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  • Summary
    • AC arthritis is the most common cause of AC joint pain with repetitive microtrauma leading to the development of osteoarthritis in the AC joint.
    • Diagnosis is made with dedicated shoulder radiographs that reveal osteophytes and joint space narrowing in the AC joint. 
    • Treatment is a trial of NSAIDs, activity modifications, and corticosteroid injections. Arthroscopic versus open distal clavicle excision is indicated for patients with persistent symptoms that have failed nonoperative treatment.
  • Epidemiology
    • Demographics
      • more common with age but can occur by second decade of life
      • more common in weight-lifters and other sports
    • Risk factors
      • trauma
      • post-traumatic (i.e. clavicle fractures, AC instability)
      • distal clavicle osteolysis
      • inflammatory arthropathy (i.e. RA)
      • post-infectious arthropathy (i.e. septic arthritis)
      • Commonly associated with individuals who engage in constant heavy overhead activities
        • especially in weight-lifters and overhead throwing athletes
  • Etiology
    • Pathophysiology
      • AC joint arthritis is caused by transmission of axial large loads through a small contact area resulting in repetitive microtrauma (same mechanism as distal clavicle osteolysis)
  • Anatomy
    • Acromioclavicular Joint Anatomy
      • diarthrodial joint
        • articulation scapula to clavicle
        • contains a fibrocartilaginous intraarticular disc analogous to the meniscus of the knee
      • Small articular surface area with relatively high axial and rotational loads leads to high contact forces across AC joint
        • Exacerbated by articular disk degeneration and oblique joint surface orientation
      • Ligaments
        • acromioclavicular (AC) ligaments
          • provide anterior-posterior stability
            • posterior and superior AC ligaments are most important for stability
        • coracoclavicular (CC) ligaments
          • provide superior-inferior stability
  • Presentation
    • Symptoms
      • activity related superior shoulder pain
        • with overhead activity
        • with cross body arm adduction
        • with O'Brien's active compression test (at 90 degrees forward flexion)
        • exacerbated with pressing motion (i.e. bench press, push-up) and leaning on affected side (i.e. while sleeping)
    • Physical examination
      • palpation
        • pain with direct palpation of AC joint
        • prominence of the distal clavicle (osteophytes)
      • provocative tests
        • pain with cross body adduction test
  • Imaging
    • Radiographs
      • recommended views
        • best evaluated using Zanca view (15° cephalic tilt)
      • Findings
        • osteophytes and joint space narrowing
        • distal clavicle osteolysis
        • imaging findings do not always correlate with patient symptoms (often present on radiographs without clinical signs or symptoms)
    • MRI
      • increased signal and edema in AC joint
      • visualize associated pathology (i.e. rotator cuff, long head of biceps tendon)
  • Treatment
    • Nonoperative
      • activity modification and physical therapy
        • first line of treatment
        • avoid aggravating activity such as pushing/pressing activities
        • physical therapy should focus on strengthening and stretching of shoulder girdle
      • AC joint injection with corticosteriods
        • can be both diagnostic and therapeutic modality
        • access to the AC joint is challenging
        • AC joint injections often miss the joint
          • ultrasound improves accuracy of injection
        • most patients do not experience long term relief after injections
    • Operative
      • arthroscopic vs. open distal clavicle resection (Mumford procedure)
        • indications
          • severe symptoms that have failed nonoperative treatment
        • outcomes
          • open vs. arthroscopic based on surgeon preference and comfort
            • arthroscopic resection has the advantage of allowing evaluation of the glenohumeral joint and treatment of any associated injuries (rotator cuff, long head of biceps and glenoid labrum)
            • can combine diagnostic arthroscopy with open distal clavicle resection
            • open procedures require meticulous repair of deltotrapezial fascia
  • Techniques
    • Arthroscopic distal clavicle resection
      • should only resect 0.5-1cm of distal clavicle
  • Complications
    • AC joint instability
      • anterior-posterior instability
        • can be due to aggressive surgical distal clavicle resection ( >1-1.5cm)
        • aggressive debridement sacrificing posterior and superior AC ligaments
      • superior-inferior instability
        • usually iatrogenic due to aggressive surgical resection compromising coracoclavicular ligaments
    • Persistent pain
      • most commonly due to incomplete resection of distal clavicle
        • posterior-superior area of the distal clavicle
    • Heterotopic ossification
    • Deltoid dehiscence
      • inadequate deltotrapezial fascia repair after open distal clavicle resection
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