Article

The effects of arthroscopic acromioplasty on the acromioclavicular joint

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Abstract

Thirty patients with 31 shoulders underwent clinical and radiologic evaluation 5 to 6 years after arthroscopic acromioplasty. The mean age was 51 years. The acromioclavicular (AC) joint was assessed for tenderness on palpation and pain on horizontal adduction of the shoulder. All patients underwent a radiologic examination consisting of an anteroposterior view of the AC joint and bilateral stress views. No patient had superior translation or widening of more than 1 mm of the AC joint on stress views on the unoperated side. On the operated side 12 (38%) shoulders showed signs of instability consisting of a superior translation of the clavicle of 2 to 3 mm, distraction on weight bearing view, or both. No severely osteoarthritic AC joint (grade 3 or 4) was unstable. The degree of osteoarthritis did not differ for both shoulders, suggesting that arthroscopic acromioplasty does not accelerate osteoarthritic change in the AC joint but can induce instability. Nine patients had tenderness over the AC joint and instability on stress views. They had a significantly reduced University of California Los Angeles score of 25 +/- 5 compared with the other patients (29.5 +/- 7). We conclude that preservation of the inferior capsule during arthroscopic acromioplasty is important for the integrity of the AC joint in patients without severe osteoarthritic changes.

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... Resection of as little as 5 mm of distal clavicle reduces AC joint stiffness in cadaveric models. 6,14 Clinically, violation of the AC joint leads to radiographic instability in up to 38% of patients, 15 residual symptoms in up to 40% of patients, 8 and a poor outcome in up to 13% of patients. 17 DCE also extends surgical time, may involve additional portals, and requires the introduction of additional instruments and debris into the subacromial space, which could increase infection rates or postoperative pain. ...
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Background Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident. Purpose To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR. Study Design Case-control study; Level of evidence, 3. Methods The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision. Results In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery. Conclusion This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered.
... [14] The common finding is that the coplaning may disrupt the AC joint capsule and the joint may become unstable. [6,8,[15][16][17][18] Resection of a big portion of the joint capsule may likely result in increase of the movement. Destabilization of the AC joint would make it possible for future arthritis of the joint with symptoms. ...
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BACKGROUND: Coplaning means the removal of medial acromial spurs and inferior aspect of the distal clavicle. The aim of the study was to evaluate the outcomes of arthroscopic acromioplasty with and without coplaning in patients without acromioclavicular (AC) joint arthritis. METHODS: Because of impingement syndrome, arthroscopic subacromial decompression and acromioplasty was performed in Group 1 (9 males/31 female). In addition, coplaning was performed in Group 2 (8 males/21 females) by two different surgeons. The mean age was 48 in Group 1, 46 in Group 2. The mean follow-up was 50 months and 44 months, respectively. RESULTS: Constant score, cross-body adduction test and AC joint tenderness was used for follow-up. The mean preoperative Constant scores were 45 points (range: 34–76 points) in Group 1, 39 points (range: 32–69 points) in Group 2. The mean Constant scores at the latest follow-up was 78 points (range: 68–100 points) for Group 1, 84 points (range: 72–100 points) for Group 2. There was no statistically difference between two groups at the latest follow-up (p<0.05). In two patients in Group 2, cross-body adduction test was positive but asymptomatic. CONCLUSION: Excision of the inferior side of the lateral clavicle to the level of the acromion with minimal disruption of the joint capsule does not develop AC joint symptoms in long-term follow-up.
... Most cases of progressive, degenerative disease of the AC joint remain asymptomatic [14]. Despite these findings, some authors believe that subclinical osteophytes at the inferior surface of the shoulder joint can mechanically damage RC tendons, ultimately causing them to break [11,15,16]. However, resection of an asymptomatic AC joint is not routinely performed during RC repair [4,5,7]. ...
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Background: Rotator cuff (RC) tear is one of the most common disorders affecting the shoulder. Acromioclavicular (AC) joint arthritis is an equally common pathology of the shoulder. The coexistence of both disorders is common, although RC tear is more frequently the cause of shoulder pain than AC joint arthritis. The purpose of this study was to compare the results of arthroscopic treatment of RC tear and simultaneous resection of symptomatic AC joint with arthritis. Material/methods: We retrospectively evaluated 40 patients who underwent arthroscopic RC repair between January 2008 and December 2009. Patients were divided into two groups. The first group consisted of 20 patients with symptomatic arthritis of AC joint, specifically painful joint palpation test and painful cross-body adduction test. The control group included 20 patients with asymptomatic degenerative changes of AC joint. The first group of patients underwent RC resection and AC joint repair; the second group had an isolated RC repair. Follow-up period lasted from 44 to 68 months, an average of 54.4 months. Results: Analysis using chi-squared test for independence has shown no statistically significant difference in terms of subjects' gender or age in both groups. No significant difference in terms of pain intensity (VAS) was observed before and after surgery in either group. Significant reduction in pain intensity after surgery was observed in both groups, the AC joint resection group (p<0.001) and the without joint resection group (p<0.001). An increase in Constant's scale score was recorded in both groups after the surgery. Analysis has shown that patients who had undergone AC joint resection, had lower scores on a Constant's scale (p<0.022) before the surgery than those who were not resected. There were no statistically significant differences between the two groups after the surgery. Conclusions: Supplementary resection of a painful AC joint with arthritis during RC tear repair provides good, long-term outcomes. In contrast to patients with asymptomatic AC joint arthritis, the coexistence of a torn RC and symptomatic AC joint with arthritis, can worsen shoulder function in the preoperative period.
... Además del riesgo de hematoma, sobre todo en caso se asociación con una resección del centímetro externo de la clavícula, las lisis radiológicas del extremo distal de la clavícula [21] , cuya evolución por regla general es favorable, el postoperatorio se puede ver marcado por: • el desarrollo de un edema global del hombro que le da a este un aspecto «seudoatlético» que se relaciona con la extravasación en el tejido subcutáneo del líquido de lavado; generalmente la evolución es favorable en algunos días; • el síndrome de dolor regional complejo de tipo 1 (SDRC de tipo 1) o capsulitis retráctil, que se caracteriza por la instauración postoperatoria de rigidez progresiva, acompañada de una exacerbación del dolor y una disminución de la rotación lateral del hombro en posición E1. Este síndrome corresponde al antiguo «síndrome algodistrófico» postoperatorio, y se observa en el 5-10% de los casos, por lo que es indispensable prevenir al paciente en el marco de la información preoperatoria de la existencia de esta complicación. ...
Article
Resumen La bóveda acromiocoracoidea presenta relaciones anatómicas estrechas con el manguito de los rotadores. Neer describió en 1972 el conflicto (impingement syndrome) entre la parte anterior del acromion y el manguito de los rotadores (supraespinoso). Así, el acromion se considera como el factor extrínseco responsable de rupturas de los tendones del manguito. Entonces se describió la acromioplastia anteroinferior. Esto permite reducir el conflicto subacromial en caso de un pico acromial importante e igualmente puede permitir aumentar el espacio de trabajo durante una reparación concomitante del manguito de los rotadores. En caso de artrosis acromioclavicular con un voluminoso osteofito inferior, se puede considerar una resección parcial de la articulación acromioclavicular (coplaning). Si esta artrosis es sintomática, podría estar indicada también una resección del cuarto externo de la clavícula. En un principio, la técnica de acromioplastia se describió a cielo abierto pero en la actualidad se realiza casi exclusivamente bajo artroscopia, para respetar mejor la capa deltoidea. Por último, el reciente concepto del critical shoulder angle puede motivar la realización de una acromioplastia lateral para disminuir este ángulo y reducir así las fuerzas de compresión de los tendones del manguito contra la bóveda acromial.
Article
The past year has seen numerous important developments relating to the rotator cuff. The traditional view that tendon failure results from subacromial space compression has been reevaluated. The function of the rotator cuff as a dynamic stabilizer is becoming better understood. Arthroscopy is being used more extensively in surgical management of impingement and tears of the rotator cuff. Curr Opin Orthop 1999, 10:289-293 © 1999 Lippincott Williams & Wilkins, Inc.
Article
Coplaning removes medial acromial spurs and portions of the distal clavicle with an arthroscopic subacromial decompression (ASD). Concerns exist that this violates inferior acromioclavicular (AC) ligaments and increases AC joint mobility, resulting in long-term problems. The purpose of this study was to re-evaluate 3 cohorts of patients who underwent ASD with various degrees of coplaning and to determine if late AC joint tenderness or reoperation had occurred. Nonrandomized control study. Eighty-one patients undergoing ASD were divided into 3 groups. Group 1 (24) underwent removal of inferior clavicle osteophytes, group 2 (34) had a distal clavicle hemiresection with up to 50% of the articular cartilage removed, and group 3 (23) had complete distal clavicle resection. Radiographs, charts, and arthroscopic videotapes were reviewed to determine the amount of clavicle removed. Follow-up evaluations included Constant-Murley, American Shoulder and Elbow Surgeons (ASES), SANE, and Rowe shoulder scores with special attention given to AC joint pain and additional procedures. The average patient age was 46 years (range, 19 to 81 years) and follow-up was 73 months. At follow-up, the average Constant, ASES, Row, and SANE scores were: for group 1, 97.1, 97.5, 96.9, and 95.8, respectively; for group 2, 95.1, 97.4, 96, and 92.8, respectively; and for group 3, 96.3, 98.3, 96.1, and 95.7. No patient required additional shoulder surgery. Coplaning did not increase AC joint symptoms, compromise clinical results, or lead to additional surgery at an average follow-up of 6 years. Level IV, therapeutic case series study.
Article
Shoulder pain is a frequent presenting complaint to physiatrists. Commonly encountered pathogeneses include rotator cuff pathology, bursitis, biceps tendonitis, and labral tears. Because the majority of shoulder pain originates within the subacromial region and the glenohumeral joint, the acromioclavicular, sternoclavicular, and scapulothoracic articulations may be overlooked. Osteoarthritis of the acromioclavicular joint is a common source of shoulder pain that is often neglected by clinicians and researchers. The proper diagnosis of acromioclavicular joint osteoarthritis requires a thorough physical exam, plain-film radiograph, and a diagnostic local anesthetic injection. Current treatment options are rather limited. Initial therapies are similar to that of osteoarthritis in other joints and include oral analgesics or anti-inflammatories and an emphasis on activity modification. Physical therapy, unfortunately, has little to offer, as therapeutic exercise and range of motion play only a minor role. If a diagnostic local anesthetic injection provides relief, there may be a role for corticosteroid injections. It seems that the administration of local corticosteroids into the acromioclavicular joint may provide short-term pain relief. The judicious administration of such injections remains controversial, and most experts agree that steroid injections do not alter the natural progression of the disease. Surgical options, indicated typically after a minimum of 6 mos of unsuccessful conservative treatment consist of open or arthroscopic distal clavicle resection.
Article
The goal of this study is to determine whether suturing is superior to non-closure in terms of the subjective long-term outcome in large rotator cuff tears. A total of 64 shoulders with rotator cuff tears of at least 3 cm diameter and followed up for a mean period of 5 years and 8 months were retrospectively examined. The patients' medical history, clinical findings, radiographs and Constant scores were studied. Patients whose tears had been closed with an open suture (n=33) were compared with those whose tears had not been closed (n=31). Neither the comparison between open suturing and debridement nor that between open and arthroscopic debridement reveal a significant difference with regard to the overall Constant score or the individual parameters. These results suggest that in the long-term, suturing of large rotator cuff tears is not superior to debridement.
Article
Subacromial decompression is a well-accepted treatment for impingement syndrome when nonoperative therapies have failed. However, recent clinical data have raised concern that arthroscopic subacromial decompression may lead to laxity of the acromioclavicular joint and, potentially, predispose patients to late postoperative acromioclavicular joint pain. Our goal was to determine whether subacromial decompression with co-planing of the distal clavicle alters the laxity, or compliance, of the acromioclavicular joint in a cadaveric model. Eighteen cadaveric shoulders were dissected and tested in a specially designed rig, driven by a hydraulic materials testing machine. One hundred-Newton loads were applied to the distal clavicle in the superior, posterior, and anterior directions, while acromioclavicular joint motion was recorded with a 3-dimensional infrared optical measurement system. Acromioplasty was performed with a posterior-referenced cutting block technique and included co-planing of the distal clavicle in all specimens. Joint compliance before and after subacromial decompression was compared with the paired t test. Subacromial decompression increased anteroposterior compliance by 13%, from 8.8 +/- 2.9 mm (mean +/- SD) in the intact joint to 9.9 +/- 3.1 mm (P =.001). Subacromial decompression increased superior compliance by 32%, from 3.1 +/- 1.5 mm in the native specimen to 4.1 +/- 1.8 mm (P =.03). These observations may have implications for the technique of acromioplasty. Although the immediate result of acromioplasty with co-planing appears to be an increase in the compliance of the acromioclavicular joint, the clinical significance of these findings has yet to be determined.
Article
The purpose of the study was to compare the laxity of the acromioclavicular (AC) joint in the superior, posterior, and anterior planes after isolated acromioplasty and after acromioplasty with inferior clavicular coplaning. In vitro (cadaveric) analysis. Eight fresh-frozen cadaveric shoulders were evaluated using a hydraulic actuator. While the scapula was stabilized, a 30-N force was applied to the distal clavicle perpendicular to the AC joint in the superoinferior plane and parallel to the joint in the anteroposterior plane. Laxity of the AC joint in the superior, anterior, and posterior directions was evaluated via load-displacement analysis after acromioplasty and after acromioplasty with coplaning. Coplaning the distal clavicle increased superior AC laxity by 53% compared with acromioplasty alone (P =.012). With regard to anteroposterior laxity, coplaning increased anterior translation by 19% (P =.047) and increased posterior translation by 16% (P =.237). Bony impingement was seen to limit posterior translation in 3 specimens. Acromioplasty with coplaning increases AC laxity significantly in the superior and anterior directions as compared with acromioplasty alone. A trend toward increased posterior translation was found; posterior bony impingement may limit posterior laxity.
Article
Although AC pathology usually represents a late manifestation of outlet impingement, it typically presents as a cause of pain that is resistant to nonoperative and operative measures designed to treat purely anterior acromial pathology. The bursitis that occurs with AC joint impingement may be indistinguishable from anterior acromial impingement on clinical presentation; however, physical examination, diagnostic injection, and radiographic evaluation are generally sufficient to establish the diagnosis of AC joint impingement. Nonoperative measures are indicated for the treatment of acute bursitis, although operative intervention may be necessary in cases of large, distally projecting osteophytes in the presence of AC joint degeneration. Acromioclavicular pathology, when present, should be addressed at the time of subacromial decompression, and may involve distal clavicular resection, beveling of the AC joint, or excision of marginal osteophytes. The results of surgery to address the AC contribution to impingement are generally favorable; future investigation may further clarify the role of coplaning and its potential contribution to continued postoperative AC pain and symptomatic instability.
Article
The purpose of this study was to determine the prevalence of acromioclavicular joint (ACJ) arthritis with magnetic resonance imaging (MRI) evaluation in asymptomatic patients. Fifty shoulders in 42 patients were evaluated with the use of standard MRI techniques. There were 18 men and 24 women with an average age of 35 years (range, 19 to 72). 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. Forty-one (82%) of 50 shoulders had abnormalities consistent with arthritis on MRI. Patients were divided into two groups according to age: those older than 30 years and those 30 years old or younger. In the 30-and-under age group, 68% of the shoulders had arthritic changes, whereas in the over-30 age group, 93% had arthritic changes. Furthermore, in a comparison of the two groups, more advanced arthritic changes were found in the over-30 age group (P <.05). Clinical decisions to resect the ACJ should correlate the physical examination with the MRI findings because many patients may be clinically asymptomatic.
Article
There has been recent concern about long-term morbidity associated with arthroscopic co-planing of the acromioclavicular joint in the treatment of impingement syndrome. The purpose of this study was to assess the results of the co-planing procedure, special attention being paid to acromioclavicular joint morbidity. The study included 56 patients who were operated on by the senior author. Outcomes were evaluated both objectively and subjectively through physical examinations and telephone surveying. Each patient had subacromial decompression at the time of the index surgery. Other concomitant arthroscopic procedures included rotator cuff repair and labral debridement or repair. Average follow-up was 4 years (range, 2-7 years). Thirty-five (95%) of 37 patients had no subjective pain and no objective tenderness to direct palpation or compression of the acromioclavicular joint. The joint was not clinically hypermobile in comparison with that on the opposite side in any patient. In all, 95% of patients had good or excellent results in terms of the University of California at Los Angeles Shoulder Score. Of the 2 patients who did have pain and tenderness at the acromioclavicular joint, both had had multiple operations on their shoulders before the index procedure. Nineteen patients were not examined clinically but did complete a telephone survey; these 19 patients were not symptomatic at the acromioclavicular joint. To fully treat impingement syndrome, the surgeon should remove osteophytes under the lateral clavicle and medial acromion. With good technique, the surgeon can leave the anterior, posterior, and superior acromioclavicular joint capsule intact. We conclude that for appropriate clinical indications, beveling the inferior 20% to 25% of the clavicle to make it co-planar with the decompressed acromion is safe and is not an etiologic factor in acromioclavicular joint pain or instability.
Article
Arthroscopic acromioclavicular joint (ACJ) resection for asymptomatic ACJ arthritis combined with rotator cuff repair leads to more satisfactory pain relief and decrease reoperation rate when inferiorly directed osteophytes present at the undersurface of ACJ. Between January 2006 and May 2008, a total of 83 patients (83 shoulders), 40 males and 43 females, who were planned to have arthroscopic repair of a tear measuring 1-3 cm in the anterior-posterior dimension with advanced ACJ arthritis with inferiorly directed osteophytes at the undersurface of the ACJ on MRI were entered into this study. Patients were randomized into two groups. Group 1 included 31 patients, who underwent arthroscopic distal clavicle resection combined with rotator cuff repair. Group 2 included 52 patients, who underwent isolated rotator cuff repair. Patients were evaluated preoperatively and postoperatively using the University of California Los Angeles (UCLA) score and the American Shoulder and Elbow Surgeons (ASES) score. Pain, tenderness on ACJ, and cross body adduction test were compared between groups. The mean follow-up was 31.7 months (range 34-38). The UCLA scores and ASES scores were lower in group 1 at week 6 (p < .05), and week 12 (p < .05), but higher at the last follow-up at 2 years (p < .05) postoperatively. VAS score was higher in group 1 at week 6 (p < .05), and at week 12 (p < .05), but lower in group 2 at the last follow-up (p < .05). Only in group 2, two (3.8%) cases developed ACJ pain during follow-up and one (1.9%) case underwent reoperation for additional ACJ resection. This study shows that distal clavicle resection combined with rotator cuff repair for asymptomatic ACJ arthritis with inferiorly directed osteophytes lower functional scores due to temporary pain in early postoperative periods, but better functional outcomes with satisfactory pain relief and no reoperation rate were observed after 2 years.
Article
The acromioclavicular (AC) joint is a recognized source of persistent pain following subacromial decompression. However, as both arthroscopic and open lateral clavicle excision may create unacceptable clavicle instability, excision is recommended only if there are preoperative symptoms referable to the AC joint, or if the inferior capsule or clavicle is compromised intraoperatively by subacromial coplaning. The AC joint appears to be less commonly involved in the presence of a cuff tear; however, the presence of an AC joint cyst or effusion is indicative of a rotator cuff tear. Cumulative published experience provides little support for the routine repair of traumatic AC joint disruption. Of the small proportion of patients who remain symptomatic, secondary reconstruction using transferred coracoacromial ligament with artificial or local tissue augmentation provides a predictable recovery of function and stability. Traumatic posterior displacement of the sternoclavicular joint remains an uncommon but potentially serious injury if unrecognized, because of documented mediastinal structure damage. Appropriate imaging (ideally three-dimensional computed tomography scan) is essential where such an injury is suspected, and if the injury is recognized and treated early, closed reduction is usually effective.
Article
I risultati clinici della decompressione sottoacromiale per via artroscopica sono paragonabili ai risultati ottenuti mediante un’acromioplastica a cielo aperto. Questa procedura è caratterizzata da una lunga curva di apprendimento, ma le complicanze gravi sono rare. In genere si inserisce l’artroscopio nel portale posteriore, mentre le procedure chirurgiche vengono eseguite attraverso un portale laterale. Prima di effettuare la resezione, è importante avere un quadro completo dell’anatomia. Successivamente alla resezione del tessuto bursale e del periostio, si procede all’asportazione di un’area di tessuto osseo della superficie inferiore dell’acromion anteriore, di 5 mm di larghezza e 2 cm di lunghezza.
The removal of osteophytes and prominences on both sides of the acromioclavicular joint to open up the supraspinatus outlet is an element of a subacromial decompression. The arthroscopic technique that removes these inferior spurs or portions of the distal clavicle to decrease injury to the rotator cuff is known as coplaning. Controversy exists about the benefits and advisability of coplaning. However, these concerns are not supported by several clinical studies. The resection of the inferior medial acromion and distal clavicle spurs, although theoretically causing an increase in clavicular mobility, does not cause late clinical problems and does achieve the primary goal of fully decompressing the supraspinatus outlet.
Article
The acromioclavicular (AC) joint is a diarthrodial joint ostensibly connecting the acromion and the distal clavicle, but in reality suspending the entire arm, via the clavicle and sternoclavicular joint, from the axial skeleton. Using the AC joint as a pivot point, the scapula (acromion) can protract and retract. The AC joint, which is approximately 9 mm by 19 mm, is formed by the distal clavicle and the acromion process of the scapula (Fig. 2.1). The articular surface of the acromion is concave (relative to the subacromial space) and has an anterior and medial orientation toward the convex, distal, end of the clavicle. The joint allows gliding, shearing and rotational motion. The articular surface of the acromial end of the clavicle is hyaline cartilage until 17 years of age, at which time it acquires the structure of fibrocartilage. Similarly, the articular surface of the clavicular side of the acromion becomes fibrocartilage at approximately 23 years of age [1]. The angle of the AC joint on AP view is variable. Urist found it was inclined from superolateral to inferomedial in 49% of cases, vertically oriented in 27%, incongruous in 21% and laterally oriented in 3% [2]. The joint is also inclined a few degrees from anterolateral to posterior medial on the axillary view. Viewed anteriorly, the inclination of the joint may be almost vertical or downward medially, the clavicle overriding the acromion by an angle of as much as 50°.
Article
La bóveda acromiocoracoidea presenta relaciones anatómicas estrechas con el manguito de los rotadores. Neer describió en 1972 el conflicto (síndrome de compresión o pinzamiento, impingement syndrome) entre la parte anterior del acromion y el manguito de los rotadores (supraespinoso), a partir del cual describió la acromioplastia anteroinferior. Este procedimiento quirúrgico permite disminuir el conflicto subacromial. Cuando existe una artrosis acromioclavicular sintomática, puede estar indicada la resección del cuarto externo de la clavícula. Inicialmente se describió la técnica a cielo abierto. En la actualidad se realiza bajo artroscopia, cuya principal ventaja es que respeta la capa protectora deltoidea. Al principio se recomendaba una acromioplastia masiva; hoy día, esta acromioplastia masiva se cuestiona debido a la aparición de dolores intrínsecos de los tendones y de la bolsa subacromial. No obstante, este procedimiento quirúrgico sigue siendo necesario en caso de pico acromial de gran tamaño y, en ocasiones, para crear un espacio de trabajo durante la reparación del manguito de los rotadores. El dominio de la artroscopia implica una curva de aprendizaje necesaria para la realización de esta técnica, que permite una notable disminución de la morbilidad.
Article
La artrosis acromioclavicular es una afección extremadamente frecuente que se manifiesta por dolores en el hombro. El diagnóstico es esencialmente clínico: el dolor aparece al movilizar la articulación, pero el diagnóstico se confirma cuando cede tras una infiltración intraarticular radioguiada. El estudio por imagen revela signos típicos de artrosis, con pinzamiento y remodelación ósea considerable. El tratamiento es básicamente clínico: las infiltraciones conducen a la desaparición del dolor de forma reproducible y duradera. Esta artrosis es común en el deportista joven con gran actividad de los hombros, en quien el tratamiento médico y un cambio en las prácticas deportivas pueden conducir a la curación. Si este tratamiento fracasa, se justifica la resección quirúrgica. Mediante un procedimiento artroscópico es posible resecar la zona artrósica preservando los ligamentos acromioclaviculares superiores, que son los estabilizadores más potentes de esta articulación. Si la artrosis forma parte de un hombro doloroso degenerativo global no hay un consenso claro y, en caso de cirugía, además de la resección del cuarto externo de la clavícula se pueden asociar otras técnicas.
Article
The treatment of symptomatic acromioclavicular joint (ACJ) injury in the rotator cuff (RC) tear has not been well clarified. To compare the clinical results between patients who had distal clavicle resection (DCR) and those who did not during RC repair. Randomized controlled trial; Level of evidence, 1. From August 2008 to December 2009, a total of 56 consecutive patients (58 shoulders) were included. All patients had either a full-thickness or high-grade (>50%) RC tear, ACJ tenderness, arthritic change visible on plain radiographs, and a positive ACJ lidocaine injection test the day before surgery. Patients were randomized into 2 groups: DCR and RC repair (DCR+RCR group) and RC repair only (isolated RCR). Evaluation was performed preoperatively, at 6 months postoperatively, and at a final follow-up a minimum of 24 months postoperatively using the American Shoulder and Elbow Surgeons (ASES) score, the Constant shoulder score, range of motion examination, and pain visual analog scale (VAS). After simple randomization, 26 shoulders were allocated in the DCR+RCR group, and 32 were placed in the isolated RCR group. Five shoulders in the DCR+RCR group and 6 in the isolated RCR group were excluded from analysis due to loss of follow-up. Therefore, the evaluation was performed for 21 shoulders in the DCR+RCR group and 26 shoulders in the isolated RCR group. The mean follow-up period was 44.2 months in the DCR+RCR group and 44.0 months in the isolated RCR group. There were no differences in age, sex, symptom duration, RC tear size, or preoperative ASES, Constant, and VAS scores between the 2 groups (P > .05). At final follow-up, the ASES, Constant, and VAS scores were significantly improved in both groups (P < .001). There were no differences in ASES, Constant, and VAS scores between the 2 groups at final follow-up (P > .05), and there was no difference in residual ACJ tenderness (7 in the DCR+RCR group and 5 in the isolated RCR group) between the 2 groups (P = .270). There was no difference in the clinical evaluations between the combined arthroscopic DCR and RCR group and the isolated RCR group at a minimum 24-month follow-up. Arthroscopic DCR should be carefully considered in patients who have symptomatic ACJ arthritis with RC tears. © 2015 The Author(s).
Article
Our understanding of the biomechanics of the acromioclavicular (AC) joint continues to evolve, and treatment methods, both conservative and surgical, continue to be refined. Controversy over the ideal treatment for a type III AC joint injury persists, with the pendulum swinging once again toward an initial attempt at nonsurgical management. Rehabilitation techniques in conservative treatment have focused on a more functional approach and a quicker return to activities. The optimal amount of bone to remove in a distal clavicle resection is still unknown. Some studies have shown that as little as 5 mm need be resected to achieve adequate decompression and pain relief. Recent biomechanical studies have reexamined the functional contributions of the four components of the AC ligament in an effort to determine which ones should be preserved during an arthroscopic AC resection to avoid destabilizing the joint. Finally, the potential pitfalls of AC co-planing during acromioplasty have been examined both clinically and biomechanically. This paper attempts to bring the most recent issues, concerns, and controversies surrounding the acromioclavicular joint into focus.
Article
Subacromial decompression is a well-accepted treatment for impingement syndrome when nonoperative therapies have failed. However, recent clinical data have raised concern that arthroscopic subacromial decompression may lead to laxity of the acromioclavicu-lar joint and, potentially, predispose patients to late postoperative acromioclavicular joint pain. Our goal was to determine whether subacromial decompression with co-planing of the distal clavicle alters the laxity, or compliance, of the acromioclavicular joint in a cad-averic model. Eighteen cadaveric shoulders were dissected and tested in a specially designed rig, driven by a hydraulic materials testing machine. One hundred-Newton loads were applied to the distal clavicle in the superior, posterior, and anterior directions, while acromioclavicular joint motion was recorded with a 3-dimensional infrared optical measurement system. Acromioplasty was performed with a posterior-referenced cutting block technique and included co-planing of the distal clavicle in all specimens. Joint compliance before and after subacromial decompression was compared with the paired t test. Subacromial decompression increased anteroposterior compliance by 13%, from 8.8 +/- 2.9 mm (mean +/- SD) in the intact joint to 9.9 +/- 3.1 mm (P = 001). Subacromial decompression increased superior compliance by 32%, from 3.1 +/- 1.5 mm in the native specimen to 4.1 +/- 1.8 mm (P = .03). These observations may have implications for the technique of acromioplasty. Although the immediate result of acromioplasty with co-planing appears to be on increase in the compli-ance of the acromioclavicular joint, the clinical significance of these findings has yet to be determined.
Chapter
Das Impingementsyndrom ist die häufigste Ursache von vorderen Schulterschmerzen. Der Begriff „Impingement“ (to impinge: anstoßen) wurde von Neer in seiner klassischen Arbeit [24] geprägt und beschreibt die Einklemmung der Rotatorenmanschette (RM) und der Bursa subdeltoidea zwischen anterolateralem Akromioneck und Humeruskopf.
Chapter
The concept of shoulder impingement was first described by Meyer in 1937. Afterwards, Neer expanded on Meyer’s study, describing the different stages of impingement. Shoulder impingement syndrome is caused by an anatomic narrowing of the subacromial space by the structures that form the coracoacromial arch leading to progressive bursitis, tendinitis, and rotator cuff tear. Acromioclavicular joint degeneration and pain may exist alone or in addition to shoulder impingement.
Article
Riassunto L'arco coraco-acromiale ha stretti rapporti anatomici con la cuffia dei rotatori. Nel 1972 Neer descrisse il conflitto (impingement syndrome) tra la parte anteriore dell'acromion e la cuffia dei rotatori (sovraspinoso). L'acromion viene quindi considerato come il fattore estrinseco causa di rotture dei tendini della cuffia. Si descrive così l'acromionplastica antero-inferiore. Consente di diminuire il conflitto subacromiale in caso di uncino acromiale grave e può anche permettere di aumentare uno spazio d'azione durante una concomitante riparazione della cuffia dei rotatori. In caso di artrosi acromioclaveare con una notevole osteofitosi inferiore, si può valutare un coplaning. Se questa artrosi è sintomatica si può indicare anche una resezione del quarto esterno della clavicola. Inizialmente, la tecnica di acromionplastica è stata descritta a cielo aperto, ma attualmente viene realizzata quasi esclusivamente in artroscopia per meglio rispettare il complesso deltoideo. Infine il concetto recente di critical shoulder angle può motivare la realizzazione di un'acromionplastica laterale per diminuire questo angolo e così ridurre le forze di compressione dei tendini della cuffia contro l'arco acromiale.
Article
The purpose of this study was to examine the reoperation rate on the acromioclavicular (AC) joint after arthroscopic subacromial decompression (ASAD) with and without concomitant AC joint surgery and to identify factors related to continued AC joint symptoms. We conducted a retrospective review of 1,482 cases without concomitant shoulder pathology that were followed up by physical examination, phone interview, questionnaire, or chart review. Group A, patients who underwent ASAD alone, consisted of 1,091 cases. Group B, patients who underwent ASAD with concomitant AC joint surgery consisting of either co-planing or arthroscopic distal clavicle resection (ADCR), consisted of 391 cases. A total of 22 patients underwent reoperation on the AC joint. The overall reoperation rate was 1.5%, or 22 of 1,482 patients. The index procedure failed in 16 patients from the ASAD group (group A), yielding a reoperation rate of 1.5%. The index procedure failed in 6 patients from the group undergoing ASAD with concomitant AC joint surgery (group B), for a reoperation rate of 1.5%. Reoperation occurred at a mean of 22 months and 8 months for group A and group B, respectively. Overall, 17 of 22 patients (77%) who required AC joint reoperation were either Workers' Compensation (WC) or litigation cases. The reoperation rate was 2.4% for WC patients and 0.8% for non-WC patients. WC status was found to be a statistically significant factor in the rate of reoperation for AC joint symptoms (P < .05). Of the 22 patients, 10 continued to have pain at a mean of 25.9 months (range, 9 to 53 months) after reoperation. Given the similar rates of reoperation, routine AC joint violation by co-planing or ADCR is not recommended during ASAD. Reoperation for continued AC joint symptoms was associated with a nearly 50% rate of continued symptoms. The results of the study show that the incidence of reoperation on the AC joint after ASAD with or without concomitant AC joint surgery is small for both groups with a 1.5% rate of reoperation for each group. The incidence of reoperation is lower, at 0.8%, for non-WC cases. In addition, there was a high rate of continued symptoms, with 45% of patients having continued pain after reoperation. Violation of the AC joint during the initial surgery by co-planing or ADCR did not alter the reoperation rate for AC joint symptoms. Level IV, therapeutic case series.
Article
Subacromial decompression was performed arthroscopically on 65 patients who were evaluated two to five years after the procedure. None had full thickness rotator cuff tears. Patients with partial thickness cuff tears were included in this study in order to allow comparison of arthroscopic acromioplasty with open acromioplasty for stage II impingement. On the UCLA shoulder rating scale, 89% of the cases in this study achieved a satisfactory result. These results compare favourably with those reported following open acromioplasty. The arthroscopic procedure is technically demanding. When properly performed in patients with appropriate indications, hospitalisation is brief, return to activities is rapid, there is little risk of deltoid muscle complications, and the results are lasting.
Article
Arthroscopic subacromial decompression has become a popular technique supplanting the open Neer acromioplasty in many instances of chronic rotator cuff disease. A review of 61 consecutive decompressions with a minimum follow-up of 12 months was undertaken to evaluate preoperative criteria and surgical outcomes. Of the 61 patients, 53 patients with an average follow-up of 23 months were available for review. Thirty-four men and 19 women with an average age of 47 years comprised the study group. Eleven (21%) had full-thickness tears, 35 (66%) had partial-thickness injuries, and 7 (13%) had normal-appearing rotator cuffs at the time of arthroscopy. The UCLA shoulder rating system was used to evaluate outcome. Eighty-one percent of the patients had an excellent (32%) or good (49%) result whereas 19% (15% fair and 4% poor) were considered unsatisfactory. Those with early impingement findings and partial rotator cuff tears were likely to experience a satisfactory outcome. Patients with full-thickness rotator cuff tears were less likely to experience a successful result (55%). Workmen's compensation cases had a satisfactory outcome in 74%, with a predominance of good over excellent results. Excluding those with full-thickness tears and work-related injuries, a satisfactory outcome was achieved in 90%. Arthroscopic subacromial decompression for mechanical impingement of the rotator cuff is a technically demanding procedure requiring appropriate skills as well as careful preoperative treatment and evaluation. For individuals in whom conservative measures fail and who meet stringent criteria, namely, a largely intact rotator cuff and a non-work-related injury, a highly reliable and satisfying outcome can be anticipated by both patient and surgeon.
Article
A study group composed of 25 shoulders in 24 patients underwent arthroscopic subacromial decompression for advanced impingement syndrome. There were no full thickness rotator cuff tears, biceps tendon ruptures, significant acromioclavicular arthrosis, or evidence of glenohumeral instability. Twenty men and four women ranging in age from 18 to 63 years (mean age 37) with dominant arm involvement in 17/24 were evaluated for an average follow-up of 20.3 months (range 14-32) postoperatively. Operative results were based on the UCLA shoulder rating scale. Eighty-eight percent of the cases (22/25) had good or excellent results. Twelve percent had fair results (3/25). There were no poor results. The average UCLA pain score improved from 2.6 preoperative (constant pain) to 7.8 postoperative (occasional pain). Ninety-two percent of the patients were satisfied, said they were better, and that they would have the surgery again. Arthroscopic subacromial decompression is recommended as an alternative to open anterior acromioplasty in advanced impingement syndrome.
Article
Arthroscopic acromioplasty was done for a lesion of the rotator cuff in 165 patients: 100 who had stage-II impingement syndrome (no actual tear of the rotator cuff) (group 1), forty who had a partial tear (group 2), and twenty-five who had a full-thickness tear (group 3). The operation consisted of acromioplasty, resection of the coracoacromial ligament and subacromial bursa, and removal of osteophytes, when present, near the inferior aspect of the acromioclavicular joint. In the patients who had a partial or complete tear, minimum debridement of the rotator cuff also was performed. In group 1, eighty-six patients (eighty-nine shoulders) were available for review at a minimum follow-up to two years (average, 31.2 months). The preoperative ratings for pain, activities of daily living, work, and sports improved markedly in eighty-one patients postoperatively. The most common findings at operation were proliferative subacromial bursitis and an acromial protuberance. Two complications were recorded. Seven patients had a subsequent open operation on the shoulder. In group 2, the average follow-up was 28.9 months (range, twenty-four to forty-eight months). Of the forty patients, thirty-three had a major improvement in the ratings for pain, activities of daily living, work, and sports. One complication, transient palsy of the lateral femoral cutaneous nerve, was noted. Two patients who had an unsatisfactory result had a second operation: one, open acromioplasty and the other, repair of the rotator cuff. In group 3, the average follow-up was 30.8 months (range, twenty-four to fifty-five months). There were fourteen satisfactory and eleven unsatisfactory results. Of the twenty-five patients, seven later had open repair of the rotator cuff, and six had a satisfactory result from that procedure. No complications were recorded. It was concluded that arthroscopic acromioplasty is effective in the treatment of isolated stage-II impingement and partial tears of the rotator cuff. Arthroscopic treatment of complete tears produced over-all results that were inferior to those of traditional open repair. Arthroscopic subacromial decompression cannot be supported as treatment for complete tears of the rotator cuff.
Article
In a total of 108 acromioclavicular articulations from cadavers the osteoarthrotic changes were studied. The articulations were macroscopically and radiographically ranked according to their grade of osteoarthrosis. The two ranking lines were correlated statistically and showed a rank correlation of 0.741. In 38 articulations tomography was also carried out. These articulations were classified into five grades of osteoarthrosis and the macroscopic, conventional radiographic and tomographic gradings were compared. The correlation coefficient for tomography versus macroscopy was 0.714. Tomography versus standard radiography showed a correlation of 0.767 and standard radiography versus macroscopy a correlation of 0.841. The standard radiographic investigation reveals moderate and severe osteoarthrotic changes in the acromioclavicular joint but cannot depict smaller changes. Tomography does not seem to improve the specificity. There is a need for a better radiologic technique in the examination of the acromioclavicular joint. Radiography during some kind of loading might be a practical way of improving the specificity and make it possible to show early osteoarthrosis in the acromioclavicular articulation.
Article
Arthroscopic subacromial decompression (ASD) is a method of performing anterior acromioplasty utilizing basic arthroscopic techniques. The procedure is indicated in cases of chronic impingement syndrome that have failed to respond to prolonged conservative management. The purpose of this study is to present an analysis of the 1- to 3-year follow-up results of the initial 50 consecutive cases of ASD that I have performed. Forty (80%) of the cases had advanced stage II impingement without rotator cuff tear. Ten (20%) had full-thickness tears of the rotator cuff. Patients were evaluated pre and postoperatively on the UCLA Shoulder Rating Scale, which includes an assessment of pain, function, range of motion (ROM), strength, and patient satisfaction. Eighty-eight percent of the cases were rated "satisfactory" (excellent or good), and 12% were rated "unsatisfactory" (fair or poor). The procedure is technically demanding, and to achieve a satisfactory result the criteria of open anterior acromioplasty must be met. Arthroscopic subacromial decompression is presented as an alternative to open anterior acromioplasty in advanced stage II and selected cases of stage III impingement syndrome.
Article
The ligamentous structures of the acromioclavicular joint were studied by gross examination and quantitative measurement in twelve human cadaver specimens. Distances between insertions at various extreme positions of the clavicle were studied with the biplane radiographic technique. Ligamentous contributions to joint constraint under displacements were determined by performing load-displacement tests along with sequential sectioning of the ligaments. Twelve modes of joint displacement were examined. The acromioclavicular ligament acted as a primary constraint for posterior displacement of the clavicle and posterior axial rotation. The conoid ligament appeared to be more important than has been previously described. That ligament played a primary role in constraining anterior and superior rotation as well as anterior and superior displacement of the clavicle. The trapezoid ligament contributed less constraint to movement of the clavicle in both the horizontal and the vertical plane except when the clavicle moved in axial compression toward the acromion process. The various contributions of different ligaments to constraint changed not only with the direction of joint displacement but also with the amount of loading and displacement. For many directions of displacement, the acromioclavicular joint contributed a greater amount to constraint at smaller degrees of displacement, while the coracoclavicular ligaments, primarily the conoid ligament, contributed a greater amount of constraint with larger amounts of displacement.
Article
Between May 1988 and May 1990, 44 patients with Stage II impingement were randomized into open and arthroscopic treatment groups. Forty-one patients were available for final follow-up in May 1991: 22 in the open group, 19 in the arthroscopic group. Comparisons of pain, function, motion, and strength were made preoperatively and at 2, 6, 12, 26, and 52 weeks postoperatively. Final analysis showed that the main benefits of arthroscopic acromioplasty were evident in the first 3 months postoperatively. Arthroscopic patients regained flexion and strength more rapidly than did open patients, had shorter hospitalizations, used less narcotics, and returned more quickly to both work and activities of daily living. By 3 months postoperatively, open patients tended to "catch up" with arthroscopic patients, and further recovery was equivalent. In both groups, full recovery took at least 1 year for the majority of patients and in both groups at 1 year > 90% of patients achieved a satisfactory result. Because of its medical and economic advantages for both the patient and the health-care system, we conclude that arthroscopic acromioplasty should become the procedure of choice for patients with impingement syndrome refractory to conservative treatment.
Article
In a prospective study, 20 patients were randomly selected for either open acromioplasty according to Neer or for arthroscopic subacromial + decompression (ASD). All suffered from shoulder impingement for which conservative treatment had been unsuccessful. Functional results after two years were assessed. All patients were assessed radiographically to visualize recurrence of subacromial osteophytes. Functional results in the arthroscopic group are good and similar to those after open surgery. Both methods seem to result in adequate subacromial decompression, including bone resection. The arthroscopic method also has in its favor less operating time, earlier restoration of active range of motion, and reduction in time away from work.
Correlation of macroscopic osteoarthritic changes and radiographic findings in the acromioclavicular joint
  • Stenlund