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Arthroscopic Subacromial Decompression And Excision Distal Clavicle – A Case Series Using A Novel Portal

Templeton-Ward O, van-Hegan I, Sawalliah S, Dodd L, Proctor M.

Kingston General Hospital. UK.

Address for Correspondence:
Templeton-Ward O
Kingston General Hospital. UK.


Introduction: We describe the technique and report the outcome of 100 arthroscopic subacromial decompressions with excision of the distal clavicle performed using a new arthroscopy portal.

Methods: We prospectively collected data on all patients who underwent simultaneous arthroscopic subacromial decompression and excision of distal clavicle by a single surgeon in one institution over an 8 month period. All patients had symptoms as a result of subacromial impingement persisting for at least 6 months despite conservative measures. All patients had MRI scans confirming subacromial impingement and acromioclavicular joint degenerative changes except two patients who were claustrophobic and had ultrasound scans instead. Arthroscopic subacromial decompression was performed via a postero-lateral viewing portal and a postero-medial working portal described by Declercq. Excision of the distal clavicle was performed via a new portal located posteriorly at the superior edge of the scapular spine and in-line with the acromioclavicular joint. All operations were performed under general anaesthesia with instillation of local anaesthetic into the subacromial bursa at the end of the operation. Postoperative analgesia consisted of paracetamol, codeine phosphate and non-steroidal anti-inflammatory drugs unless contraindicated. Patients were encouraged to start shoulder movements immediately after surgery. Time to return to work and driving were recorded. Oxford Shoulder Score (OSS) was recorded preoperatively and at 2 weeks and 6 months postoperatively.

Results: 100 patients were included. (58 men and 42 women, mean age 58 years, range 39-75 years). The mean time to return to work was 12 days and to driving was 9 days. The mean pre-operative VAS pain score was 7.2 and 6 weeks post-op was 3. The mean pre-operative oxford shoulder score (OSS) was 22.4 and a 6 week follow-up was 36.2. Eleven patients (11) had their operations done as inpatient due to medical co-morbidities and were discharged on the first postoperative day. Eighty-Nine patients (89) had their operations done as day-case procedures; one of them required overnight admission due to an allergic drug reaction. No other complications were recorded during the study period.

Discussion and conclusions: The new arthroscopy portal for excision of distal clavicle provides direct access to the acromioclavicular joint and minimises muscle and soft tissue injury. Simultaneous arthroscopic subacromial decompression and excision of distal clavicle using this technique can be done as a day-case procedure, provides good relief of pain and improvement in functional outcome scores and allows quick return to work and driving.

J.Orthopaedics 2010;7(4)e10


shoulder; arthroscopy; sub acromial decompression; portal


Neer’s work in the 1970s/80s (1) first implicated the anterior acromion as a cause for painful impingement in the subacromial space. Following Ellman’s work in the 1980s (2) arthroscopic subacromial decompression (ASAD) has become a well recognised and successful treatment for refractory painful impingement.

In the study by Fischer et al the authors studied the effect of violation of the Acromioclavicular joint (ACJ) during arthroscopic acromioplasty; the authors found that patients that either had no violation of the AC joint or patients that had complete distal clavicle resection (DCR) had no postoperative sequelae in reference to the AC joint, in contrast, 14 / 36 shoulders (39%) with documented AC joint violation and a partial DCR developed AC joint symptoms at an average of 8.4 months; this has led to the recommendation that if the AC joint must be violated to perform an adequate decompression of the subacromial space, complete resection of the distal clavicle should be performed, even if the radiographs show no preoperative degenerative changes.

Most papers describe a posterolateral viewing portal and a lateral and direct superior working portal for simultaneous decompression and excision distal clavicle however it is the primary authors view that this does not afford adequate visualisation of the ACJ to ensure full resection of the distal clavicle, thus avoiding the AC joint symptoms described by Fischer. In 1999 Declercq (4) described the use of a posteromedial working portal in the same saggital plane as the ACJ in combination with a direct anterior portal for completion of the resection.

We describe the use of Declercq’s posteromedial portal in conjunction with a second posteromedial portal located at the superior edge of the scapula spine directly in line with the ipsillateral ACJ, thus avoiding the possible damage to the superior capsular ligaments associated with the use of the anterior and superior portal.

Materials and Methods:

Patients were followed up prospectively over a period of 1 year; all of them had clinical impingement refractory to conservative management (mean symptoms 14 months) and an MRI scan confirming subacromial impingement and a degenerative ACJ. They were all scored preoperatively on the day of surgery using the oxford shoulder score (OSS) and the visual analogue (VAS) pain scoring system. Other demographic details were also collected. All operations were carried out or supervised by a single surgeon (senior author MP) using a standard technique described below.

After induction of general anaesthesia the patient is placed in the lateral decubitus position and tilted 30° posteriorly. Between 4 and 5 kg of skin traction is applied to the arm, which is placed in 20° of abduction and slight forward flexion. The arthroscope is placed through a posterolateral portal just lateral to the soft spot to inspect the glenohumeral joint and the under surface of the cuff (Fig 1). Through the same skin incision, we place the arthroscope into the subacromial space. After inspection of the subacromial space, we make the posteromedial working portal. This portal is 2.5 to 3 cm more medial to the posterolateral portal and 3 to 4 cm inferior to the spine of the scapula (Fig 1). Normally, the portal will lie in the same sagittal plane as the ipsilateral AC joint. The acromion is planned flat through this portal and the prominent CA ligament removed, initial resection of the ACJ is then performed to the extent allowable by the constraints of the portal. A third posteromedial portal is then made on the superior edge of the spine of the scapula in line with a posteriorly projected extension of the ACJ (Fig 2), the exact location of the skin incision is variable and may need to be more posterior to prevent skin and fat being compressed on the spine of the scapula depending on patient habitus. A pencil point trochar is then inserted directed towards the front of the ACJ parallel to the floor to check the alignment of the portal which should come out directly underneath the ACJ. A shaver is then introduced in place of the trochar (Fig 3) and a full 1cm resection of the distal clavicle is performed from posterior to anterior under direct vision.

The subacromial space is the infiltrated with 20mls of chirocaine following removal of the skin traction and closure of the 2 posteromedial portals with 4.0 vicryl and steristrips. The postero-lateral portal is then closed in a similar fashion and spirit gauze and mepore dressings applied.

Postoperatively the patient is advised to fully mobilise the shoulder and no sling is required. The patients were then followed up by the surgical team at 2 weeks and 6 months and again scored using the VAS and OSS questionnaires.

Figure 1: Location of 3 arthroscopy portals

Figure 2: Illustrates the position of the second posteromedial working portal superior to the spine of the scapula in line with a posterior projection of the ACJ.

Figure 3: Insertion of shaver to perform complete resection of ACJ

Results :

100 consecutive patients (100 shoulders) were followed prospectively. There were 58 men and 42 women with a mean age of 58 (39-75). The dominant arm was operated on in 64 patients. The mean follow-up was 7 months (6-14). 35 patients had a full thickness rotator cuff tear confirmed at arthroscopy and 19 had evidence of Grade 2 or above osteoarthritis on either the humeral head or glenoid surface. The mean preoperative VAS was 7.2 decreasing to 3.8 at 2 weeks and 3.0 at 6 months, no patients reported an increase in their VAS score. The mean pre-operative oxford score was 22.4, 30.8 at 2 weeks and 34.2 at 6 months. The average time to return to driving was 9 days (2-36) and to work was 12 days (1-42) 21 patients did manual work.

In the cohort who had a full thickness rotator cuff tears the mean pre-operative VAS was 6.9 and at 6 months post op was 3.2. The mean increase in Oxford shoulder score from pre-operative to 6 month follow up was 13 (average 18 pre-op, 31 at 6 months).  All of these patients were offered a second procedure to repair their cuff tears but none accepted as they were all satisfied with their pain and function post decompression. In the group of patients with co-existing Glenohumeral osteoarthritis the mean vas improved from 8.1 to 3.2 and the mean OSS from 20.7 to 33.4 at 6 weeks.

89 patients were done as day case procedures with 1 requiring admission overnight for management of an allergic drug reaction and 11 patients had their surgery on an in-patient list as a result of medical co-morbidities. There were no early or late complications from surgery and 100% of patients declared they were satisfied with their surgery at 6 months, no patients went on to have further shoulder surgery.

Discussion :

Our results show ASAD with EDC carried out through 3 posterior portals as described above is an effective way of treating coexistent impingement and ACJ degenerative change and in particular has as much beneficial effect in patients with full thickness rotator cuff tears and or GHJ arthritis as in those with otherwise normal shoulders. The senior author (MP) started using this portal in 1995 and has since performed over 1500 cases he has found it to be both simple and effective.

In 1999 Declercq (3) described the posteromedial working portal used here for the acromioplasty and demonstrated that in conjunction with a direct anterior portal it is effective for performing concomitant decompression and resection of the AC joint, our second posteromedial portal was developed as an alternative to the addition of an anterior portal. We feel it allows easier triangulation and more effective resection of the distal clavicle, in particular the posterior portion, therefore preventing the most common cause of failure of the procedure – incomplete resection of bone. The second posteromedial working portal at the superior edge of the scapula spine allows direct access to the ACJ in line with it, affording easy resection of the distal clavicle whilst avoiding trauma to the soft tissues posteriorly as a result of compression against the spine of the scapula. Its’ approach through the muscle bulk of supraspinatus greater than 5cm medial to the suprascapular notch means there is no risk of damaging either the axillary or suprascapular nerve. Levine et al (6) compared the bursal and direct approaches to the distal clavicle in 2006 and found both to be effective at treating AC joint arthrosis, however he found the direct approach using posterosuperior and anteriosuperior portals led to possible disruption of the superior capsular ligaments which on occasions caused post operative ACJ instability. This approach enters inferior to the ACJ and prevents any risk of damage to the key stabilising structures.

It is the senior authors feeling that decompressive surgery carried out in this way often provides satisfactory pain relief and functional improvement in patients with degenerative rotator cuff tears as to negate the need for further cuff repair surgery and the morbidity associated with it. This is supported by our results which indicate patients with full thickness cuff tears or osteoarthritis of the glenohumeral joint have had equally as much improvement in both their pain and functional scores as those with otherwise normal shoulders, also no patients in our series elected to have further surgery (either cuff repair or arthroplasty).


Arthroscopic subacromial decompression carried out using a third posterior working portal located posteriorly at the superior edge of the scapular spine and in-line with the acromioclavicular joint is a safe and effective way of treating sub-acromial impingement with coexisting degenerative change in the ACJ.


  1. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg Am 1972;54: 41-50.

  2. Ellman H. Arthroscopic subacromial decompression: Analysis of one- to three-year results. Arthroscopy 1987;3:173-181.

  3. Fischer, BW, MD Arthroscopic subacromial decompression. Arthroscopy, Vol 15, No 3 (April), 1999: (pp 241-248)

  4. Declercq G, M.D., Petre´D, M.D., and De Mulder K, M.D. A posteromedial working portal for arthroscopic subacromial decompression and acromioclavicular joint arthroplasty. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 4 (May-June), 1999: pp 456–458

  5. Neviaser TJ. Arthroscopy of the shoulder. Orthop Clin North Am. 1987;18:361–372

  6. Levine W, M.D., Soong M, M.D., Ahmad S, M.D., Blaine T, M.D., and Bigliani L, M.D. Arthroscopic Distal Clavicle Resection: A Comparison of Bursal and Direct Approaches. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 5 (May), 2006: pp 516-520

  7. Woolf S, M.D.,Guttmann D, M.D., Karch M, M.D., Lubowitz J, M.D. The Superior-Medial Shoulder Arthroscopy Portal Is Safe. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 3 (March), 2007: pp 247-250

This is a peer reviewed paper 

Please cite as: Templeton-Ward O: Arthroscopic Subacromial Decompression And Excision Distal Clavicle – A Case Series Using A Novel Portal.

J.Orthopaedics 2010;7(4)e10





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