CHAPTER 9 Arthroscopic Distal Clavicular Resection
ANATOMY AND PATHOPHYSIOLOGY
The acromioclavicular joint is subcutaneous and exposed to substantial biomechanical forces during shoulder motion. It is therefore susceptible to degenerative processes and acute trauma. Located between the distal end of the clavicle and the anteromedial aspect of the acromion, the AC joint is a diarthrodial joint. The joint is initially composed of hyaline cartilage articulations incompletely separated by a fibrocartilaginous disk1; however, it undergoes degeneration to fibrocartilage by 40 years.1
Although the exact dimensions are debated, the average size of the adult acromioclavicular joint is approximately 9 mm in the coronal plane and 19 mm in the sagittal plane.2 There is tremendous variability in the coronal orientation of the joint.1,3 Three coronal orientations have been described: an overriding clavicle (the clavicle overrides the acromion), a neutral AC joint, and an underriding clavicle (the acromion overrides the clavicle).4 The overriding clavicle is the most common variant, occurring in almost 50% of individuals.5
The CC ligaments include the medial conoid and lateral trapezoid ligaments; however, up to 1% of patients have a coracoclavicular bar.6 The average distance between the clavicle and coracoid is from 11 to 13 mm.2,7 The CC ligaments are extracapsular and the average distance from the most lateral extent of the trapezoid ligament fibers to the joint is 15.3 mm (range, 11 to 22 mm).8 The CC ligaments are the primary constraints to superior and inferior translation, whereas the AC ligaments and capsule are the primary restraints to anteroposterior instability. However, the AC and CC ligaments have a dynamic interplay, whose contributions to stability vary with the directions and forces applied.9
Given its anatomy, the potential motion of the AC joint far exceeds that actually demonstrated during active motion of the shoulder girdle.10 Actually, very little motion occurs at the AC joint in comparison to that of the sternoclavicular joint; less than 10 degrees of rotation occur at the AC joint with full elevation of the arm.11
MECHANISM OF INJURY
Acromioclavicular joint pathology can be stratified into two broad categories, instability and arthritic conditions. Either condition may be the sequel of direct or indirect forces applied to the upper extremity. Direct forces are the most common mechanism of injury, resulting from a fall on the point of the shoulder, usually with the arm adducted. Indirect forces may be transmitted through the upper extremity and dissipated within the acromioclavicular articulation, leading to ligamentous and cartilaginous injury. These forces may lead to an acute injury or, with chronic degeneration, an arthritic condition. An isolated subset of the arthritic population is the younger athlete or weightlifter whose repetitive exercises have induced a stress reaction in the distal clavicle, known as distal clavicular osteolysis. Instability may also be iatrogenic, caused by an overzealous previous distal clavicle resection.
HISTORY AND PHYSICAL EXAMINATION
Whereas pain arising in the AC joint is often localized to the anterosuperior aspect of the shoulder, referred pain may exist, given the rich innervation of the joint by the suprascapular, lateral pectoral, and axillary nerves. With injection studies, Gerber and colleagues12 have demonstrated that patients may complain of pain distributed over the anterolateral neck, posterior trapezius, and anterolateral deltoid. Painful motions will often include cross-body adduction, overhead activities, internal rotation, and extension of the arm behind the plane of the scapula. Common complaints are pain while putting on a coat, strapping a bra, or washing the contralateral axilla. Weightlifters and athletes with distal clavicular osteolysis describe soreness and pain with flat and inclined bench presses, shoulder presses, and dips. Special attention should be paid to patients in whom a previous distal clavicular resection has been performed. These patients may present for inadequate resection, instability, or a missed diagnosis.
DIAGNOSTIC IMAGING OF ACROMIOCLAVICULAR JOINT PATHOLOGY
If AC joint stability is in question, an AP of bilateral shoulders including the AC joints should be taken to compare the coracoclavicular distances with the identical tangential view. Stress views may also be obtained, but are not usually required.13
Magnetic resonance imaging is not typically necessary for diagnosing acromioclavicular pathology; however, it is useful to evaluate for masses or cysts about the AC joint and concomitant shoulder pathology that may need to be addressed. Unfortunately, findings of increased T2 signal intensity can be nonspecific for symptomatic pathology14 and therefore must be correlated with physical findings that support the diagnosis of AC pathology.