ACJ Arthritis

Aetiology

 

Post-traumatic (type III clavicle fractures)

Idiopathic

 

4 patterns 

 

1. OA with osteophytes 

-  contribute to impingement

 

 Acromioclavicular Arthritis

 

2. Osteolysis with resorption & gross osteoporosis 

- due to repetitive microtrauma (eg weight lifters)

 

ACJ OsteolysisACj Osteolysis

 

3. RA

 

4. Hyperparathyroidism

 

Symptoms

 

Anterosuperior shoulder pain

- difficulty sleeping on affected side

- pain radiates to trapezius / spasm

 

Signs

 

ACJ OA Clinical Photo

 

Tenderness to direct palpation is most reliable sign

- may feel osteophytes

- must compare to ensure other side is not tender (but may have bilateral ACJ OA)

 

Cross body adduction of arm 

- tends to overlap with impingement

 

Diagnosis

 

LA + Cortisone

- inject into joint

- diagnostic / therapeutic

 

DDx

 

Intrinsic

- Impingement

- Calcific tendonitis

- ACJ gout

- ACJ sepsis

 

Extrinsic

- Cervical root C4/5

- shoulder tip pain from abdominal pathology

 

Xray

 

Zanca view

- AP 10° cephalic tilt with 50% penetration 

 

ACJ OA Inferior Clavicle Osteophyte

 

Bone Scan

 

Not usually necessary

 

ACJ OA Hot Bone Scan

 

Management

 

Non-operative

 

Most patients respond well

NSAIDs

Activity modification

Steroid injection

 

Operative

 

Indications for surgery

- X-ray evidence of degenerative change

- tenderness at ACJ

- pain relieved by LA injection to ACJ

- failure of non operative treatment

 

Aim

 

Resect sufficient distal clavicle to prevent abutment

 

Options

 

1.  Open excision distal clavicle

2.  Arthroscopic resection

 

Open Excision of distal clavicle

 

Post Open ACJ Excision

 

Technique

- incision centered over the ACJ

- minimal takedown of deltopectoral fascia and anterior deltoid

- incise ACJ capsule longitudinally in midline

- elevate subperiosteally and repair later for stability

- resect 1cm only so as to not destabilise clavicle

- must leave conoid / trapezoid ligaments intact

 

90% success rate

 

Arthroscopic ACJ Resection

 

Advantage

- minimal incisions

- preserves superior AC ligament and deltoid

- quicker rehabilitation

 

Results

 

Freedman et al J Should Elbow Surg 2007

- routine GH scope initially

- identified subtle intra-articular changes not seen on MRI  which were treated

- labral tears, partial RC tears

- resection performed via subacromial space

- very similar results at 1 year to open resection

 

Technique

 

1.  Identify distal clavivle

- remove bursa and perform SAD

- use electrocautery from lateral portal to identify the distal clavicle (push down on clavicle repetitively)

- clean and identify clavicle anterior and posterior

 

ACJ OA 1ACJ OA 2

 

2.  Anterior portal

- placed just at lateral aspect of distal acromion

- remove anterior then posterior clavicle

- must remove full thickness of distal clavicle superiorly / be able to visualise superior AC ligament

- must not leave posterior edge

 

ACJ OA 3 Anterior CannulaACJ OA Debridement 1ACJ OA Debridement 2

 

Post Arthroscopic ACJ resectionSuperior AC Ligament post arthroscopic resection