Upon concrete examination, the Air conditioning joint may be tender to palpation [21]. Pain elicited past the motion of forward flexion to xc° with horizontal adduction (cross-over test) or directly-ahead pushing (equally in the bench press practice) farther suggests Air conditioning joint involvement [22] (Fig.4).
The cross-over adduction test is performed by the motion of forward flexion to 90° with horizontal adduction of the arm across the chest. Reproducible pain over the joint suggests Ac joint involvement. ©1999 American Academy of Orthopaedic Surgeons. Reprinted from the Journal of the American Academy of Orthopaedic Surgeons, Volume vii (three), pp. 176–188 with permission
Acromioclavicular joint interest tin can exist confirmed past an injection of a local anesthetic. Injection of 0.5–2 mL of one% or 2% lidocaine or 0.5 mL of 0.25 or 0.5% bupivacaine into the Air conditioning articulation should provide a significant reduction in symptoms [21]. A continuation of pain following coldhearted injection suggests other shoulder pathologies, most commonly rotator gage injury [14] due to the close proximity of the Air-conditioning articulation to the subacromial bursa and rotator gage [17]. Another diagnostic method to confirm the location of a pathological process involving the Air conditioning joint is injection of five mL of 1% lidocaine into the subacromial space, with persistence of AC joint pain following the injection [21].
Radiographs are the initial diagnostic imaging modality of choice [23], with anterior-posterior views demonstrating degenerative changes, subchondral cysts, sclerosis, osteophytes, and joint-space narrowing [17]. The Zanca view, which consists of angling the X-ray source 10–15° superiorly and decreasing the kilovoltage to fifty% standard exposure [17], is helpful in evaluating AC articulation pathology by allowing visualization of distally projecting osteophytes of the acromion [14] (Fig.5). Computed tomography is preferred when evaluating arthritic osseous changes of the AC joint such as joint narrowing, erosions, and subchondral cysts [14, 23]. Magnetic resonance imaging has the ability to detect capsular hypertrophy, effusions, and subchondral edema [17]. A comparison of MRI findings of the Air-conditioning joint in symptomatic and asymptomatic patients correlates edema of the distal clavicle with the presence of symptoms [24]. Though ultrasound can be used to find the presence of AC joint effusions, information technology cannot differentiate betwixt effusions due to acute inflammatory processes versus degenerative changes [25], thus rendering it less effective in the evaluation of AC joint pathology [17].
The Zanca view of the AC joint, which is obtained by angling the X-ray source 10–15° superiorly and decreasing the kilovoltage to 50% standard exposure, is helpful in evaluating Ac joint pathology such every bit distally projecting osteophytes. ©1999 American University of Orthopaedic Surgeons. Reprinted from the Journal of the American University of Orthopaedic Surgeons, Volume 7 (3), pp. 176–188 with permission
Non-surgical treatments
Initial handling of Ac joint arthritis is not-operative and includes activeness modification, physical therapy, not-steriodal anti-inflammatory medications (NSAIDs), and local Air conditioning joint injection of anesthetics or corticosteroids [26]. Activity modification includes avoidance of repetitive motions causing the pain, such equally push button-ups, dips, flies, and bench press exercises [17]. Physical therapy would include exercises to maintain active range of motion and increase muscle strength for scapular stabilization [26]. However, concrete therapy is not as constructive for AC joint arthritis as it is for rotator gage illness [27].
Corticosteroid injection into the AC joint is warranted following previous failed trials of NSAIDs and activeness modification, and as well if a diagnostic local anesthetic injection provides relief. The AC joint can be located past first palpating the soft spot where the clavicle and spine of the scapula meet and so moving slightly inductive [27]. The skin is anesthetized and the needle is inserted into the joint-space using a superior approach and moved inferiorly until a decrease in resistance is felt as the needle enters the capsule [14]. Injections of 0.25–0.five mL of betamethasone sodium phosphate and acetate or 0.25–0.five mL methylprednisolone, 40 mg/mL are recommended [17]. Limits of two to four injections per yr with a total of twenty [17, 21] are recommended, as excessive corticosteroid administration may crusade subcutaneous fat atrophy and dermal thinning [28].
In some cases the pain relief afforded by corticosteroid injection may be short in duration. Jacob and Sallay [8] followed 31 patients diagnosed with Air conditioning articulation arthropathy and concluded Ac joint corticosteroid injection offered brusk-term pain relief simply did not alter natural disease progression. The 31 patients received 1 mL of Celestone/Soluspan or dexamethasone and two mL of lidocaine injections. Of the 31 patients four were excluded from the study every bit they were lost to follow-upward. The mean elapsing of improvement was 20 days, as reported by patients, with a range of ii h to three months. Of the 27 patients eighteen underwent distal clavicle resection at an average of 4 months postinjection. Only 5 of the remaining nine patients were considered to take had long-term therapeutic benefit from the injections. Of the 31 patients with Air conditioning joint arthropathy who received corticosteroid injection, 93% reported improvement in pain and office, 81% failed to obtain long-term results, and 67% underwent distal clavicle resection. Though osteoarthritis is considered a non-inflammatory process, recent evidence demonstrates a likely inflammatory component [17] which suggests corticosteroids should play a role in treatment.
Surgical treatments
Treatment selection
Surgical handling options become credible one time all non-invasive treatment modalities have failed to provide adequate pain relief and persistent symptoms go on to interfere with activities of daily living [17, 26]. At least 6 months of conservative treatment should be attempted before surgery [17]. Variables such equally patient occupation, historic period, caste of activeness limitation, shoulder dominance, and patient goals should be considered by both patient and physician before a decision apropos surgical treatment is made [14].
Distal clavicle excision, which prevents abutment of the distal clavicle confronting the medial acromion [22], is the mainstay of surgical treatment for Air-conditioning joint arthritis [26] (Fig.6). Various surgical techniques, such equally an open approach or direct and indirect arthroscopic approaches, are available. The open up technique often utilizes a 3- to v-cm transverse or perpendicular saber skin incision with division of the deltotrapezial fascia. An oscillating saw is used to excise a 1- to two-cm portion of the distal clavicle [26].
Post-operative Zanca radiograph post-obit arthroscopic distal clavicle resection. Epitome courtesy of Gregory North. Lervick, Dr., Minnesota Sports Medicine
The direct, or superior, arthroscopic technique utilizes a bursal-sparing approach, requiring a 2.7-mm arthroscope and mechanized burr to begin excision and a larger four-mm arthroscope and instruments to complete the process [29]. This approach is ideal for patients with isolated AC joint pathology where exploration of the subacromial space is not required [22].
The indirect, or bursal, arthroscopic technique requires a bursectomy for visualization of the Air-conditioning joint [26]. Because nearly patients with Air conditioning joint pathology also suffer from some degree of impingement and subacromial pathology, the indirect approach becomes the more popular surgical choice [22]. This approach can exist used for distal clavicle excision merely, or in combination with acromioplasty and/or subacromial decompression, or rotator cuff repair [26, 29, xxx]. An indirect technique also reduces the risk of post-operative instability of the clavicle by preserving the superior Air conditioning ligaments [22].
Complications
In an attempt to classify the complications of Air-conditioning joint resection, Basmania et al. [31] performed an assay of 42 patients who underwent open distal clavicle resection and determined inadequate resection, diagnostic errors, joint instability, and weakness deemed for the majority of problems. These complications take also been reported in arthroscopic techniques and are not limited to the open procedure [14].
Inadequate resection of the distal clavicle is also a common cause of persistent pain post-operatively [14]. Neer [32] reported inadequate resection of the posterior attribute of the distal clavicle during arthroscopic procedures tin can cause abutment with the acromion leading to pain. Inadequate resection is not a common complication of the open technique [33].
Diagnostic mistake plays a role in postoperative complications if Air-conditioning joint pathology is merely a partial contributing factor to a patient's shoulder pain. A diagnosis isolating the Air-conditioning joint equally the sole crusade of shoulder hurting is necessary before proceeding with a surgical treatment. Nuber and Bowen [22] land a lidocaine injection into the AC articulation with 100% resolution tin can ensure a localized Air-conditioning joint pathology. If pathology beyond the Air-conditioning joint is suspected, the indirect arthroscopic technique can be utilized to allow a more than thorough examination of the glenohumeral articulation and subacromial space.
Joint instability can occur post-obit damage to the superior and posterior portions of the Air-conditioning ligaments which provide the maximum restraint to posterior motility of the clavicle [34]. Blazar et al. [35] noted inductive–posterior move of the clavicle was increased by an average of v.5 mm, compared to a normal shoulder, following both open and arthroscopic techniques. Nuber and Bowen [22] state resection of larger amounts of the distal clavicle may disrupt the Ac ligaments causing horizontal instability of the clavicle with abutment against the spine of the clavicle. Surgical approaches, such as the indirect arthroscopic technique, will avoid the more superior portions of the AC ligament and reduce the adventure of articulation instability.
Weakness of the shoulder following distal clavicle resection has been varied. Resultant weakness following an open technique, according to Shaffer [14], is due to the reattachment of the deltoid and trapezius muscles. Cook and Tibone [36] attribute the lack of strength to AC ligament injury. Martin et al. [37] found no weakness among 29 shoulders examined following indirect distal clavicle resection.
Outcomes
Patients are supported in a sling for a few days following both open up and arthroscopic surgical techniques. Postal service-operative concrete therapy with assisted exercises may brainstorm within 2–5 days later on surgery. While recovery fourth dimension varies, patients can look to render to activities within 2–3 months [22].
Literature demonstrates the open up distal clavicle resection has yielded a return of 50–100% practiced or positive results, with an average of 76.3% [26]. Eskola et al. [38] found 72% of 73 patients who underwent an open technique to have had "good" or "satisfactory" results. Slawski and Cahill [39] study a 100% satisfaction rate among 17 patients who underwent open distal clavicle excision for non-traumatic osteolysis.
An evaluation of 50 indirect distal clavicle resections performed by Snyder et al. [40] demonstrated the average amount of clavicle resection was 14.eight mm, with 47 patients (94%) reporting skillful to fantabulous results, 3 patients (vi%) reporting fair results, and 98% of patients reporting they were satisfied with the procedure. In an evaluation of 41 patients who underwent direct arthroscopic distal clavicle resection by Zawadsky et al. [41], 22 cases (54%) demonstrated fantabulous results, 16 (39%) good results, and 3 (7%) poor results due to continued instability of the distal clavicle. The written report proposed a distal clavicular resection of 4–7 mm could yield proficient results.
Summary
The prominence of complaints related to shoulder pain demands an increased understanding of all clinical aspects related to the Air conditioning articulation. Awareness of appropriate diagnostic techniques is necessary in localizing pathology to the Air-conditioning articulation. In the initial stages of treatment for Air conditioning joint osteoarthritis, attempts at non-surgical treatment modalities are recommended. All decisions regarding surgical intervention should (1) take place following the failure of non-surgical treatment options and (ii) take into account the demand for farther diagnostic evaluation. The open and direct techniques are both ideal for patients with isolated AC joint pathology where exploration of the subacromial space is not required, whereas the indirect arthroscopic approach can provide further evaluation of the subacromial space and an increased flexibility if further surgical repair beyond the Air-conditioning articulation is needed. Surgical complications, such as weakness of the deltoid and trapezius muscles and clavicular instability, should too exist considered prior to deciding on the all-time surgical approach.
Contributor Data
Salvatore Docimo, Jr., Phone: +1-203-5548114, Email: ude.tiyn@omicods.
Dellene Kornitsky, Email: ude.tiyn@stinrokd.
Bennett Futterman, Email: ude.tiyn@mrettufb.
David E. Elkowitz, Email: ude.tiyn@tiwokled.
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Articles from Current Reviews in Musculoskeletal Medicine are provided here courtesy of Humana Press
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684214/
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