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Distal Clavicle Osteolysis Treatment & Management

  • Author: Brett D Owens, MD; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Mar 06, 2015
 

Medical Therapy

Distal clavicle osteolysis is a self-limiting disorder that typically resolves within 1-2 years with activity modification. Conservative management consists of rest and avoidance of symptomatic activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also help alleviate symptoms. Corticosteroid injections are often given; however, they provide little long-term relief. Although most patients respond to conservative management (see the image below), symptoms often return with resumption of previous activity.

Anteroposterior radiograph of 26-year-old male weiAnteroposterior radiograph of 26-year-old male weightlifter with symptomatic distal clavicle osteolysis that responded to conservative measures.
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Surgical Therapy

The classic surgical treatment for distal clavicle osteolysis is distal clavicle resection, a reliable procedure with good-to-excellent results. Excellent results have been reported with arthroscopic distal clavicle resection.[10, 11, 12, 13, 14, 15, 16] This approach affords a more cosmetically appealing result, allows earlier return to activity, and provides a means of addressing concomitant intra-articular pathology. Arthroscopic resection can be performed through standard portals from the subacromial space, as well as via a direct superior portal (see the image below).

Left distal clavicle excision for distal clavicle Left distal clavicle excision for distal clavicle osteolysis performed with bone-cutting shaver placed in anterior portal, as viewed from direct posterior-superior portal.

A randomized, controlled trial of 38 athletes with osteolysis of the distal clavicle or isolated posttraumatic arthrosis of the acromioclavicular (AC) joint addressed the question of whether the direct superior approach or the indirect subacromial approach was the better procedure for arthroscopic distal clavicle resection.[17] The authors found that both procedures had successful clinical outcomes, with insignificant differences at follow-up, but that the direct approach provided faster improvement and return to activity.

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Intraoperative Details

The necessary extent of distal clavicle resection has been a subject of debate in the literature. Although Cahill reported excellent results with an open approach resecting 1-2 cm of bone, subsequent arthroscopic studies showed that resection of as little as 4 mm is effective.[1, 12, 14] The distal clavicle should be resected enough to prevent AC impingement through a full range of shoulder motion.

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Postoperative Details

Early passive range of motion (ROM), including pendulum exercises, is important to prevent loss of shoulder motion. Because the open procedure requires partial detachment of the deltoid, active ROM is usually restricted in the early postoperative course. After arthroscopic treatment, activity is comparatively accelerated, with active ROM started within the first week.

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Follow-up

Routine postoperative follow-up at 1-2 weeks is recommended.

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Complications

Few complications from surgical treatment of distal clavicle osteolysis have been reported. One theoretical concern with aggressive distal clavicle resection is damage to the underlying neurovascular structures. A risk of infection always exists, though the risk is low in this setting. Potential development of frozen shoulder because of limited motion is a concern during the postoperative course.

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Outcome and Prognosis

Although the outcome with conservative treatment is good, many patients are unable to limit their activities. These patients, as well as those in whom conservative treatment is ineffective, can expect good-to-excellent results from surgical intervention. Patients with an etiology of trauma may have an increased risk of unfavorable results. Patients can also develop symptoms in the contralateral extremity.

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Contributor Information and Disclosures
Author

Brett D Owens, MD Professor of Surgery, F Edward Hebert School of Medicine, Uniformed Services University of Health Sciences; Assistant Professor of Orthopedic Surgery, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Chief of Orthopedic Surgery, Keller Army Hospital

Brett D Owens, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Orthopaedic Trauma Association, Society of Military Orthopaedic Surgeons

Disclosure: Received consulting fee from Musculoskeletal Transplant Foundation for consulting; Received consulting fee from Johnson & Johnson (MITEK) for consulting; Received royalty from SLACK Publishing for other; Received salary from American Journal of Sports Medicine for employment.

Coauthor(s)

Robert Q Terrill, MD Assistant Professor, Department of Orthopedic Surgery, University of Massachusetts Medical Center

Robert Q Terrill, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Anthony Schena, MD Consulting Surgeon, ProSports Orthopedics; Associate Professor, Department of Orthopedics, Tufts Medical School

Anthony Schena, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America

Disclosure: genzyme Honoraria Speaking and teaching

References
  1. Cahill BR. Osteolysis of the distal part of the clavicle in male athletes. J Bone Joint Surg Am. 1982 Sep. 64(7):1053-8. [Medline].

  2. Schwarzkopf R, Ishak C, Elman M, Gelber J, Strauss DN, Jazrawi LM. Distal clavicular osteolysis: a review of the literature. Bull NYU Hosp Jt Dis. 2008. 66(2):94-101. [Medline].

  3. Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. Am J Sports Med. 1992 Jul-Aug. 20(4):463-7. [Medline].

  4. Matthews LS, Simonson BG, Wolock BS. Osteolysis of the distal clavicle in a female body builder. A case report. Am J Sports Med. 1993 Jan-Feb. 21(1):150-2. [Medline].

  5. Roedl JB, Nevalainen M, Gonzalez FM, Dodson CC, Morrison WB, Zoga AC. Frequency, imaging findings, risk factors, and long-term sequelae of distal clavicular osteolysis in young patients. Skeletal Radiol. 2015 Jan 7. [Medline].

  6. Brunet ME, Reynolds MC, Cook SD. Atraumatic osteolysis of the distal clavicle: histologic evidence of synovial pathogenesis. A case report. Orthopedics. 1986 Apr. 9(4):557-9. [Medline].

  7. Tao HM, Chen J, Ji YY. Post-traumatic osteolysis of the distal clavicle, pubis and ischium in 7 patients. Chin J Traumatol. 2004 Aug. 7(4):247-52. [Medline].

  8. Kassarjian A, Llopis E, Palmer WE. Distal clavicular osteolysis: MR evidence for subchondral fracture. Skeletal Radiol. 2007 Jan. 36(1):17-22. [Medline].

  9. Shaffer BS. Painful conditions of the acromioclavicular joint. J Am Acad Orthop Surg. 1999 May-Jun. 7(3):176-88. [Medline].

  10. Flatow EL, Cordasco FA, Bigliani LU. Arthroscopic resection of the outer end of the clavicle from a superior approach: a critical, quantitative, radiographic assessment of bone removal. Arthroscopy. 1992. 8(1):55-64. [Medline].

  11. Flatow EL, Duralde XA, Nicholson GP. Arthroscopic resection of the distal clavicle with a superior approach. J Shoulder Elbow Surg. 1995 Jan-Feb. 4(1 Pt 1):41-50. [Medline].

  12. Auge WK, Fischer RA. Arthroscopic distal clavicle resection for isolated atraumatic osteolysis in weight lifters. Am J Sports Med. 1998 Mar-Apr. 26(2):189-92. [Medline].

  13. Freedman BA, Javernick MA, O'Brien FP, Ross AE, Doukas WC. Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial. J Shoulder Elbow Surg. 2007 Jul-Aug. 16(4):413-8. [Medline].

  14. Nuber GW, Bowen MK. Arthroscopic treatment of acromioclavicular joint injuries and results. Clin Sports Med. 2003 Apr. 22(2):301-17. [Medline].

  15. Zawadsky M, Marra G, Wiater JM. Osteolysis of the distal clavicle: long-term results of arthroscopic resection. Arthroscopy. 2000 Sep. 16(6):600-5. [Medline].

  16. Rabalais RD, McCarty E. Surgical treatment of symptomatic acromioclavicular joint problems: a systematic review. Clin Orthop Relat Res. 2007 Feb. 455:30-7. [Medline].

  17. Charron KM, Schepsis AA, Voloshin I. Arthroscopic distal clavicle resection in athletes: a prospective comparison of the direct and indirect approach. Am J Sports Med. 2007 Jan. 35(1):53-8. [Medline].

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Anteroposterior radiograph of 26-year-old male weightlifter with symptomatic distal clavicle osteolysis that responded to conservative measures.
Left distal clavicle excision for distal clavicle osteolysis performed with bone-cutting shaver placed in anterior portal, as viewed from direct posterior-superior portal.
 
 
 
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