Medication Summary
The initial treatment of degenerative arthritis of the acromioclavicular joint may include the use of nonsteroidal anti-inflammatory drugs (NSAIDs), along with occasional corticosteroid injections.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. The mechanism of action of these agents is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well; these may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Ibuprofen (Motrin, Advil, IBU-200, Caldolor, Addaprin)
Ibuprofen is the drug of choice for patients with mild to moderate pain. This agent inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses exceeding 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe patients for a response.
Naproxen (Naprelan, Anaprox, Naprosyn, Aleve)
Naproxen is used for relief of mild to moderate pain. This agent inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Indomethacin (Indocin)
Indomethacin is rapidly absorbed; its metabolism occurs in the liver by demethylation, deacetylation, and glucuronide conjugation. This agent inhibits prostaglandin synthesis.
Diclofenac (Voltaren-XR, Cataflam, Zipsor, Zorvolex, Cambia)
Diclofenac inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which in turn decreases the formation of prostaglandin precursors.
Sulindac (Clinoril)
Sulindac decreases the activity of cyclooxygenase and in turn inhibits prostaglandin synthesis. This process results in a decreased formation of inflammatory mediators.
Fenoprofen (Nalfon)
Fenoprofen decreases the formation of prostaglandin precursors by inhibiting cyclooxygenase (COX)–1 and 2 enzymes. It may also inhibit neutrophil aggregation/activation and chemotaxis and may alter lymphocyte activity and decrease proinflammatory cytokine levels.
Flurbiprofen
Flurbiprofen may inhibit COX, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Cyclo-oxygenase 2 Inhibitors
Class Summary
COX-2 inhibitors are used to control pain and inflammation, especially in cases of contraindication to conventional anti-inflammatories. Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Celecoxib inhibits primarily COX-2, an isoenzyme induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity, but at therapeutic concentrations, COX-1 isoenzyme is not inhibited and thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.
Nonopioid Analgesics
Class Summary
Nonopioid analgesic agents are used for relief of mild to moderate pain. Acetaminophen (with or without an opiate) is the most commonly used analgesic.
Acetaminophen (Tylenol, Aspirin Free Anacin Extra Strength, Acephen, FeverAll)
Acetaminophen is the drug of choice for pain in patients with documented hypersensitivity to aspirin or NSAIDs, in those diagnosed with upper gastrointestinal disease, or in those taking oral anticoagulants.
Opioid Analgesics
Class Summary
Opioid agents are used for moderate to strong analgesic effects.
Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lorcet 10/650, Lortab, Norco, Zydone)
The combination of hydrocodone bitartrate and acetaminophen is indicated for the relief of moderate to severe pain.
Acetaminophen and codeine (Tylenol with Codeine, Capital and Codeine)
The combination of acetaminophen and codeine is indicated for the treatment of mild to moderate pain.
Corticosteroids
Class Summary
Corticosteroid agents have both anti-inflammatory and salt retaining properties. Glucocorticoids have profound and varied metabolic effects. In addition these agents modify the body's immune response to diverse stimuli.
Hydrocortisone (Solu-Cortef, Cortef, A-Hydrocort)
Hydrocortisone decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Triamcinolone (Aristospan Intra-Articular, Aristospan intralesional, Kenalog)
Triamcinolone is used for inflammatory dermatoses that are responsive to steroids. This agent decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Methylprednisolone (Depo-Medrol, Solu-Medrol, A-Methapred, Medrol)
Methylprednisolone decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
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Acromioclavicular joint anatomy.
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Classification of acromioclavicular joint injuries.
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Allman/Rockwood classification of acromioclavicular injuries.
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Anteroposterior (AP) radiograph of right shoulder showing step-off of the acromioclavicular (AC) joint.
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Type III acromioclavicular joint separation.
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Type III acromioclavicular joint separation.
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Postoperative coracoclavicular ligament reconstruction. The clavicle is back to its normal position. The anchor in the clavicle keeps the allograft tendon from coming off of the clavicle. Also note the distal clavicle has been excised, because it had traumatic arthritis from the injury.
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Type V separation, characterized by wide displacement of the clavicle in a superior direction relative to the acromion. The radiographic findings denote disruption of the acromioclavicular AC ligaments and coracoclavicular (CC) ligament, as well as the deltoid attachment to the distal clavicle.
