Abstract
Seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a painful condition of the acromioclavicular joint. Thirty-two of the patients had had a traumatic separation of the acromioclavicular joint, eight had had a fracture of the lateral end of the clavicle, and thirty-three had primary acromioclavicular osteoarthrosis. An average of sixteen millimeters (range, five to thirty-seven millimeters) was resected; the amount was similar in each of the three groups.The patients were evaluated an average of nine years (range, four to sixteen years) after the operation. The result was considered good in twenty-one patients, satisfactory in twenty-nine, and poor in twenty-three. A poor result was more common in the patients who had had a fracture of the lateral end of the clavicle (p < 0.01). Forty-six patients reported pain with exertion, and thirteen noted pain at rest. Eighteen patients had a decrease in the strength of the involved upper extremity, and sixteen had some limitation of the mobility of the shoulder. Elevation of the lateral end of the remaining part of the clavicle as compared with the scapula was noted in eighteen patients and was more likely to be associated with pain (p < 0.05). The extent of the resection was significantly associated with pain; patients who had had a smaller amount of resection (ten millimeters or less) had less pain than those who had had a larger amount (p < 0.03). A good result was more common in the patients in whom less than ten millimeters had been resected and who had had a previous traumatic separation of the acromioclavicular joint or had primary acromioclavicular osteoarthrosis.We recommend that resection of the lateral end of the clavicle be considered with caution for patients who have severe post-traumatic or degenerative osteoarthrosis of the acromioclavicular joint. If resection is performed, it should not exceed ten millimeters.
Resection of the lateral end of the clavicle has been recommended by a number of authors for the treatment of chronic painful disorders of the acromioclavicular joint1,7,9-11,13. The indications have included chronic idiopathic osteoarthrosis1,7,9-11, post-traumatic osteoarthrosis2,8,14, and instability of the acromioclavicular joint1,7,14. Although most series have included a small number of patients, the results have generally been favorable. However, Petersson, in 1983, reported a poor result in thirteen of fifty patients.
The purpose of the current study was to analyze the long-term results of patients who had been managed with resection of the lateral end of the clavicle for a pathological condition involving the acromioclavicular joint.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Orthopaedic Hospital of the Invalid Foundation, Tenholantie 10, SF-00280 Helsinki, Finland.
‡Department of Orthopaedics and Traumatology, Helsinki University Central Hospital, SF-00260 Helsinki, Finland.
§Tampere University Central Hospital, SF-33520 Tampere, Finland.
¶The Central Hospital of Middle-Finland, SF-40620 Jyväskylä, Finland.
Between 1973 and 1985, seventy-three patients had operative resection of the lateral end of the clavicle for the treatment of a pathological condition of the acromioclavicular joint. The procedures were performed at the Orthopaedic Hospital of the Invalid Foundation, The Central Hospital of Middle-Finland, and Tampere University Central Hospital. Fifty-two of the patients were men and twenty-one were women. The average age of the patients was forty-three years (range, twenty-two to seventy years). Eight patients were retired, eight performed sedentary work, thirty-six performed mildly strenuous work, and twenty-one had a job involving strenuous manual labor.
The condition was due to a traumatic event in forty patients. Thirty-two of these patients had had a traumatic, complete separation of the acromioclavicular joint12; it had been treated non-operatively in twenty-four and operatively with use of Kirschner-wire fixation without reconstruction of the ligaments in the other eight. All of these patients had also been managed by us for the original injury.
Of the thirty-two patients who had had a traumatic separation of the acromioclavicular joint, fifteen had sustained the injury in a fall from a standing height; nine, in a motor-vehicle accident; and eight, in a sports-related accident. Twenty-five of the patients were men and seven were women, and the average age was forty-two years (range, twenty-three to sixty-seven years). All thirty-two patients had radiographic signs of osteoarthrosis. The indication for the excision of the lateral end of the clavicle was disabling symptoms. No other abnormalities of the shoulder were identified in these patients. Before the operation, two of the thirty-two patients had had a decrease in abduction of the shoulder of more than 30 degrees. The resection of the lateral end of the clavicle was performed an average of 1.2 years (range, 0.5 to 4.2 years) after the primary injury, and an average of seventeen millimeters (range, five to thirty-seven millimeters) was resected.
Eight patients had had a fracture of the lateral end of the clavicle: three had had a Neer type-I fracture (a fracture of the lateral one-third, with the coracoclavicular ligament intact) and five, a Neer type-III fracture (an intra-articular fracture of the lateral end). All of these fractures were sustained in a fall from a standing height. Six of the patients were men and two were women, and the average age was thirty-eight years (range, twenty-two to sixty-three years). The primary treatment had consisted of three weeks of immobilization with use of a sling. All eight patients had radiographic signs of osteoarthrosis, and one had a decrease in abduction of more than 30 degrees. The resection was performed an average of 1.8 years (range, 0.3 to 4.3 years) after the injury, and an average of fourteen millimeters (range, five to twenty-five millimeters) was resected.
Of the thirty-three patients who were operated on for chronically painful acromioclavicular osteoarthrosis, eight reported a possible history of minor trauma. These patients had been symptomatic for an average of 4.0 years (range, 2.5 to 7.0 years) before the operative procedure. There were twenty-one men and twelve women, and the average age was forty-six years (range, twenty-seven to seventy years). All thirty-three patients had radiographic signs of osteoarthrosis, and all had a decrease in abduction of more than 30 degrees. An average of sixteen millimeters (range, five to thirty-seven millimeters) of the lateral end of the clavicle was removed.
The postoperative treatment was similar for all three groups. On the second postoperative day, range-of-motion exercises for the elbow were begun; on the the seventh day, active pendulum exercises of the shoulder were started. The sling support was worn for three weeks, after which a full range of shoulder exercises was initiated.
The follow-up examination of most patients was performed by the original surgeon, and a radiograph was made for each patient. The physical examination included evaluation of pain according to the classification of Darrow et al., in which 0 to 4 points are assigned for function of the shoulder joint; 0 to 4 points, for pain; 0, 1, or 2 points, for the subjective result; and 0, 1, or 2 points, for the cosmetic result. The abduction strength of both shoulders was recorded in kiloponds, with use of a dynamic stretch recorder. The physical assessment also included the grip strength of both hands, the range of motion of the shoulder joint, local pain, local deformity, two-point-discrimination testing in the hand, the Adson test, and—when there was any suspicion of a neural injury—electromyography4. Abduction of the shoulder against the resistance of the examiner, and the presence and degree of pain, were also documented.
All of the patients had similar health and retirement insurance.
The subjective result was considered good if the patient had no symptoms related to the shoulder, satisfactory if there was slight pain with exertion or a slightly limited range of motion of the shoulder joint, and poor if the symptoms were more extensive or the patient had decreased muscle power in the upper extremity, or both.
For the statistical analysis, we used the Student pairless t test.
The seventy-three patients were examined an average of nine years (range, four to sixteen years) after the operation. The duration of follow-up for the three groups was similar.
According to the classification of Darrow et al., twenty-one patients had a good result, twenty-nine had a satisfactory result, and twenty-three had a poor result. Forty-six patients reported pain in the shoulder with exertion. Thirty-two patients had pain with manually resisted abduction. Sixteen patients had a limitation of glenohumeral motion (20 degrees or more in external rotation or 30 degrees in abduction, or both). Five patients had a 30-degree decrease in abduction; one, a 70-degree decrease; and one, a 110-degree decrease. Twelve patients had a 20 to 30-degree decrease in external rotation.
After the operation, forty-five patients were able to return to their previous work, eight had retired because of their age, twelve retired because of problems related to the shoulder, and eight changed to a less strenuous occupation. Of the twenty-one patients whose work had included strenuous manual labor, seven retired because of disability and four were transferred to less strenuous work.
Of the thirty-two patients who had had a traumatic separation of the acromioclavicular joint, nine were considered to have a good result; thirteen, a satisfactory result; and ten, a poor result. Twenty-one patients had pain with exertion, and twelve had pain with resisted abduction of the shoulder joint. Six patients had a 30-degree decrease in external rotation; one also had a decrease in internal rotation (maximum internal rotation, 30 degrees), and one had a decrease in abduction (maximum abduction, 110 degrees). Six patients had an average decrease in the abduction strength of the involved upper extremity of more than 30 per cent compared with that of the contralateral extremity. Two patients had sensory two-point discrimination of more than eight millimeters in the index and long fingers. One patient had a lesion of the suprascapular nerve, which was confirmed with electromyography and was probably related to the original trauma. Three patients had a positive Adson test, although none of them had any other signs or symptoms of thoracic outlet syndrome.
Of the eight patients who had had a fracture, one had a good result; three, a satisfactory result; and four, a poor result. Five patients had pain with exertion, and three had pain with resisted abduction. One patient had a 30-degree decrease in external rotation, internal rotation, and abduction. Four patients had a decrease of more than 30 per cent in the abduction strength of the involved upper extremity.
Of the thirty-three patients who had had chronic pain caused by primary osteoarthrosis of the acromioclavicular joint, eleven had a good result; thirteen, a satisfactory result; and nine, a poor result. Twenty of these patients had pain with exertion, and seventeen had pain with resisted abduction. Seven patients had a decrease in external rotation of 20 to 30 degrees, and two had a decrease in internal rotation of 20 and 30 degrees. Eight patients had more than a 30 per cent decrease in the abduction strength of the involved extremity.
A poor result was more common (p < 0.01) in the patients who had had a fracture of the lateral end of the clavicle.
Eighteen patients had elevation (average, 5.7 millimeters; range, three to twenty millimeters) of the lateral end of the remaining part of the clavicle as compared with the scapula. Pain was noted significantly more often in this group of patients (p < 0.05). The follow-up radiographs revealed osteolysis or resorption of an average of four millimeters of the lateral end of the clavicle as compared with the appearance on the initial postoperative radiographs.
The extent of the clavicular resection was significantly associated with pain. The patients who had had resection of ten millimeters or less had less pain than those who had had a larger amount of resection (p < 0.03). Additional analysis revealed that a good result was significantly more likely in the patients in whom less than ten millimeters had been resected (p < 0.05) because of a previous traumatic separation of the acromioclavicular joint or primary acromioclavicular osteoarthrosis.
In 1941, Curd and Mumford independently reported success with resection of the lateral end of the clavicle for both acute and chronic acromioclavicular dislocations. This encouraged others to use this treatment both in patients who had a traumatic condition and in those who had chronic pain due to a non-traumatic, degenerative condition. Because the current literature does not give any generally recognized guidelines for the extent of the resection, the orthopaedic surgeons who performed the operations in the present series independently decided on the extent of the clavicular resection. Our review revealed that the decision was not made according to the pathological condition.
Although our study was retrospective, we regard the results as valuable and the main conclusion as valid. As the latest follow-up data suggest, the results of this operative procedure were unpredictable and often poor; thus, the decision to perform a resection should be made with caution. The variation between our results and those of previous investigators may be due in part to the fact that our series of patients was larger, the duration of follow-up was longer, and the follow-up evaluation was more detailed.
The previously reported successful results have been based on short-term follow-up studies. Petersson reported on fifty patients who had had excision of the lateral end of the clavicle. At an average of nine years postoperatively, twenty-seven of his patients had a good result; there was no difference in the results between the sixteen patients who had had a non-traumatic mechanism of injury and the thirty-four who had had a traumatic one.
Rauschning et al. reported on seventeen patients who had had a complete separation of the acromioclavicular joint and had been managed acutely with oblique resection of the clavicle combined with transfer of the coracoacromial ligament. All of their patients were pain-free at the latest follow-up evaluation, one to five years later. Moseley advocated attachment of the resected end of the clavicle to the coracoid with a fascial suture to prevent displacement. Worcester and Green thought that ligamentoplasty (to prevent upward and backward displacement) was less important. In the current series, eighteen (25 per cent) of the seventy-three patients had upward displacement of the lateral end of the remaining clavicle at the most recent follow-up evaluation, and this finding was significantly associated with pain (p < 0.05).
Although Worcester and Green suggested two and one-half centimeters as the proper extent of the resection, we disagree with this recommendation. We suggest that, in patients who have chronic pain of either traumatic or non-traumatic origin, the resection should be limited to ten millimeters.
It is our impression that elevation of the lateral end of the clavicle may change the biomechanical balance of the shoulder joint, leading to a decrease in the range of motion as well as to muscular weakness3. We advise against resection in patients who hope to return to athletic endeavors or to a strenuous occupation.
Flatow et al. reported on six patients who had had an arthroscopic resection, with use of a superior approach, of an average of seventeen millimeters of the lateral end of the clavicle; the results were as good as those in a comparable group that had been managed with open resection. A benefit of the arthroscopic method is that the rotator cuff can be examined before the resection; however, we have found that the rotator cuff can be examined accurately with either ultrasonography or arthrography before it is decided whether or not to resect the clavicle.
The current series represents a large cohort of patients who were followed for a relatively long duration. With only twenty-one good results in seventy-three patients, it is difficult to advocate this procedure as a common treatment for chronic pain of the acromioclavicular joint due to a post-traumatic or degenerative condition. If such a resection is performed, it should not exceed ten millimeters.
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