Arthroscopic distal clavicle resection

The acromioclavicular joint is a potential source of pain in the shoulder. There are a variety of disorders that can affect this joint, including distal clavicle osteolysis, posttraumatic arthritis, osteoarthritis, and rheumatoid arthritis. Nonoperative treatment for this condition with nonsteroidal medication and activity modification can alleviate the pain. When conservative treatment is exhausted, surgical resection of the distal clavicle is often necessary. Arthroscopic resection of the distal clavicle preserves the acromioclavicular ligaments to prevent postoperative distal clavicle instability. The procedure is performed in either the beach chair or lateral position and requires the use of a shaver, electrocautery, and a burr for soft tissue and debridement and bone resection.     

Arthroscopic debridement of theacromioclavicular joint and distal clavicle resection

Painful disorders of the acromioclavicular joint that have not responded to extensive nonoperative management are well treated by arthroscopic resection of the distal clavicle. When the acromioclavicular and coracoclavicular ligaments are intact and the joint is stable, excellent pain relief and function may be achieved, and bone removal is comparable with that obtained with open techniques. When acromioclavicular disease is isolated, a direct (superior) approach to the acromioclavicular joint is preferred. When a sub-acromial procedure (usually acromioplasty) is also planned, a bursal approach is used.     

Arthroscopic treatment of distal clavicle fractures: a technical note

This article describes a new technique for the arthroscopic treatment of distal clavicle fractures. This technique requires the use of posterior and anterior standard arthroscopic portals. The base of the coracoid process is exposed through the rotator interval. The ancillary system drill guide is placed at the undersurface of the coracoid process. A small incision is performed above the clavicular body and the corresponding part of the guide is pushed down to the clavicle. A 4-mm hole is drilled through the clavicle and the coracoid process. A double button device is pushed through both the holes. The first button is pushed below the coracoid. The device is tightened and the second button is fixed on top of the clavicular cortical bone, allowing reduction and fixation of the fracture. Four patients treated with this technique were evaluated at 6 months postoperatively. All patients showed bony union and a full recovery of the shoulder function. The technique provides firm fixation of fractures of the distal clavicle.     

Stabilization of the clavicle after distal resection: a biomechanical study

BACKGROUND: The potential destabilizing effect of distal clavicle resection has received limited attention. HYPOTHESIS: Suturing the coracoacromial ligament to the undersurface of the distal clavicle after resection could counter clavicle instability. STUDY DESIGN: Controlled laboratory study. METHODS: The effect of ligament augmentation on posterior translation of the clavicle after resection was evaluated using 12 fresh-frozen cadaveric shoulders. Posterior clavicular displacement was measured after the application of a 70-N load under 4 different conditions: (1) the intact joint, (2) after distal clavicle resection, (3) clavicle resection plus acromioclavicular capsular ligament repair, and (4) clavicle resection plus acromioclavicular capsular ligament repair plus coracoacromial ligament augmentation. RESULTS: Mean displacements for each of the test conditions were as follows: (1) 5.60 mm, (2) 7.38 mm, (3) 7.54 mm, and (4) 6.34 mm. A 32% increase in posterior translation was measured after resection compared to the intact specimen. No reduction in posterior displacement was noted after capsular repair; however, displacement decreased significantly when capsular repair was coupled with ligament augmentation. CONCLUSIONS: Results suggest that the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation. CLINICAL RELEVANCE: That the destabilizing effect of clavicle resection can be partially countered by the proposed ligament augmentation may be particularly relevant in cases of resection for posttraumatic arthritis after acromioclavicular separation in which some degree of preexisting acromioclavicular capsular attenuation and consequently acromioclavicular joint laxity may be presumed.     

Unusual fracture of distal third of the clavicle in a hockey player: case report and a new approach to treatment

Clavicle fractures represent 5% of all skeletal injuries, and the distal third of the clavicle is involved in approximately 10%–15% of all these fractures. The incidence of delayed union or non-union in Neer type II fractures of the distal third of the clavicle is high. The ideal treatment for Neer type II fractures of the distal third of the clavicle is still open to controversy. Several treatments have been proposed, but there is no consensus about the treatment of choice. The case reported here presents a unique type of fracture of the lateral end of the clavicle that, since a medial fragment is involved, is a Neer type II fracture, but because of the nature of the fracture line the coracoclavicular ligaments remained intact. Trans-bony suture between the two fracture fragments was perfomed as the only treatment. This treatment has not been previously described and, although it has just been used in a single case, it appears to be an effective, efficient and simple alternative for the treatment of Neer type II fractures of the distal third of the clavicle. Received: 9 November 1997 Accepted: 1 March 1998     

Arthroscopic treatment of elbowarthritis in athletes

Arthroscopy has a valuable role in the treatment of elbow arthritis in the athletic population. General arthroscopicdebridement techniques used in the treatment of arthritis in other joints are quite valuable. Arthroscopic modifications of open techniques unique to the elbow, such as ulnohumeral arthroplasty, also are useful. As in other joints, the benefits of arthroscopic treatment of elbow arthritis may be temporary. Proper patient selection and attention to technical detail are critical in this population.     

Osteolysis of the distal clavicle in the overhead athlete

Atraumatic osteolysis of the distal clavicle (AODC) is a painful stress overload syndrome of the distal clavicle. Early AODC research basically concentrated on primary weight-lifters (PWL). A review of the literature shows that this condition has been infrequently described in throwing athletes who were adjunct weight-lifters (AWL). Adjunct weight-lifters train with heavy resistance in addition to their sport-specific conditioning program. It appears that the throwing athlete who lifts weight as adjunct training is susceptible to AODC. Although throwing athletes have been included in previous research studies, there has been no specific review of the relationship between AODC and the throwing athlete. The purpose of this article is to investigate whether there are significant differences between the presentation, diagnosis, and treatment of AODC in the throwing athlete who is an AWL and the PWL. It is our belief that there is a cumulative affect, when combining throwing sports with weight-training, that leads to an earlier age of presentation of AODC in adjunct weight-lifters. We have found the diagnostic results, treatment options, and treatment outcomes to be identical for AWLs and PWLs with AODC. Therefore, we recommend all throwing athletes with a history of weight training and shoulder pain be evaluated for AODC, even when presenting as a teenager.     

Evaluation and treatment of distal clavicle fractures

Of all clavicle fractures, those involving the lateral aspect are the most controversial. These fractures, adjacent to the strong coracoclavicular ligaments, often create an imbalance of stability and motion between the proximal and distal fragment. There are many surgical options, but the complication rates of these procedures can be high. Although nonsurgical management results in relatively high nonunion rates, the subjective and functional outcome is usually quite good. The evaluation and controversies involving management of distal clavicle fractures are reviewed in this article.     

Experimental comparison of flat-panel detector performance for direct and indirect systems

The purpose of this study was to compare direct and indirect detectors in terms of their presampled modulation transfer function (MTF), Wiener spectrum (WS), and noise-equivalent quanta (NEQ). Measurements were made on two flat-panel detectors, the GE Revolution XR/d (indirect) and Shimadzu Safire (direct) radiographic techniques. The presampled MTFs of the systems were measured using an edge method. The WS calculated the difference in uniform images that changed exposure to radiation using the two-dimensional Fourier method. The NEQ were assessed from the measured MTF, WS, and estimated signal-to-noise ratios (SNR). The system linearity was excellent in the direct Safire system. Presampled MTF was notably higher for the direct Safire system. For the direct Safire system, the WS was relatively uniform across all frequencies. In comparison, the indirect Revolution XR/d system exhibited a drop in the WS at high frequencies. At lower frequencies, the NEQ for the indirect Revolution XR/d system was noticeably higher than the direct Safire system. For the direct Safire system, the NEQ at mid to high spatial frequencies were higher linearity.     

Measuring portal venous perfusion with contrast-enhanced CT: comparison of direct and indirect methods

RATIONALE AND OBJECTIVES: Two algorithms can be used to measure portal venous perfusion (PVP) with contrast material-enhanced single-level liver computed tomography. The "direct" and "indirect" algorithms use data from the portal vein and aorta, respectively. This study compared PVP values obtained with direct and with indirect algorithms in a series of patients. MATERIALS AND METHODS: Both techniques were applied in 27 patients with cirrhosis (14 men and 13 women; mean age, 56.1 years +/- 9.4) and 18 control patients (seven men and 11 women; 52.8 years +/- 12.3). A single section through the liver was scanned after intravenous injection of ioversol (40-mL bolus; 320 mg of iodine per milliliter). RESULTS: Both techniques showed reduced PVP in patients with cirrhosis (0.63 for direct and 0.17 for indirect method) compared with control patients (1.06 and 0.26, respectively), but only the direct method agreed with physiologic expectations based on animal and human studies. In separating cirrhotic and control patients, the area under the receiver operating characteristic curve was significantly greater for the direct method (0.91 vs 0.78; P = .03). CONCLUSION: Both direct and indirect methods are feasible and distinguish well between cirrhotic and control patients, but the direct method is more physiologic and is preferable if portal venous data are available.     

Rhinosporidiosis isolated to the distal clavicle: a rare presentation clinicoradiologically mimicking a bone tumor

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi, which commonly affects young men and predominantly involves the mucous membranes of the nose, nasopharynx and eyes. Involvement of extranasal sites including bone has been reported, but rarely. We present a case of a 32-year-old farmer, who presented with a non-tender, fixed swelling over his right shoulder. Radiography and CT imaging showed an expansile, lytic, destructive lesion involving the lateral end of the right clavicle with soft tissue extension. The clinicoradiological impression was that of a primary bone tumor. Biopsy and wide excision of the lesion revealed features of rhinosporidiosis. There were no mucocutaneous lesions. Involvement of bone without associated mucocutaneous lesions is exceedingly rare in rhinosporidiosis. Involvement of the clavicle, as seen in the present case, has not been reported in the English language-peer reviewed literature, to the best of our knowledge.     

Arthroscopic treatment of shoulder impingement in athletes.

Twenty-nine patients (1 high school athlete, 9 college athletes, and 20 recreational or nonathletes) with Neer stage II impingement syndrome were treated by arthroscopic subacromial decompression after their injuries failed to improve with conservative therapy. Followup averaged 32.2 months, and results were rated based on subjective responses and the UCLA Shoulder Rating Scale. Of the results, 82.2% were rated as satisfactory, while 17.2% were unsatisfactory. The greatest margin of improvement was in the pain rating. Postoperatively, 65.5% of the patients returned to their previous level of activity and 56% of the collegiate athletes returned to their previous competitive level. The average time to return to college-level competitive athletics for the recreational or nonathletes was 6.6 months (average 5.4). There were no infections or neurovascular complications in the series.     

Arthroscopic treatment of antirior synovitis of the ankle in athletes

In a retrospective study we analysed the results of arthroscopic treatment of anterior synovitis of the ankle in 35 athletes. Five athletes additionally suffered from anterior osteophytes, and three presented with an anterolateral plica. Their average age was 25 years (SD 8.3), and the follow-up interval was 32.4 months (SD 19.4). Eight patients suffered from additional hyperlaxity of the ankle joint. At the time of follow-up, the patients were examined clinically as well as radiologically. The results were scored according to an ankle index containing the criteria pain, function, athletic activity, walking aids, range of motion and swelling. During surgery a partial synovectomy was performed and removal of anterior osteophytes or anterolateral plica as necessary. The overall score increased non-significantly from 66.2 preoperatively to 78.7 postoperatively (P>0.05). Comparing the different criteria, the score parameter pain significantly increased after arthroscopy. All other parameters (function, athletic activity, walking aids, range of motion, swelling) showed only slight changes in this patient group. Athletes with a hypermobile joint showed worse results compared with the others. Even after surgery we documented severe restriction concerning athletic activity. Only 9 patients performed their activities at their previous level, 19 had reduced their activity level, and 7 had discontinued their athletic activity. In 6 cases we found temporary iatrogenic neurological damage. Regarding the uncertain clinical outcome and the documented high risk for neurovascular complication, patient selection for arthroscopic partial synovectomy in the athletic population should be extremely carefully performed. Prior to surgery all other conservative options including changes of running shoes as well as modifications in the exercise programme and athletic activiy should be taken into account.     

Arthroscopic treatment of posterior impingement of the elbow in athletes

Arthroscopic treatment of posterior impingement of the elbow in athletes consistently can improve comfort and function. Arthroscopic treatment is particularly valuable because of increased intra-articular visualization of the anterior and posterior compartments and diminished soft tissue trauma. Arthroscopic visualization also can help the surgeon assess small pathologic changes in joint congruity seen in subtle forms of ligamentous instability, which are often symptomatic in high-demand athletes. Treatment of these subtle instabilities can be individualized to the athlete. Most athletes are able to return to the same level of their sport after arthroscopic surgery for posterior impingement of the elbow. In certain athletes, however, depending on the position played, reoperation rates are high, and return rates to the same level of competition can be less than in other athletes with posterior impingement of the elbow. Patient selection, technical expertise, and familiarity with open and arthroscopic elbow surgery are all criteria for success.