ACROMIO-CLAVICULAR AND CORACO-CLAVICULAR FUSION – AN APPROACH TO PAINFUL INSTABILITY OF THE SCAPULA FOLLOWING EXCISION OF THE DISTAL CLAVICLE

Abstract

Aim: To review the experience of a tertiary referral shoulder practice in managing a group of patients each of whom presented with disabling pain and loss of function following excision of the distal end of the clavicle.

Methods: A retrospective analysis was performed of eight male patients (average age 46) who underwent this procedure between August 1998 and December 1999. All patients were assessed using a standard protocol pre and post-operatively.

The surgical technique involved an arthrodesis at the acromio-clavicular joint and coraco-clavicular space using autogenous iliac crest bone graft and fixation with both tension band wires and a cancellous screw.

Results: The minimum follow-up was six months and clinical assessments demonstrated painful instability of the residual clavicle predominantly in the antero-posterior plane presumably because of disruption of the posterior acromio-clavicular joint capsule which is the major restraint to posterior translation of the clavicle. The patients had undergone on average 3.1 operations and had had symptoms for an average of 79 months before the fusion.

The fusion rate was 75% (six out of eight). Pain, measured using a Visual Analogue Scale (0 to 10), was reduced from 8.5 pre-operatively to 3.1 post-operatively. The patient’s perception of instability reduced from an average of 9.0 to an average of 1.0. The range of motion increased in five patients, decreased in two and remained the same in one. All of the patients would have the operation again and seven out of eight were very satisfied. The complications included the two non-unions, mild sterno-clavicular pain in two cases and a need to remove K-wires in seven instances.

Conclusions: Acromio-clavicular and coraco-clavicular fusions are worthwhile salvage techniques in the difficult situation of painful instability of the distal clavicle after multiple previous procedures. This complication can be avoided primarily by preservation of the posterior acromio-clavicular joint capsule.