Arthroscopic Subacromial Decompression and Distal Clavicle Resection

Albert Lin, MD

Mark William Rodosky, MD

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Lin and Dr. Rodosky.

PATIENT SELECTION

Subacromial impingement and degenerative changes of the acromioclavicular joint are common causes of shoulder pain. Repetitive overhead use can lead to a painful inflammatory process, termed impingement, of the subacromial bursa and the supraspinatus as they traverse a bony outlet under the acromion.¹^,² These patients often report pain with overhead activities, lateral shoulder pain, night pain, and pain with abduction and internal rotation.² Likewise, hypertrophic changes from a degenerative acromioclavicular joint can lead to localized pain as well as impingement of the underlying rotator cuff. In these patients, anterosuperior pain that worsens with cross-body adduction or reaching behind the back may be more typical.³^,⁴

Surgical intervention, either open or arthroscopic, may be indicated in patients in whom nonsurgical management fails. The advantages of all-arthroscopic techniques include decreased surgical pain and, often, faster postoperative recovery, improved cosmesis, less trauma to the deltoid, and decreased blood loss.² Arthroscopic subacromial decompression and distal clavicle resection are excellent options for impingement and acromioclavicular degenerative joint disease and can be performed at the same time for concomitant pathology.⁴

Indications for surgery include failure of a 3- to 6-month course of nonsurgical management that includes anti-inflammatory medications such as steroid injections and nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy that includes a rotator cuff strengthening protocol, and activity modification. In patients with a massive and irreparable rotator cuff tear or with rotator cuff arthropathy, disruption of the coracoacromial ligament is contraindicated.¹^,² Distal clavicle resection without a stabilizing procedure is also contraindicated in patients with grade III or higher acromioclavicular joint instability.³

FIGURE 1 Radiographs of a shoulder obtained before arthroscopic subacromial decompression and distal clavicle resection. A, Outlet view shows an undersurface acromial spur encroaching on the subacromial space (SAS). B, Zanca view shows osteolysis of the acromioclavicular (AC) joint.

PREOPERATIVE IMAGING

Radiography

A radiographic series for impingement should include a true AP view of the glenohumeral joint (to assess for glenohumeral arthritis), an outlet view to evaluate the acromion (Figure 1, A), and an axillary lateral view to rule out an os acromiale. A Zanca view is best for evaluating the acromioclavicular joint for degenerative changes and osteolysis (Figure 1, B). Radiographs of the asymptomatic shoulder can allow side-to-side comparison.

Magnetic Resonance Imaging

MRI may be helpful in assessing the condition of the rotator cuff, including tendinopathy, partial tearing, or full-thickness tearing as well as any associated pathologies. Increased signal intensity or inflammatory changes around the acromioclavicular joint seen on MRI may also aid in confirming a suspected diagnosis based on history and physical examination.

VIDEO 24.1 Subacromial Decompression and Distal Clavicle Resection. Mark Rodosky, MD; Albert Lin, MD (6 min)

View Quicktime Video

Video 24.1

PROCEDURE

Room Setup/Patient Positioning

The patient is placed in an upright beach-chair position with the acromion parallel to the floor (Figure 2). Bony prominences are well padded.

Special Instruments/Equipment/Implants

The following equipment should be on hand for this procedure: a 30° arthroscope, 4.5- and 5.5-mm arthroscopic shavers, a 5.5-mm arthroscopic burr, a standard arthroscopic electrocautery device, and a hooked arthroscopic electrocautery device.

Surgical Technique

Examination Under Anesthesia

A thorough examination under anesthesia (EUA) should be performed to evaluate range of motion and ligamentous laxity. One advantage of performing an EUA (examination under anesthesia) before preparing and draping the patient is that a side-to-side comparison with the nonsurgical limb can be performed.

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