PROCEDURE 24
Open Distal Clavicle Excision
Lauren M. MacCormick, Alicia K. Harrison, and Edward V. Craig
INDICATIONS CONTROVERSIES
• Although open and arthroscopic distal clavicle
excision have demonstrated equivalent
outcomes in shoulder function and patient
satisfaction for treating AC joint pain, patients
undergoing arthroscopic technique have less
residual pain at 5 years (Robertson et al.,
2011).
• Arthroscopic technique allows the surgeon
to diagnose and treat subtle concomitant
intraarticular pathology. Open technique may
be performed using the same incision during
shoulder arthroplasty or an open rotator cuff
repair.
• Indication for treatment of a distal clavicle
fracture is limited and should be reserved
for symptomatic nonunion or malunion of
a clavicle fracture that is distal to intact
coracoclavicular ligaments.
TREATMENT OPTIONS
• Nonoperative treatment: Initial management
should focus on antiinflammatories and activity
modification. Corticosteroid injections can
also provide relief and aid in diagnosis. Due to
the superficial nature of the AC joint, steroid
injections can cause skin discoloration or
fatty atrophy. After 6 months of conservative
management, surgical intervention can be
considered.
• Arthroscopic distal clavicle excision
244
INDICATIONS
• Acromioclavicular (AC) arthritis
• Distal clavicle osteolysis
• Distal clavicle fracture
• Type IV, V, VI AC injuries in conjunction with coracoclavicular ligament reconstruction
• Chronic AC joint instability in conjunction with coracoclavicular ligament reconstruction
EXAMINATION/IMAGING
• Visual inspection for asymmetric bony anatomy with prominence over the AC joint.
• Direct palpation of AC joint to illicit pain with comparison to contralateral extremity.
• Provocative tests include cross-body adduction stress test (Fig. 24.1), AC-resisted
extension, and active compression (Chronopoulos et al., 2004). Similar to palpation,
it is useful to compare with the contralateral extremity.
• Initial radiographs should include anteroposterior (AP), Grashey, scapular Y lateral,
and axillary views of the shoulder to evaluate the AC joint and glenohumeral joint.
• A Zanca view can be helpful in evaluation of the AC joint, which is an anteroposterior
view with 10–15 degrees of cephalic tilt (Fig. 24.2) and the voltage decreased by
50% (Zanca, 1971). Evidence of AC arthritis includes AC joint subluxation, sclerosis,
joint space narrowing, subchondral cyst formation, and osteophytes (Fig. 24.3).
• A high rate of degenerative findings in asymptomatic patients (75%), particularly in
patients older than 50 years old, has been reported (Needell et al., 1996; Petersson,
1983).
• Magnetic resonance imaging (MRI) is a sensitive study for AC arthritis, but lacks
specificity and is not recommended for diagnosis. Fig. 24.4A and B demonstrate
edema within the AC joint capsule in a symptomatic and asymptomatic patient,
respectively.
FIG. 24.1
 PROCEDURE 24 Open Distal Clavicle Excision 245

X-ray
10˚

FIG. 24.3

FIG. 24.2

A B

FIG. 24.4 A–B

SURGICAL ANATOMY
• The distal clavicle meets the acromion to form the diarthroidal AC joint and allow for
three types of motion: rotation of the clavicle, tilting of the acromion, and anteropos-
terior gliding of the acromion.
• The average size of the adult AC joint is 9 × 19 mm (Bosworth, 1949).
• The AC joint has both dynamic (deltoid and trapezius) and static (AC and coracocla-
vicular ligaments) stabilizers (Fig. 24.5A).
• The AC ligament provides horizontal stability and is the most important ligamentous
stabilizer in daily activities.
• The coracoclavicular (trapezoid and conoid) ligaments provide vertical stability (see
Fig. 24.5B, disrupted coracoclavicular ligaments, black arrow; coracoacromial liga-
ment, white arrow).
246 PROCEDURE 24 Open Distal Clavicle Excision

Acromioclavicular ligament

Coraco-acromial Trapezoid
ligament ligament
Synovial Conoid
sheath of ligament
biceps

Transverse
humeral
ligament

Biceps

A B

FIG. 24.5 A–B

FIG. 24.6 FIG. 24.7

POSITIONING
• Supine beach chair positioning with the head elevated 20–30 degrees.
• Drape and prepare the entire upper extremity in a sterile manner that allows for
­adequate clavicle exposure.
• The arm may be placed in an arm holder to stabilize the upper extremity.

PORTALS/EXPOSURES
• After induction, an examination under anesthesia is performed to assess range of
motion and evidence of instability.
• The surface is marked to identify the location of the coracoid and AC joint.
• The surface is marked to identify the location of the coracoid (black arrow) and AC
joint (white arrow; Fig. 24.6). A vertical saber incision is made over the AC joint mea­
suring 3–4 cm in length (Fig. 24.7).
• The skin and subcutaneous tissues are retracted with small skin rakes.
• The soft tissue is elevated off the AC joint for exposure and palpation. Fig. 24.8
shows an intraoperative subcutaneous dissection with skin retractors exposing the
intact AC joint.
 PROCEDURE 24 Open Distal Clavicle Excision 247

AC joint

FIG. 24.8

• 
Deep dissection is performed subperiosteally along the clavicle by splitting the PORTALS/EXPOSURES PITFALLS
­deltotrapezial fascia in line with the deltoid fibers.
• Avoid drifting too far anterior or posterior,
where there is limited soft tissue for closure.
PROCEDURE
Step 1: Exposure and Identification STEP 2 PEARLS
• Confirmation of the AC joint location is made with a needle (Fig. 24.9). • The surgeon should be able to place his or her
• Thin Hohmann retractors are used anteriorly and posteriorly to protect soft tissue. finger in the resected space while taking the
arm through cross-body adduction to confirm
Step 2: Resection adequate resection.
• Using an oscillating saw, approximately 10 mm of the distal clavicle is excised. In Fig. • It is typical to take slightly more posterior than
anterior.
24.10A, the saw blade is at a blue line marking 10 mm of resection from the end of • It may be possible to manually or visually
the clavicle. Note the slight lateral angle to the blade so as to resect a wedge of distal inspect the rotator cuff following clavicle
clavicle. excision.
• A towel clamp is used to grasp the end of the resected section to aid in mobilization
(see Fig. 24.10B).
STEP 2 PITFALLS
• Take the shoulder through range of motion, including cross-body adduction, to digi-
tally confirm the elimination of contact between the acromion and clavicle. • The trapezoid ligament is medial to the
• Fig. 24.11 is a bird’s-eye view of a cadaveric specimen following 10 mm distal clavi- distal clavicle excision border and should be
preserved to prevent instability.
cle resection (A, acromion; C, clavicle; D, reflected deltoid). Note the intact trapezoid
ligament (T).
STEP 2 CONTROVERSIES
Step 3: Closure
• The amount of distal clavicle resection has
• Hemostasis can be achieved by using bone wax on the exposed clavicle. been described as between 5 and 10 mm to
• Perform a layered closure of the periosteum, deltotrapezial fascia, subcutaneous achieve improvement in symptoms without
layer, and skin. creating AC joint instability (Branch et al.,
1996).
POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Amount of resection differs depending on the
patient’s anatomy and amount of hypertrophic
• This is an outpatient procedure; the patient may be discharged home in a sling with bone formation.
ice, antiinflammatories, and a short course of narcotics.
• Elbow and wrist range of motion should begin immediately postoperatively.
• The sling may be discontinued as tolerated and should no longer be used after STEP 3 PEARLS
2 weeks following surgery. • This technically straightforward, short
• Rehabilitation consists of active and passive range-of-motion exercises as tolerated and procedure results in a small cosmetic incision.
should begin in the first week following surgery. Goals of physical therapy should be
active and passive range of motion while focusing on rotator cuff, trapezius, and deltoid
strengthening. Patients can typically return to sedentary or light work after 5–7 days.
248 PROCEDURE 24 Open Distal Clavicle Excision

Clavicle

Acromion

FIG. 24.9

A B

Medial Clavicle Lateral

FIG. 24.10 A–B

FIG. 24.11
 PROCEDURE 24 Open Distal Clavicle Excision 249

EVIDENCE
Bosworth BM. Complete acromioclavicular dislocation. N Engl J Med. 1949;241:221–5.
In this early review article, the author examined the anatomy, etiology, pathology, and treatment for
AC dislocation.
Branch TP, Burdette HL, Shahriari AS. The role of the acromioclavicular ligaments and the effect of
distal clavicle resection. Am J Sports Med. 1996;24:293–7.
This biomechanical cadaver study looked at the role of the AC ligaments in controlling scapular
rotation. It examined each of the three orthogonal axes of rotation of the scapula with reference to
the clavicle after sectioning the AC ligament before and after removing 5 mm of distal clavicle.
Chronopoulos E, Kim TK, Park HB, Ashenbrenner D, McFarland EG. Diagnostic value of physical tests
for isolated chronic acromioclavicular lesions. Am J Sports Med. 2004;32:655–61.
This retrospective case-control study examined provocative examination techniques in 35 patients
who underwent distal clavicle excision with the goal to evaluate their diagnostic values.
Needell SD, Zlatkin MB, Sher JS, Murphy BJ, Uribe JW. MR imaging of the rotator cuff: peritendinous
and bone abnormalities in an asymptomatic population. AJR Am J Roentgenol. 1996;166:863–7.
This imaging study examined shoulder MRIs in 100 asymptomatic volunteers. The authors reported
that changes characteristic of AC joint osteoarthrosis were present in three-fourths of the shoul-
ders. Therefore, its presence alone does not appear to be a reliable indicator of pain or tendon
disease.
Petersson CJ. Degeneration of the acromioclavicular joint. A morphological study. Acta Orthop Scan.
1983;54(3):434–8.
There were 168 acromioclavicular resections performed. Degenerative changes were graded mac-
roscopically, and they found age-related disintegration of the joint cartilage.
Robertson WJ, Griffith MH, Carroll K, O’Donnell T, Gill TJ. Arthroscopic versus open distal clavi-
cle excision: a comparative assessment at intermediate-term follow-up. Am J Sports Med.
2011;39(11):2415–20.
This prospective cohort study compared outcomes after open versus arthroscopic distal clavicle
excision. Results were based on American Shoulder and Elbow Surgeons Shoulder (ASES) score,
visual analog scale (VAS), surgical time, radiographs, and satisfaction questionnaire with a mean
follow up of 4–5 years.
Zanca P. Shoulder pain: involvement of the acromioclavicular joint. (Analysis of 1,000 cases). Am J
Roentgenol Radium Ther Nucl Med. 1971;112:493–506.
This radiographic study described the “gold standard” method for plain film images of the AC joint.