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Acromioclavicular Joint Resection
Arthroscopic Three Portal Technique
Mumford and Gurd first described excision of the distal clavicle by open means in 1945. The development of a variety of arthroscopic techniques has evolved over the past 15 years. Arthroscopic resection appears to be an improvement over traditional open procedures as it results in reduced pain, improved cosmesis, and an accelerated rehabilitation process, and it allows for ligament preservation. If arthroscopic resection is not done correctly, however, morbidity can be increased over traditional open procedures. Anatomically, the acromioclavicular (AC) joint is protected by a capsule and a variety of ligamentous structures, which need to be recognized and protected. A three portal technique will be described in the following outline.
Indications
1. Symptomatic posttraumatic degenerative arthritis, osteoarthritis, or rheumatoid arthritis
2. Osteolysis
3. Symptomatic meniscal derangement
Contraindications
1. Open or infected wounds
2. Unstable AC joints requiring reconstruction
3. Asymptomatic joints that merely present radiographic degenerative changes
Mechanism of Injury
AC joint symptomatology may result from posttraumatic changes following a sprain, separation, or fracture. This joint may be affected by generalized osteoarthritis and rheumatoid arthritis. It can also be the site of osteolysis, which is particularly prevalent in weight lifters.
Physical Examination
1. Direct tenderness over the AC joint and pain with anteroposterior translation
2. Pain at the AC joint with cross-arm adduction
3. Pain with internal rotation and extension of the shoulder
4. Pain referred to the AC joint with resistance in forward elevation with the arm adducted and thumbs up
5. Positive response to a differential injection into the AC joint
Diagnostic Tests
1. Standard radiographs of the shoulder with comparison films
2. 15-degree cephalic with comparative views of the opposite shoulder
3. Bone scan
4. Differential subacromial and AC joint injection
Differential Diagnoses
1. Impingement syndrome
2. Subcoracoid impingement
3. Rotator cuff pathology
Special Considerations
Care must be taken to avoid making the diagnosis based on radiographic findings.
Indications for AC Joint Resection
Must include some positive physical findings as well as radiographic confirmation before surgery is indicated.
Preoperative Planning and Timing of Surgery
This is an elective procedure and can be done as an isolated procedure or in conjunction with an arthroscopic subacromial decompression.
Special Instruments
1. Bipolar radio frequency device: Arthrocare Co-Vac or Diamond Vac (Arthrocare Corp., Sunnyvale, CA)
2. Conventional shavers, HeliCut (Smith & Nephew Endoscopy, Andover, MA) and/or burrs (3.5 and 4.5 mm)
3. Pump—recommended
Anesthetic Options
1. General anesthesia
2. Interscalene block
3. Hypotensive anesthesia with systolic pressure below 95 mm Hg pressure
Patient and Equipment Position
1. Decubitus or beach chair position
2. Standard arthroscopic equipment
3. 30-degree arthroscope
4. Traction/suspension equipment if decubitus position utilized
5. Arm prepped and draped free
6. Arthroscopic pump
7. Spinal curettes with narrow shaft (optional)
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