Sternoclavicular joint surgery: how far does danger lurk below?

Incidence of Intraoperative Cardiothoracic Intervention During Open Surgery Following Acute Posterior Sternoclavicular Joint Injury: A Case Series and Review of the Literature

BACKGROUND

Acute posterior sternoclavicular joint injuries are rare but potentially lethal injuries-signs of mediastinal compression range from nonspecific to neurovascular compromise. Currently, orthopaedic experts recommend a cardiothoracic surgeon be placed on standby during open surgery for potential intraoperative complications. However, few studies have reported on how often cardiothoracic intervention is required.

METHODS

First, we identified patients in our institution by CPT codes 23530, 23525, and 23532 from January 1, 2002 to May 1, 2023. Demographic variables and intraoperative cardiothoracic intervention rates were collected. Second, we systematically reviewed the literature to identify articles on acute posterior sternoclavicular injury using PubMed, Embase, and CINAHL databases (through August 20, 2023). Exclusion criteria included conservative treatment, successful closed reduction, chronic injury (>6 wk) cadaver studies, reviews, and nonavailable text.

RESULTS

Thirteen local patients underwent open surgery for an acute posterior sternoclavicular joint injury, 11 males and 2 females with an average age of 18.2 years old (range: 15 to 32.4). The most common mechanism of injury was sports (n=9; 69.2%). Four (30.8%) patients had physical or radiographic evidence of mediastinal compression. No patients required intraoperative cardiothoracic intervention in our institution. The literature search yielded 132 articles and 512 open surgeries for acute posterior sternoclavicular joint injuries. Four patients required intraoperative cardiothoracic intervention, all of whom presented with polytrauma and/or clinical or radiographic signs of neurovascular compromise, giving a combined overall rate of 0.76%.

CONCLUSIONS

Expert opinion commonly recommends cardiothoracic backup during open surgery for acute posterior sternoclavicular joint injuries. On the basis of our local data and systematic literature review, we found an overall cardiothoracic intervention rate of 0.76%. In the presence of polytrauma and/or findings of neurovascular compromise, we suggest having cardiothoracic surgery on close standby during the procedure. However, a patient with an isolated acute posterior sternoclavicular joint injury and no clinical or radiographic findings of neurovascular compromise does not appear to require a cardiothoracic surgeon on standby. Ultimately, the decision to involve cardiothoracic backup during open surgery for an acute posterior sternoclavicular injury should be made on a case-by-case basis after a thorough physical and radiographic evaluation of the patient.

LEVEL OF EVIDENCE

Level III.

Missed Medial Clavicular Physeal Fracture-Posterior Dislocation Complicated by Brachiocephalic Pseudoaneurysm: A Case Report

CASE

We present a 17-year-old male patient with an initially missed posterior sternoclavicular fracture dislocation who presented with symptoms related to thrombotic emboli arising from a pseudoaneurysm. He was treated 6 weeks after injury with a figure-of-eight tendon allograft repair with good clinical outcomes.

CONCLUSION

This is a unique presentation that highlights the significant risk of a missed diagnosis, life-threatening complications that may ensue, and biomechanically superior surgical intervention.

Traumatic posterior sternoclavicular joint dislocation - Current aspects of management

The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.

Traumatic Sternoclavicular Dislocations in Athletes: Diagnosis, Indications for Surgical Reconstruction, and Guide for Return to Play

Injuries to the sternoclavicular (SC) joint are rare, however, when they occur prompt recognition, evaluation, and treatment are crucial. SC joint injuries can occur following high-energy mechanisms such as motor vehicle collisions and contact sports. Injury to the SC joint can be evaluated with the use of plain radiographs as well as computed tomography. If an injury to the SC joint is suspected, injury to vital mediastinal structures must be evaluated. SC joint dislocations can be treated by either closed reduction or open reduction and stabilization. Many stabilization methods have been described including plate stabilization and ligament reconstruction.

Current Concepts in Sternoclavicular Joint Injuries

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Two cases of sternoclavicular joint replacement arthroplasty: A case report. A novel prosthesis and surgical technique for recalcitrant instability, arthropathy of the sternoclavicular joint with medial clavicular bone loss

Instability arthropathy of the sternoclavicular joint is most commonly managed by rehabilitation, injection, and either arthroscopic or open debridement with or without interposition arthroplasty. When these options fail to achieve symptom relief, excision arthroplasty is an option. This is associated with a risk of persistent instability and incomplete pain relief. We describe two cases in which custom sternoclavicular joint replacement was performed for painful insufficiency of scapular suspension. Although the prostheses remained secure in both cases, the first case was complicated by persistent instability due to insufficient reconstruction of the intrinsic sternoclavicular capsular ligaments. This was recognised and corrected for in the second case, in which stability of the sternoclavicular joint replacement has been noted on more than a 5-year review. We conclude that sternoclavicular joint replacement is an option for patients in whom instability arthropathy remains an intrusive problem in daily life after other conventional treatments have not controlled symptoms. Stability of the joint remains a concern. We offer one method of achieving stability through an iterative design process including the ability to reconstruct the intrinsic capsular ligaments around the articulation.

Displaced medial clavicle fractures: a systematic review of outcomes after nonoperative and operative management

Background

Fractures of the medial clavicle are uncommon. There is no consensus regarding the optimal treatment of displaced medial clavicle fractures.

Methods

A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried using the terms medial clavicle and fracture to identify all studies reporting on outcomes following either nonoperative or operative treatment of displaced medial clavicle fractures. Data extracted included patient demographics, fracture classification, surgical technique, patient-reported outcomes, physical, and radiographic findings. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) scoring system.

Results

The analysis included 15 studies (mean MINORS score, 10 ± 1.5) with a total of 135 patients (85% male, mean age 47 ± 10.9 years [range, 15-87 years]). Five studies (39 patients) reported outcomes following nonoperative treatment. At a mean follow-up of 27 months, there were 5 (13%) symptomatic nonunions, 2 (5%) malunions, and 2 (5%) delayed unions. Eleven studies (96 patients) reported outcomes following surgical treatment with a mean follow-up of 23 months. There were no reported nonunions. Complications included plate prominence/ irritation (30%) and additional surgery was performed for plate removal (27%), fixation failure (3%), and wound débridement (1%).

Conclusion

There is limited, low-quality evidence in the literature to guide treatment of displaced medial clavicle fractures. The available data suggest that surgical treatment is associated with good functional outcomes and a lower risk of nonunion and malunion, compared to nonoperative treatment but plate irritation and further surgery to remove the plate was common.

Open sternoclavicular osteophyte debridement in the surgical management of sternoclavicular osteoarthritis: clinical outcome of a new procedure

INTRODUCTION

Symptomatic sternoclavicular osteoarthritis is uncommon but remains the most frequent non-traumatic condition affecting the sternoclavicular joint and tends to have a predilection for middle-aged women. It responds well to conservative management. Surgery is indicated when conservative management fails. We present the clinical outcome of open symptomatic sternoclavicular osteophyte debridement, a new operation for treating recalcitrant symptomatic sternoclavicular osteoarthritis.

METHODS

Five patients (five symptomatic sternoclavicular joints) with symptomatic sternoclavicular osteoarthritis underwent open sternoclavicular debridement following failure of conservative treatment. There were three females and two males. Mean age was 46.6 years (range 37.17-66). Four cases were primary osteoarthritis and one case was secondary to trauma. They were reviewed at mean follow-up at 35.4 months with minimum follow-up of 29 months. Assessment included Quick Disabilities of Arm Shoulder and Hand (DASH) and subjective patient satisfaction score.

RESULTS

There was no post-operative complication. Mean Quick DASH score 10.9 (range 0-29.5) at mean 35.4-month follow-up (range 29-43 months). Three patients reported excellent and two reported good outcome as per subjective satisfaction score.

CONCLUSIONS

Open sternoclavicular debridement has proved to be a simple, safe and highly effective new surgical treatment for patients with symptomatic sternoclavicular osteoarthritis unresponsive to non-operative management.

Acute Dislocations of the Sternoclavicular Joint: A Review Article

Acute dislocations of the sternoclavicular joint are uncommon injuries, and it is difficult for physicians to develop expertise in treating these injuries because of their infrequent nature. No level I evidence currently exists for these injuries, but several retrospective studies and surgical techniques have been described. For acute injuries, current recommendations include early treatment with closed reduction. If unable to attain or maintain reduction after a closed attempt, open management should be considered. Previous reviews have outlined relevant anatomy, physical examination findings, and imaging for these injuries. This article aims to review updated information from the past decade regarding techniques for reduction, outcomes, and complications related to the injury and surgical management.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department

BACKGROUND

Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician.

DISCUSSION

SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification.

CONCLUSIONS

SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

Complications after sternoclavicular surgery

BACKGROUND

Sternoclavicular joint (SCJ) pathologies such as instability are rare; therefore, SCJ surgery is performed infrequently. Complications of these surgeries can be devastating. This study evaluated complications, and particularly infections, after SCJ surgery.

METHODS

A retrospective cohort of 68 patients who underwent SCJ surgery with a minimum follow-up of 1 year was reviewed. Patients' characteristics, intraoperative, and postoperative complications were retrieved. In case of a reoperation, relevant data from the reoperation and microbiological findings were collected.

RESULTS

Twenty-two men and 46 women with a mean age of 37.5 years (range, 13-70 years) were analyzed. A complication occurred in 26 of 68 patients (38.2%). In 16 patients (23.5%), this was an infection. Cutibacterium acnes was the pathogen in 14 of these infections. Infection occurred more often in men than in women (P = .02). A total of 26 reoperations were performed in our cohort: 14 due to clinical signs of infection, 9 due to instability, 1 due to complaints of SCJ osteoarthritis, and 2 due to other causes.

CONCLUSION

Complications after SCJ surgery occur more often than previously described. C. acnes infections are often seen. When left untreated, these complications can lead to persistent complaints or recurrent instability due to failure of reconstruction. Therefore, it is of utmost importance to identify infections at an early stage, or better, to prevent them. The use of benzoyl peroxide gel preoperatively seems effective in reducing early C. acnes infections in this type of surgery.

Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management

Sternoclavicular joint (SCJ) instability is a rare condition and results from either a traumatic high energy impact, such as a motor vehicle crash or contact sports injury, or non-traumatically as a result of structural pathology. The infrequency of this injury has contributed to its diagnosis being missed as well as the paucity of literature on treatment and outcomes. Patients with SCJ instability often report diminished range of motion as well as shoulder girdle pain. The presentation of instability in the sternoclavicular joint can vary in severity and anterior or posterior directionality. Variation in severity of the instability changes the course of treatment regarding either operative or non-operative interventions to stabilize the SCJ. In general, anterior instability of the SCJ (the medial clavicle is displaced anterior to the sternum) is less urgent and generally manageable by symptom alleviation and rehabilitation, although some anterior instability cases require surgical intervention. In the case of posterior SCJ instability (the medial clavicle is displaced posterior to the sternum), patients require prompt joint reduction as they are at the greater risk of life-threatening injury due to the location of critical structures of the mediastinum posterior to the SCJ. Computed tomography visualization is useful to confirm dislocation or subluxation direction to better formulate a proper treatment plan. The purpose of this review is to report the clinical presentation and management of SCJ instability including pertinent symptoms, the diagnostic approaches to evaluating SCJ instability, as well as operative and non-operative management of the joint instability.

Posterior Sternoclavicular Dislocation: Do We Need "Cardiothoracic Backup"? Insights From a National Sample

OBJECTIVES

To describe the incidence of and risk factors for vascular injury associated with P-SCD.

METHODS

We used data from the HCUP-NIS from 2015 to 2016 and defined a cohort of patients with sternoclavicular dislocation (SCD) using ICD-10-CM diagnosis codes. We further isolated a subset with P-SCD. We describe the incidence of thoracic vascular injury, demographics, and injury severity score in this cohort.

RESULTS

Of an estimated 550 patients who had SCD, 140 (25%) were identified as having a P-SCD. No vascular injuries occurred in the P-SCD cohort. Among all patients with SCD, <2% of patients had a vascular injury, all of whom had an injury severity score ≥15, independent of the vascular injury itself. Among patients with an isolated P-SCD injury (55), overall length of stay was 1.8 days and total charges averaged $29,724.45. There was no mortality among patients with isolated P-SCD.

CONCLUSIONS

Here, we report no vascular injuries in the largest known series of P-SCD. Among all patients with SCD, vascular injury was rare, occurring only in severely polytraumatized patients. The recommendation for routine involvement of cardiothoracic surgeons in all cases of P-SCD should be re-examined.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes and Complications Following Surgical Management of Traumatic Posterior Sternoclavicular Joint Dislocations: A Systematic Review

BACKGROUND

Traumatic posterior sternoclavicular joint dislocations are rare orthopaedic emergencies. Treatment typically consists of closed reduction, with surgical management reserved for unstable cases. Because of the low prevalence of this condition, limited clinical evidence exists for a superior surgical stabilization technique.

METHODS

A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. MEDLINE and Embase databases were searched using a comprehensive search strategy. A descriptive and critical analysis of the results was performed.

RESULTS

Forty relevant studies (108 cases) were identified. Favorable subjective and objective outcomes were reported for all 5 categories of stabilization described. The overall complication rate was 16%, including 4 cases of recurrent instability. Ligament reconstruction using tendon graft had the lowest recurrent instability and complication rates, and open reduction and internal fixation techniques required a second operation for implant removal in 80% of cases.

CONCLUSIONS

A comprehensive review of the surgical management of traumatic posterior sternoclavicular joint dislocations is presented. Results suggest favorable outcomes for all of the methods of stabilization, with a modest complication rate. The trends observed have helped to guide the development of clinical care recommendations that aid in treatment decision-making for these injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies

The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome.

The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.

Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078

MEASURING THE DISTANCE BETWEEN STERNOCLAVICULAR JOINT AND HILAR STRUCTURES WITH TOMOGRAPHY

OBJECTIVES

To evaluate the tomographic distance between the sternoclavicular joints and the nearest hilar structures.

METHODS

Computed tomography images (axial and sagittal slices) in 120 healthy individuals (60 men and 60 women) between 18 and 60 years old were prospectively analyzed. The distances from both sternoclavicular joints to the respective brachiocephalic veins, trachea, esophagus, and lung apexes were measured and related to age, sex, and body mass index.

RESULTS

Statistically significant differences were found in the distance from the right and left sternoclavicular joint distances and the corresponding brachiocephalic vein, esophagus, and lung apexes. In women, both sides were closer to the noble structures. In patients with body mass index <25, the distances were significantly less than in heavier patients.

CONCLUSION

The left sternoclavicular joint is closer to the hilar structures than the contralateral side. In women, both sternoclavicular joints are closer to the brachiocephalic veins, esophagus, and lung apexes than in men. Patients with body mass index <25 have shorter distances between these joints and the brachiocephalic veins and esophagus. Level of Evidence II; Prognostic studies - Investigating the effect of a patient characteristic on the outcome of disease.

Sternoclavicular joint osteophytosis: a difficult diagnosis to swallow

Unexplained dysphagia requires prompt investigation to rule out a possible underlying malignancy. We describe the case of a 60-year-old man who presented to his family practitioner with a 1-year history of increasing dysphagia with associated pain over the front of his chest. He was referred on to an ear, nose and throat specialist where no obvious laryngeal pathology was found at direct laryngoscopy, but an 'indentation' of the right anterior larynx, which increased with external pressure on the sternoclavicular joint (SCJ), was noted. A subsequent CT scan of his neck demonstrated osteoarthritis of the right SCJ with an abnormally large posterior osteophyte. The patient was subsequently referred on to an orthopaedic surgeon specialising in SCJ surgery and underwent an arthroscopic excision of his right SCJ. Soon after surgery, the patient's dysphagia had settled and his symptoms remain resolved 1 year post surgery.

Surgical Treatment of Sternoclavicular Joint Dislocation Using a T-plate

A 22-year-old man was hospitalized with a sternoclavicular joint (SCJ) dislocation caused by a traffic accident. Surgical reduction and fixation of the SCJ were performed using a T-plate. SCJ dislocation is rare, accounting for less than 1% of all dislocations, and is usually treated conservatively, although severe cases may require surgery. Surgery typically involves joint reduction and fixation using an autologous tendon graft, but this has disadvantages such as the requirement for additional surgery to obtain autologous tissue and an extended operative time. To overcome these issues, here, we performed a simple SCJ reduction and fixation using a T-plate and achieved good results.

Management and functional outcomes following sternoclavicular joint dislocation

INTRODUCTION

The aim of this study is to describe the demographics, management and functional outcomes of patients presenting with a sternoclavicular joint (SCJ) dislocation.

METHODS

A retrospective medical record review was conducted examining patients with SCJ dislocation admitted to an adult level 1 trauma centre between 2004 and 2012. Patient demographics, symptoms, associated injuries, imaging technique used in diagnosis, surgical data and neurovascular complications were recorded. Patients received a single-page questionnaire to assess physical function using two validated shoulder questionnaires.

RESULTS

A total of 22 patients were identified, out of which 77% sustained a posterior dislocation. Mean age was 30 years (range 16-65), and the most common cause of injury was a direct blow during sport (n=11). Open reduction and internal fixation were performed in 13 patients, definitive closed reduction used in seven and two patients were managed expectantly. Functional outcomes for patients were excellent, with American Shoulder and Elbow Society (ASES) and Subjective Shoulder Value (SSV) scores >80 in 87.5% of cases. There were preoperative symptoms consistent with mediastinal compression in 50% and one delayed presentation with thoracic outlet syndrome. No patient had neurovascular compromise or functional deficit post-operatively, regardless of joint congruency.

CONCLUSION

This is the largest case series from a single institution currently available examining SCJ dislocation. We recommend an initial trial of closed reduction, followed by open reduction and internal fixation if there is joint instability or malreduction. Functional outcome following both closed and open reduction of the SCJ is excellent.

Outcomes of augmented allograft figure-of-eight sternoclavicular joint reconstruction

BACKGROUND

Sternoclavicular joint (SCJ) instability is a rare condition resulting in impaired function and shoulder girdle pain. Various methods for stabilizing the SCJ have been proposed, with biomechanical analysis demonstrating superior stiffness and peak load properties with a figure-of-8 tendon graft technique. The purpose of this study was to evaluate the clinical outcomes of SCJ reconstruction with an interference screw figure-of-8 allograft tendon technique.

METHODS

A retrospective analysis of a consecutive cohort of patients from 2007 to 2011 was performed for all patients undergoing SCJ reconstruction for instability. All patients were treated for SCJ instability with a figure-of-8 allograft reconstruction augmented by 2 tenodesis screws. Outcomes were performed with the American Shoulder and Elbow Surgeons (ASES) score, the shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and the visual analog scale (VAS) for pain score for all patients. Intraoperative and postoperative complications were recorded.

RESULTS

A total of 10 patients were included in the study, with an average follow-up of 38 months (range, 11.6-66.8 months). Preoperatively, the mean ASES score was 35.3 points (range, 21.7-55 points), whereas the postoperative mean ASES score increased to 84.7 points (range, 66.6-95 points). The mean VAS score improved from 7.0 (range, 5-10) before surgery to 1.15 (range, 0-3) at follow-up, and the QuickDASH score average was 17.0 points (range, 0 to 38.6 points). Minor postoperative complications were noted in 2 patients.

CONCLUSION

Patients who underwent repair of SCJ instability by an augmented figure-of-8 allograft tendon reconstruction report marked improvements in both shoulder function and pain relief.

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.

Clinical outcome after reconstruction for sternoclavicular joint instability using a sternocleidomastoid tendon graft

BACKGROUND

Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint.

METHODS

Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability.

RESULTS

Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred.

CONCLUSIONS

Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint.