Open Incision versus Arthroscopically to remove tip of collarbone at AC joint

Q: Do you think it makes any difference whether surgery to remove the tip of the collarbone at the AC joint is done with an open incision versus arthroscopically? I can have it done either way if I want to -- or I can leave the decision up to the surgeon.

A: Dr. William J. Robertson of Massachusetts General Hospital in Boston offers the results of his own study of surgery for acromioclavicular (AC) joint pain. Comparisons were made in terms of results (shoulder function, patient satisfaction, pain) between two groups. The first group had an open incision approach for this procedure. The second group had all all-arthroscopic approach with very small puncture holes to insert the arthroscope rather than full sized incisions.

The acromioclavicular joint is located in the front of the shoulder where the acromion meets the clavicle (collar bone). The acromion is a curved piece of bone that comes from the back of the scapula (shoulder blade). It forms a little bony "roof" over the shoulder joint.

Sometimes the end of the clavicle that meets the acromion becomes degenerated and very painful. Conservative (nonoperative) care usually takes care of the problem. If you are facing surgery, you have probably already tried antiinflammatory medications and physiotherapy. This approach to treatment should be given a fair trial over a period of at least three to six months. The goal is to reduce pain, restore normal posture and alignment, and improve motion and function.

If patients do not achieve a satisfactory response from this approach, steroid injections (up to three spread out over three to six weeks) may be suggested. When all else fails, then surgery becomes a consideration. Sounds like that's where you are at in the decision-making process. Now, which way to go: open surgery or arthroscopic technique?

In the case of the 48 patients in this study, all had failed at least six months of conservative care. Surgery to remove the distal end of the clavicle was performed by Dr. Robertson. In 32 of the shoulders, arthroscopic surgery was performed. In 17 shoulders, the open incision method was used.

Given your question, you may find the results of these two groups of interest. The group who had arthroscopic surgery to remove the tip of the clavicle had less pain than the open incision group. But all other areas measured (satisfaction, shoulder function, willingness to have the surgery again) were pretty much the same between the two groups.

Dr. Robertson concluded that for chronic acromioclavicular (AC) joint arthritic pain, either surgical method (arthroscopic or open incision) is equally effective in alleviating painful symptoms and restoring normal motion and function. Open incision is more invasive and has greater reports of pain after the procedure. But four to five years later, the final outcomes were the same.

Surgeons who are less experienced with arthroscopy may want to continue with open incision procedures. Patients with large bone spurs or cysts may also need the open incision approach. For the experienced surgeon (like Dr. Robertson), operative time was equal between these two techniques so there wasn't an advantage of one over the other from that perspective.

There were two caveats ("yes buts") to this study. The first was the small size. With only 48 patients (a total of 49 procedures), the results may not apply to everyone. A larger sample size should be studied and compared.

The second point is that patients weren't randomly assigned to one group or the other. They were given the choice of which approach they would prefer. The equal success between the two groups may be linked to the patient's positive feelings about the technique used. Further studies should include not only a larger number of patients but also random selection of treatment for each one.

But we think the study reflects the kind of information you are looking for. There may be some individual factors in your case that would sway the surgeon one way or the other if the decision was left up to him or her. Don't hesitate to ask for his or opinion. Most patients are happier when the decision is made together in a collaborative fashion. Good luck!

Reference: William J. Robertson, MD, et al. Arthroscopic Versus Open Distal Clavicle Excision. In The American Journal of Sports Medicine. November 2011. Vol. 39. No. 11. Pp. 2415-2420.