2.1 Goals of Procedure

The goals of arthroscopic acromioclavicular joint (ACJ) resection are to decompress and create a space between the acromion and arthritic clavicle, and preserve the ACJ capsule. The indirect approach utilizes an arthroscope placed in the subacromial bursa and resects bone, beginning along the inferior margins and progressing to the superior capsule. Capsular boundaries are limited, so resection is partially achieved from the acromion, and the balance of the 1-cm resection is accomplished with distal clavicle resection ( Fig. 2.1 ).

2.2 Advantages

The dorsal and posterior capsular stabilizing ligaments are not cut when performing decompression of the ACJ. By centering the decompression, the medial capsular extension of the capsuloligaments and the coracoclavicular (CC) ligaments are preserved. Cosmesis and avoiding a painful scar in the area of a shoulder strap is an advantage of the arthroscopic approach. Also, visualization of the glenohumeral articulation can be achieved using the same portals.

2.3 Indications

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  Unresponsive pain to nonoperative treatment for a 6-month period.

  
  
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  Painful distal clavicle osteolysis in a younger patient with repetitive stresses.

  
  
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  Treatment of soft-tissue ganglions that extend from the glenohumeral joint via a rotator cuff defect.

2.4 Contraindications

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  Traumatic ACJ capsular injury that may exacerbate symptoms with distal clavicle excision.

  
  
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  Unstable os acromiale can be further destabilized with distal clavicle resection.

  
  
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  Revision surgery where prior distal clavicle resection has resected the medial ACJ capsule.

2.5 Preoperative Planning/Positioning

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  Clinical examination identifying symptomatic ACJ: direct palpation and cross-chest provocative testing.

  
  
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  Imaging studies: radiograph ( Fig. 2.2 ) and MRI ( Fig. 2.3 ).

  
  
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  Beach-chair or lateral decubitus.

2.6 Operative Technique

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  Examination under anesthesia.

  
  
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  Marking structures, landmarks, and portal placement ( Fig. 2.4 ).

  
  
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  Glenohumeral joint inflation with saline.

  
  
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  Posterior portal: outside-in technique.

  
  
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  Anterior portal:

  
  
  
  
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    Skin inferior to ACJ entering rotator interval.

  
  
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  Replace viewing portal via the posterior puncture into the subacromial space.

  
  
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  Create a lateral bursal portal in line with midclavicle with the acromion, 3 cm lateral.

  
  
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  Bursectomy.

  
  
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  Subacromial resection performed via the posterior and lateral viewing portals ( Fig. 2.5 ).

  
  
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  Place scope in the posterior viewing portal and introduce cannula in the anterior portal ( Fig. 2.6 ).

  
  
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  Use shaver and cautery to debride soft tissue beneath the ACJ.

  
  
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  Begin decompression by resecting the clavicle facet of the acromion in an anterior-to-posterior direction. Superior visualization of the distal clavicle is achieved ( Fig. 2.7 ).

  
  
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  Anterior clavicle resection is begun through the anterior portal beginning along the inferior surface and progressing to the capsule ( Fig. 2.8 ).

  
  
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  The posterior clavicle resection continues by elevating the posterior capsuloligaments and resecting bone with the capsule ( Fig. 2.9 ).

  
  
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  Symmetric resection is achieved and confirmed from posterior, lateral, and anterior viewing portals ( Fig. 2.10 ).