Case Report

Vanishing Distal Clavicle After Arthroscopic Acromioplasty

Nicole Pouliart, M.D., and Pierre-Paul Casteleyn, M.D.

Summary: Arthroscopic subacromial decompression is gaining wide acceptance. There are severalreports on its technique, its limitations, and its efficacy. However, papers describing complicationsare rare. We describe a case of osteolysis of the distal clavicle after overenthusiastic arthroscopicsubacromial decompression.Key Words: Arthroscopy—Shoulder—Acromioplasty—Complica-tions—Osteolysis—Clavicle.

Acromioplasty is increasingly popular as treatmentfor subacromial pathology. It was first described

by Neer in 19721 as an open procedure. In the lastdecade, the arthroscopic form, as advocated by Ell-man,2,3 is gaining in acceptance. Reports about thefailure of the procedure to relieve symptoms are abun-dant.3-9 However, complications are rarely described.We report distal clavicular osteolysis as a complica-tion of arthroscopic subacromial decompressioncaused by a technical error.

CASE REPORT

A 40-year-old woman stumbled and fell on her rightshoulder. Radiographs revealed an undisplaced frac-ture of the greater tuberosity (Fig 1). She was treatedconservatively with a sling, followed by physiother-apy. Because of persistent pain after 4 months, mag-netic resonance imaging was performed. This showeda partial tear of the supraspinatus at its tendon inser-tion, but no obvious signs of subacromial conflict (Fig2). Mainly on clinical grounds, the tentative diagnosis

of subacromial impingement and subsequent attritionof the supraspinatus was made. Therefore, her surgeondecided to perform an arthroscopic subacromial de-compression. The operative report described an im-portant degree of impingement. Postoperative radio-graphs showed relatively little acromial resection, butan extreme amount of distal and inferior clavicularresection.

One month postoperatively, the patient suddenlyawoke at night because of severe pain in her rightshoulder. Radiographs then showed a clavicular frac-ture and partial osteolysis of the distal clavicular end

From the Department of Orthopaedics and Traumatology, Aca-demic Hospital of the Free University, Brussels, Belgium.

Address correspondence and reprint requests to Nicole Pouliart,M.D., Department of Orthopaedics and Traumatology, AcademicHospital of the Free University, Laarbeeklaan 101, 1090 Brussels,Belgium.

© 2000 by the Arthroscopy Association of North America0749-8063/00/1608-2333$3.00/0doi: 10.1053/jars.2000.7674

FIGURE 1. Radiograph showing the initial undisplaced fracture ofthe greater tubercle.

855Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 8 (November-December), 2000: pp 855-857

(Fig 3A). Four months postoperatively, she still hassevere pain at the acromioclavicular joint. On radio-graphs, the distal clavicle is seen to have almostcompletely vanished (Fig 3B).

DISCUSSION

Well over 100 papers and dozens of textbooks onshoulder surgery describe the indications, technique,and results of subacromial decompression.2-4,6-8,10-13

Initially, concern was raised whether the amount ofarthroscopic resection would be sufficient.12,14-16 Itsadequacy was shown to equal that of an open proce-dure in cadaveric as well as clinical studies.4,12,17-19

However, we have not found an article or textbookthat warns about excessive resection of the acromio-clavicular unit. Unintended clavicular resection, as inthis report, was never mentioned. If anatomic land-marks are well visualized, it would seem difficult towander into the clavicle inadvertently. Recognition ofthe limits of the resection may be facilitated by usingguiding needles at the anterior and posterior edge ofthe acromioclavicular joint.11-13

In addition, we feel that the acromioplasty was notreally necessary. A partial tear of the supraspinatustendon at its insertion in conjunction with a fracture ofthe minor tubercle is well recognized as a traumaticlesion. It may take up to 6 months to heal. Until then,the patient has clinical signs of impingement, butusually without subacromial conflict.

Osteolysis of the distal clavicle has been describedto occur in 2 different situations. The majority of casesoccur in athletes who excessively stress their acromi-oclavicular joints, e.g., weightlifters.20-24 In this pop-ulation, the process was believed to be due to boneresorption after repetitive microtrauma. Other reportsFIGURE 2. Magnetic resonance images showing the partial tear of

the supraspinatus.

FIGURE 3. Radiographs showing (A) the fracture and (B) osteolysis of the distal clavicle.

856 N. POULIART AND P-P. CASTELEYN

describe osteolysis after acute fractures of the acromi-oclavicular region.21,22,25To our knowledge, no casehas been reported in which osteolysis of the distalclavicle occurs after surgery at the acromioclavicularunit. In the case presented, the pathologic fracture ofthe clavicle has certainly played a role in diminishingthe already compromised vascularity of the remainingpart of its acromial end.

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857VANISHING CLAVICLE AFTER ACROMIOPLASTY