Novel assessment of the sternoclavicular joint with computed tomography for planning interventional approach

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients

PURPOSE

to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment.

METHODS

We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization.

RESULTS

Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again.

CONCLUSIONS

The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment.

LEVEL OF EVIDENCE

Level IV case series.

Arthroscopic Excision of the Sternoclavicular Joint

Osteoarthritis changes at the sternoclavicular joint (SCJ) have been shown to be present on computed tomography in more than 90% of people over the age of 60 years. Although usually asymptomatic, when symptoms do occur, they can be very debilitating. Most patients respond favorably to conservative treatment, but there is a small cohort of patients who continue to be symptomatic despite adequate conservative treatment. Surgical management with an open SCJ excision has been shown to give satisfactory results. However, probably due to concerns with regard to damage to the mediastinal structures, instability, and scarring, there is a high threshold for surgery. Arthroscopic SCJ excision has been shown to achieve similar results to an open procedure while avoiding some of the risks. In this Technical Note, we describe the indications, imaging, and the technique of an arthroscopic excision of the SCJ.

Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint

The sternoclavicular joint (SCJ) has a complete intra-articular disk that can be damaged either as a result of trauma or as part of ongoing degenerative joint disease. Although often asymptomatic, SCJ disk tears may lead to mechanical symptoms and pain. Previously, isolated symptomatic SCJ disk tears have only occasionally been mentioned in the literature with a few associated case reports of diskectomy by open arthrotomy. With improved imaging and availability of magnetic resonance imaging scans and the advent of SCJ arthroscopy it is now possible to treat symptomatic SCJ disk tears by arthroscopic excision. In this Technical Note, we describe the diagnosis of a torn SCJ disk and the technique of arthroscopic excision of a torn SCJ disk.

Surgical anatomy of the sternoclavicular joint: a qualitative and quantitative anatomical study

BACKGROUND

The quantitative anatomical relationships of the main ligamentous, tendinous, and osseous structures of the sternoclavicular joint have not been widely investigated. The purpose of this study was to provide a quantitative description of the sternoclavicular joint in relation to relevant surgical landmarks.

METHODS

We dissected eleven nonpaired, fresh-frozen cadaveric sternoclavicular joints from four men and seven women (mean age at death, fifty-three years; range, thirty-three to sixty-four years) and measured the ligaments, musculature, and osseous landmarks with use of a three-dimensional coordinate-measuring device.

RESULTS

The clavicular pectoralis ridge, located at the 9:30 clock-face position on a right clavicle, served as a reliable osseous landmark for reference to the soft-tissue attachments around the sternoclavicular joint. The costoclavicular ligament was the largest ligament of the sternoclavicular joint, with 80% greater footprint area than that of the posterior sternoclavicular ligament. Articular cartilage covered 67% of the medial end of the clavicle and was located anteroinferiorly. The sternohyoid muscle inserted directly over the posterior sternoclavicular joint and the medial end of the clavicle, whereas the sternothyroid muscle inserted 9.5 mm inferior to the posterior-superior articular margin of the manubrium and coursed 19.8 mm laterally along the first rib. An avascular plane that can serve as a "safe zone" for posterior dissection was observed in each specimen, posterior to the sternoclavicular joint and anterior to the sternohyoid and sternothyroid muscles.

CONCLUSIONS

The clavicular pectoralis ridge can be used as an intraoperative guide for clavicle orientation and tunnel placement in sternoclavicular ligament reconstruction. Sternoclavicular joint resection arthroplasty should avoid injuring the costoclavicular ligament, which is the largest sternoclavicular joint ligament. Resection of only the anteroinferior aspect of the medial end of the clavicle may provide adequate decompression while preserving the stability of the clavicle. The location of the sternohyoid and sternothyroid musculotendinous insertions appear to provide a "safe zone" for posterior clavicle and manubrial dissection.

Relationship of the Medial Clavicular Head to the Manubrium in Normal and Symptomatic Degenerated Sternoclavicular Joints

BACKGROUND

Clavicular prominence is common in patients with symptomatic degenerative sternoclavicular arthritis. It is unclear if this is caused by enlargement or subluxation of the clavicle. The aim of this report is to describe a reproducible measurement technique to evaluate the relationship of the medial clavicular head to the manubrium.

METHODS

One hundred normal sternoclavicular joints, twenty-five sternoclavicular joints with symptomatic degenerative arthritis, and twenty-five non-symptomatic sternoclavicular joints on the contralateral side were studied with three-dimensional (3D) reconstruction with use of computer modeling. The greatest width (anterior-posterior distance) and height (superior-inferior distance) of the clavicle in the sagittal plane were measured, and the positions of the anterior and superior borders of the medial clavicle and their distances to the frontal and axial planes, respectively, were evaluated. The ratio of the anterior-posterior distance to the anterior-frontal plane distance was measured to evaluate the anterior-posterior position of the clavicle and the ratio of the superior-inferior distance to the superior-axial plane distance was measured to evaluate its superoinferior position. If the ratio was not in the 95% normal range, the clavicle was defined as subluxated. The reproducibility of this technique was evaluated on the basis of the interobserver and intraobserver reliability.

RESULTS

This technique showed good interobserver and intraobserver reliability. The mean anterior-posterior and superior-inferior distances were significantly larger in association with symptomatic sternoclavicular arthritis than in the normal sternoclavicular joints (p < 0001). The clavicle was subluxated anteriorly in twenty-two of the twenty-five cases of symptomatic sternoclavicular arthritis, but it was not subluxated superiorly.

CONCLUSIONS

The medial clavicular head in patients with degenerative sternoclavicular arthritis is significantly larger than it is in the normal population, and it is usually subluxated anteriorly.

Arthroscopic sternoclavicular joint resection arthroplasty: a technical note and illustrated case report

Open resection arthroplasty of the sternoclavicular (SC) joint has historically provided good long-term results in patients with symptomatic osteoarthritis of the SC joint. However, the procedure is rarely performed because of the risk of injury to vital mediastinal structures and concern regarding postoperative joint instability. Arthroscopic decompression of the SC joint has therefore emerged as a potential treatment option because of many recognized advantages including minimal tissue dissection, maintenance of joint stability, avoidance of posterior SC joint dissection, expeditious recovery, and improved cosmesis. There are, however, safety concerns given the proximity of neurovascular structures. In this article we demonstrate a technique for arthroscopic SC joint resection arthroplasty in a 26-year-old active man with bilateral, painful, idiopathic degenerative SC joint osteoarthritis. This case also highlights the pearls and pitfalls of arthroscopic resection arthroplasty for the SC joint. There were no perioperative complications. Four months postoperatively, the patient had returned to full activities, including weightlifting, without pain or evidence of SC joint instability. One year postoperatively, the patient showed substantial improvements in the American Shoulder and Elbow Surgeons score; Single Assessment Numeric Evaluation score; Quick Disabilities of the Arm, Shoulder and Hand score; and Short Form 12 Physical Component Summary score over preoperative baseline values.

Arthroscopy of the sternoclavicular joint: an anatomic evaluation of structures at risk

INTRODUCTION

Recently, arthroscopy of the sternoclavicular joint (SCJ) has been described in clinical setting. The aim of this study is to examine the accessibility and safety of the SCJ by arthroscopy in a cadaveric model.

MATERIALS AND METHODS

An inferolateral and superomedial portal to the SCJ was created in 20 cadaveric specimens. After debridement, the specimens were dissected with a needle positioned in the portal tracts. The distance between the needles and bony landmarks, tendons and ligaments were measured. The integrity of the posterior capsule was evaluated macroscopically. In eight specimens, after anterior dissection, the needles were replaced by K-wires that perforated the posterior capsule to evaluate the distance to the neurovascular structures behind the SCJ.

RESULTS

Both portals were found to be safe while allowing good access to the joint. The superomedial portal went through the tendon of the sternocleidomastoideus muscle and the inferolateral portal through the pectoralis major muscle. The portals entered the capsule medial and lateral to the anterior sternoclavicular ligament. The posterior capsule was never perforated during debridement. The perforating K-wires, however, usually perforated either a major vein or artery, but were at a safe distance from the vagal nerve.

CONCLUSIONS

In this cadaver study, arthroscopy of the sternoclavicular joint could be used as a minimally invasive procedure allowing debridement of the joint without damaging the posterior capsule of the joint. If the capsule is inadvertently be breached, a major risk of neurovascular damage exists. We advise to have a backup of a cardiothoracic surgeon when performing this procedure.

Arthroscopy of the sternoclavicular joint

Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.