Distal Clavicle Osteolysis Treatment & Management

Updated: Jul 27, 2017
  • Author: Brett D Owens, MD; Chief Editor: S Ashfaq Hasan, MD  more...
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Treatment

Approach Considerations

Patients with distal clavicle osteolysis (DCO) in whom conservative treatment fails or who refuse to limit their activities are candidates for surgical treatment.

The only contraindications noted for surgical treatment of DCO are those general to surgery. Most surgical approaches, however, can be performed without general anesthesia (for instance, with intravenous [IV] sedation and interscalene block). Patients who are at particularly high risk with surgical treatment as a consequence of medical comorbidities should consult further with their primary care physician and their institution's anesthesia department for proper preoperative risk assessment.

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Medical Therapy

DCO 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, symptoms often return with resumption of previous activity. (See the image below.)

Preoperative anteroposterior radiograph of male we Preoperative anteroposterior radiograph of male weightlifter with symptomatic distal clavicle osteolysis.
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Surgical Therapy

The classic surgical treatment for DCO is distal clavicle resection, a reliable procedure with good-to-excellent results. Excellent results have been reported with arthroscopic distal clavicle resection. [14, 15, 16, 17, 18, 19, 20] 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 DCO 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. [21] 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.

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. [2, 16, 18] The distal clavicle should be resected enough to prevent AC impingement through a full range of shoulder motion. Careful attention should be taken to avoid excessive bony resection and to avoid violating the posterior superior AC joint capsule, in that this can lead to horizontal instability of the AC joint. [22]

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Postoperative Care

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.

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

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Complications

Few complications from surgical treatment of DCO 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 as a consequence of limited motion is a concern during the postoperative course. As noted (see Surgical Therapy), there is a risk of horizontal instability of the clavicle in the event of an overly surgical aggressive resection.

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