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Reserve distal clavicle resection until failure of all conservative treatments

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KOHALA COAST, Hawaii—Distal clavicle resection should be reserved for patients who have failed conservative treatment, show positive signs of acromioclavicular pain and pain relief with injection, according to a New York orthopedist.

“We are not talking about acromial-clavicular (AC) separations,” Evan L. Flatow, MD, said at Orthopedics Hawaii 2010, here. “We are talking about stable AC pathology such as AC osteoarthritis, distal clavicle osteolysis and post-traumatic conditions.”

AC pain can be in the anterolateral neck, the trapezius and a little in the anterolateral deltoid, he said. “But remember that the AC joint can simulate neck conditions.”

Diagnosis

Flatow said the good things about pain in the AC joint are that you can palpate it and compare it to the unaffected side. It can be made worse by cross-body induction, which aids in diagnosis.

“It can show up on imaging, but so much arthritis is asymptomatic and some AC joints that look perfectly normal on X-rays can be painful,” he said. “So clinical findings trump imaging in these situations.”

You can treat these patients with nonsteroidal anti-inflammatories, activity modification and corticosteroid injections. “Since the surgical treatment is to grind away the joint, I am not terribly worried about soft tissue damage due to the injections, unlike other areas,” Flatow said.

He also said physical therapy has not been effective in his hands.

Surgery

For the patients whose symptoms are significantly relieved with an injection and do not get better with nonoperative treatment, resection of the distal clavicle is indicated, according to Flatow

“The majority of these will be treated arthroscopically,” he said.

Popular arthroscopic approaches for distal clavicle resection are the bursal direct and superior direct. “The vast majority will use the bursal approach, except occasionally an isolated direct approach will be used,” he said. “This should depend on surgeon familiarity with the approach.”

Regardless of the approach it is important to preserve the ligaments. “Because if you take away the acromio-clavicular ligaments you can get instability,” he said.

• Reference:

Flatow EL. Distal clavicle resection: When and how? Presented at Orthopedics Today Hawaii 2010. Jan. 10-13, 2010. Kohala Coast, Hawaii.