Painful Congenital Coracoclavicular Joint, Treated with Arthroscopic Resec on: A Case Report

Case Report

A 39-year old Thai female presented with her severe right shoulder pain for 5 months, without any trauma c history before. The right shoulder examina on revealed full ac ve and passive range of mo on. The pain was aggravated when she forward exion and adduc on her shoulder. She can’t able to do any heavy weight li ing due to her painful shoulder. The radiographic examina on revealed the presence of an accessory joint between the coracoid and the conoid tubercle (Figure 1). The computerized tomography (Figure 2) and the Magne c resonance imaging study reveal the presence of a pseudoarthrosis with degenera ve diarthrosis between the coracoid and the distal end of the clavicle (Figure 3).

The incisional biopsy was done through the pathological lesion and mature hyaline car lage was reported from the study. The local 2% xylocaine injec on test was performed at the coracoclavicular joint to con rm the source of her pain. Drama c pain relief at her shoulder was noted a er xylocaine injec on was done. However, the pain was relieved for just only a few hours and the pain was s ll the same as before the procedure.

Treatment

After we decided to treat the patient initially by non-operative treatment. Pain management was done by oral anti-inflammatory medications(NSAIDs) and local corticosteroid injection. We also advise the patient to restrict her weight lifting activity and avoid all activities that stress the AC joint, such as pushing and pulling. 6 months after the non-operative treatment the pain was improved but still disturb her daily life activity. Arthroscopic resection of the coracoclavicular joint was performed in order to improve her life quality by  restore her shoulder motion. The procedure was performed in standard beach chair position with a cushion under the scapula of the affected shoulder by under controlled hypotension and a combination of regional and general anesthesia for better visualization and post-operative recovery.

A standard posterior portal was created and the arthroscope was inserted into the glenohumeral joint. An anteroinferior portal was created with an outside-in technique through the rotator cuff interval. The anterior capsular structures are resected until the coracoid was well visualized. The anterosuperior portal  is then identified and created with a spinal needle at a point just anterior to the anterior margin of the acromion. Then the coracoid and also the coracoclavicular joint can be identified directly after the scope was transferred to the anterosuperior portal (Fig. 4). The coracoclavicular joint was resected through the anteroinferior portal by arthroscopic burr (Fig. 5). The resection begins laterally and proceeds medially. The margin and adequate of coracoclavicular joint resection was checked by using a fluoroscope(Fig. 6) and reference with the inferior margin of the clavicle(Fig. 7).

After the operation her arm was placed in a sling for 2 weeks after that she was allowed to begin her isometric shoulder strengthening and active shoulder range of motion exercised. The range of motion exercise up to flexion and abduction of 45 degree in the first 2 weeks and up to 90 degree in next 3 weeks. At 8 weeks we used the resistance band to performed the periscapular muscle strengthening exercises. At nine months postoperatively, she regained her full active range of motion with no painful arc of motion at her shoulder at all. No evidence of recurrence or inadequate coracoclavicular joint resection was seen from the postoperative radiographic study anymore(Fig .8). 

Discussion

A coracoclavicular joint is a rare anatomical entity that is more common in Asians than in other races. From the previous study, the prevalence ranges between 0.7 – 10% in osteological studies, 1.7-30% in cadaveric dissections and 0.04-3.0% in radiographic studies. But normally this anomalous joint dose not usually produce a painful arch of motion6-7. Conservative treatment is still the first-line of treatment. However if conservative treatment was failed, coracoclavicular joint excision is a good surgical option. The excision can performed by both open and arthroscopic technique8. In our case, we resected the joint by arthroscopic technique with a good postoperative clinical and radiographic results, no painful arch of motion in just 10 months postoperatively . We recommend arthroscopic excision technique in the patient who need less postoperative recovery time.

References

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4. Gumina S, Salvatore M, De Santis R, Orsina L, et al. Coracoclavicular joint: osteologic study of 1020 human clavicles. J Anat. 2002;201(6): 513–519
5. Nalla S, Asvat R, et al. Incidence of the coracoclavicular joint in South African populations. J Anat. 1995;186(3): 645–649
6. Possati A, et al. Un caso diarticolazione coraco-clavicolare osservato radiograficamente. Chir d Org di movimento. 1926;10: 533–536
7. Timpano M, et al. Aspetti radiografici dell’ articolazione coracoclavicolare. Ann di Radiol e Fis Med. 1934;(8): 491–507
8. Singh VK, Singh PK, et al. Bilateral coracoclavicular joints as a rare cause of bilateral thoracic outlet syndrome and shoulder pain treated successfully by conservative means. Singapore Med J. 2009;50(6): 214–217

Correspondence to:

Phonphok P, Department of Orthopedics, Phramongkutklao

Hospital, Bangkok 10400 Thailand.