The Evaluation and Management of Failed Distal Clavicle Excision
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Patients with pathology of the acromioclavicular (AC) joint, including osteoarthritis and distal clavicle osteolysis commonly present with pain and difficulty with activities that require cross-arm adduction. After a trial of nonoperative management, which typically includes activity modification, nonsteroidal anti-inflammatory medications, physical therapy, and intraarticular corticosteroid injections, patients with symptomatic AC joint pathology are often indicated for surgical treatment including distal clavicle excision. Whether carried out open or with an arthroscopic technique, distal clavicle excision has been reported to result in successful outcomes in a high percentage of treated patients.
In a recent systematic review, Rabalais and McCarty reported that among 289 patients treated with open distal clavicle excision, good to excellent results occurred in 76.3% at a mean of 4.9 years of follow-up (range 50% to 100%). As techniques and instrumentation have evolved and surgical experience has increased, arthroscopic distal clavicle excision has become increasingly popular. Proponents of the arthroscopic technique report improved cosmesis, easier postoperative rehabilitation, and a faster return to function, secondary to the preservation of the AC joint ligaments, capsule, and the deltotrapezial fascia. Clinical studies have shown good to excellent outcomes after arthroscopic distal clavicle excision in 85% to 100% of treated patients.
Patients with persistent symptoms and disability after either open or arthroscopic distal clavicle excision represent a difficult clinical scenario for the treating orthopedic surgeon. Potential etiologies of failure after distal clavicle excision include under-resection, over-resection leading to postoperative joint instability, postoperative stiffness, heterotopic ossification, untreated concomitant shoulder pathology, and postoperative infection. Less common causes of failure include distal clavicle fracture, reossification, or fusion across the acromioclavicular joint, suprascapular neuropathy, and psychiatric illness.
Patients presenting as failed distal clavicle excisions require a careful work-up in an attempt to identify the etiology behind their persistent symptoms and the formulation of a treatment plan that may include revision surgery or coracoclavicular ligament reconstruction. Although careful patient selection, preoperative planning, proper surgical technique, and appropriate rehabilitation during the index procedure can minimize the likelihood of poor outcome, this paper reviews the work-up and management of cases of failed distal clavicle excision.
Full Article: The Evaluation and Management of Failed Distal Clavicle Excision
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