Reconstruction for instability of the sternoclavicular joint using the tendon of the sternocleidomastoid muscle

Sternoclavicular Joint Reconstruction With Gracilis Tendon Autograft

Clinical instability of the sternoclavicular (SC) joint is a challenging problem. Recurrent subluxation and pain can lead to significant functional limitations. Although many patients respond positively to conservative treatment, chronic dislocations often require operative intervention. The complex anatomy of the diarthrodial SC joint and the existence of concomitant SC joint degenerative changes compounded with close-by neurovascular structures present a surgical challenge. The purpose of this Technical Note is to describe a technique for the open management of symptomatic sternoclavicular joint instability using a figure-of-8 reconstruction with a gracilis autograft. The present authors believe this technique provides a technically safe and reproducible method for reconstructing the SC joint without compromising biomechanical strength.

Physiotherapy management of atraumatic anterior sternoclavicular joint instability: A prospective case series

Background

Atraumatic sternoclavicular joint (SCJ) instability is rare. Long-term outcomes are presented for patients managed with physiotherapy. A standardised method of assessment and treatment with a structured physiotherapy programme is also presented.

Methods

Long-term outcome was analysed in this prospectively collected series (2011-2019) of patients who were assigned to a structured physiotherapy programme for atraumatic SCJ instability. Outcome-measures (subjective SCJ grading of joint stability (SSGS score), Oxford shoulder instability score (OSIS adapted for SCJ) and visual analogue scale (VAS) for pain) were collected at discharge and long-term follow up.

Results

26 patients (29 SCJ's) responded (return rate 81%). Mean follow-up was 5.1 years (range 0.9-8.3 years). 17/26 patients were hyperlax. 93% (27/29) of SCJs achieved a stable joint on SSGS score. Mean OSIS score at long-term follow up was 33.4 (range 3-48) and VAS 2.7 (range 0-9). 95% who were compliant with physiotherapy had a stable SCJ (mean OSIS 37.8 (SD 7.3) and VAS 1.6 (SD 2.1)). Those non-compliant, 90% were stable but had lower function (mean OSIS 25 (SD 14, p = 0.02) and more pain, VAS 4.9 (SD 2.9, p = 0.006).

Conclusion

The structured physiotherapy programme is highly effective in treating patients with atraumatic SCJ instability. Compliance was essential in ensuring better outcomes.

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.

Sternoclavicular Joint Reconstruction with Semitendinosus Allograft and Suture Anchors after Recurrent Posterior Dislocation in a Professional North American Football Player

Background:

Posterior sternoclavicular joint dislocations are an extremely rare but potentially life-threatening injury that can occur in sports. A variety of surgical procedures have been proposed, but there is no consensus on the treatment of choice. It is also largely unknown if a safe return to high-risk sports is possible.

Case Presentation:

We present a case of a posterior sternoclavicular joint dislocation in a 22-year-old male professional North American football player who had a recurrent irreducible posterior dislocation after initial injury management by closed reduction. The patient’s desire to return to football presented unique challenges to management. His sternoclavicular joint was subsequently reconstructed with semitendinosus allograft in a figure-of-eight augmented with suture anchors. After recovery, he returned to play as a running back in professional football symptom-free.

Conclusion:

Our patient's successful return to playing professional football after the sternoclavicular joint reconstruction suggests that this should be considered an effective treatment option when managing posterior sternoclavicular dislocation in high level contact sports players.

Midterm results of chronic anterior instability of the sternoclavicular joint managed using a standardized treatment algorithm

AIMS

There remains a lack of consensus regarding the management of chronic anterior sternoclavicular joint (SCJ) instability. This study aimed to assess whether a standardized treatment algorithm (incorporating physiotherapy and surgery and based on the presence of trauma) could successfully guide management and reduce the number needing surgery.

METHODS

Patients with chronic anterior SCJ instability managed between April 2007 and April 2019 with a standardized treatment algorithm were divided into non-traumatic (offered physiotherapy) and traumatic (offered surgery) groups and evaluated at discharge. Subsequently, midterm outcomes were assessed via a postal questionnaire with a subjective SCJ stability score, Oxford Shoulder Instability Score (OSIS, adapted for the SCJ), and pain visual analogue scale (VAS), with analysis on an intention-to-treat basis.

RESULTS

A total of 47 patients (50 SCJs, three bilateral) responded for 75% return rate. Of these, 31 SCJs were treated with physiotherapy and 19 with surgery. Overall, 96% (48/50) achieved a stable SCJ, with 60% (30/50) achieving unrestricted function. In terms of outcomes, 82% (41/50) recorded good-to-excellent OSIS scores (84% (26/31) physiotherapy, 79% (15/19) surgery), and 76% (38/50) reported low pain VAS scores at final follow-up. Complications of the total surgical cohort included a 19% (5/27) revision rate, 11% (3/27) frozen shoulder, and 4% (1/27) scar sensitivity.

CONCLUSION

This is the largest midterm series reporting chronic anterior SCJ instability outcomes when managed according to a standardized treatment algorithm that emphasizes the importance of appropriate patient selection for either physiotherapy or surgery, based on a history of trauma. All but two patients achieved a stable SCJ, with stability maintained at a median of 70 months (11 to 116) for the physiotherapy group and 87 months (6 to 144) for the surgery group.Cite this article: Bone Jt Open 2022;3(10):815-825.

Sternoclavicular Joint Instability and Reconstruction

Chronic instability or degenerative arthritis of the sternoclavicular (SC) joint may occur after traumatic or spontaneous dislocation of the SC joint. Most commonly, chronic instability of the SC joint occurs anteriorly; however, posterior instability has an increased risk of serious complications because of proximity to mediastinal structures. Although chronic anterior instability of the SC joint does not resolve with nonsurgical treatment, patients often have mild symptoms that do not impair activities of daily living; however, chronic anterior SC joint instability may be functionally limiting in more active individuals. In these cases, surgical treatment with either (1) SC joint reconstruction or (2) medial clavicle resection, or both, can be done. Recurrent posterior instability of the SC joint also requires surgical treatment due to risk of injury to mediastinal structures. Recent literature describes various reconstruction techniques which generally show improved patient-reported outcomes and low complication rates.

Anterior dislocation of sternoclavicular joint: A novel surgical technique

INTRODUCTION

Anterior sternoclavicular joint dislocation (SCJ) is a relative rare injury, related to high energy trauma. The objective of the present study is to present a novel suture technique for treatment of anterior SCJ traumatic dislocation and to report clinical outcomes from a small case series undergoing this procedure.

PATIENTS AND METHODS

Patients presenting with traumatic anterior SCJ disruption in our institution were eligible to participate. Surgical technique consisted of two bone tunnels drilled in vertical direction from the anterior to the posterior cortex of the manubrium. Analogous to the sternal side of the clavicle, two vertical bone tunnels were drilled from the anterior cortex towards the posterior cortex. A non-absorbable suture was passed though the four holes in a parallel configuration. Then, by pulling the free suture edges the posterior translation of the clavicle was performed. Two additional drill holes, the first in manubrium and the second in clavicle were performed from the anterior cortex to the posterior between the previous bone tunnels. A non-absorbable suture was placed in a simple configuration in order to stabilize the SCJ in the superior-inferior direction. The final follow up was 28.2 months. The mean QuickDASH was used for functional assessment.

RESULTS

Seven patients (6 males and 1 female) with average age of 34,8 years were included in the present study. Two patients suffered from concomitant medial clavicle fracture. At final follow-up (none of the patients had experienced any symptoms of instability of SCJ, no side-to-side difference was observed, while the Mean QuickDASH score was 4.85.

CONCLUSION

The reported technique for SCJ reconstruction in traumatic anterior SCJ dislocations with two sutures has theoretical advantages, since it stabilizes the SCJ in the antero-posterior, as well as the supero- inferior direction. Outcomes from this small case series are favorable. However, more research is desirable to compare different techniques and to conclude to the optimal surgical treatment.

Locked Anterior-Inferior Sternoclavicular Joint Dislocation: A Case Report

CASE

We report a rare variant of sternoclavicular joint (SCJ) dislocation, namely locked anterior-inferior dislocation, with unique clinical, radiographic, and intraoperative findings. In this variant, the medial clavicle was displaced anteriorly and inferiorly and locked in the manubrial-intercostal space, with corresponding mechanical dysfunction of the ipsilateral shoulder girdle joints. Symptoms unique to this variant included painful neck spasms and limited glenohumeral elevation. Nonsurgical treatment was not successful, and open reduction and ligament reconstruction resulted in correction of the fixed deformity with resolution of the clinical symptoms.

CONCLUSION

Locked anterior-inferior SCJ dislocation is indicated for early open reduction and ligament reconstruction.

A rare case of complicated pure posterior sternoclavicular dislocation in a young athlete

Sternoclavicular joint dislocation (SCJD) is a rare injury, generally classified in anterior and posterior. The posterior SCJD is very infrequent yet potentially associated with life-threatening complications. In patients with unfused medial clavicle physis, SCJD can be associated with fracture-dislocation (Salter type I or II). We hereby present the case of a 12-year-old basketball player with severe pain in sternoclavicular region and arising dysphagia after a fall and tackle by another player. A SCJ injury was hypothesised and the CT scan detected the presence of a true posterior SCJD with no associated fracture, which was also confirmed during open reduction. As the patient complained dysphagia, it was also necessary to study other possible mediastinal compressions by a contrast medium CT scan of the great vessels. The CT scanned brachiocephalic vein compression without additional clinical evidence or signs. Twenty hours after the trauma the patient underwent an unsuccessful closed reduction; for this reason, surgical treatment with open reduction and fixation was mandatory. After 12 weeks of therapy she returned to her previous sport activity. (www.actabiomedica)

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.

The unicortical sternoclavicular joint reconstruction using synthetic graft

Sternoclavicular joint injuries represent 5% of all injuries to the shoulder complex. We report a safe and reproducible technique for reconstruction of anterior sternoclavicular joint dislocations, employing a synthetic graft using a unicortical technique with minimal dissection anterior to the joint.

Minimum 5-Year Clinical Outcomes, Survivorship, and Return to Sports After Hamstring Tendon Autograft Reconstruction for Sternoclavicular Joint Instability

BACKGROUND

Instability of the sternoclavicular (SC) joint is a rare but potentially devastating pathologic condition, particularly when it occurs in young or active patients, where it can lead to persistent pain and impairment of shoulder function. SC joint reconstruction using a hamstring tendon autograft is a commonly used treatment option, but midterm results are still lacking.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the clinical outcomes, survivorship, and return-to-sports rate after SC joint reconstruction using a hamstring tendon autograft in patients suffering from SC joint instability. We hypothesized that SC joint reconstruction would result in good clinical outcomes, high rate of survivorship, and a high rate of return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients who underwent SC joint reconstruction with a hamstring tendon autograft for SC joint instability, with a minimum 5-year follow-up, were included. Patient-reported outcomes were assessed prospectively by the use of the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, 12-Item Short Form Health Survey (SF-12) physical component summary (PCS), and patient satisfaction. Survivorship of reconstruction was defined as no further revision surgery or clinical failure such as recurrent instability or subluxation events. Return to sports and pain were assessed using a customized questionnaire.

RESULTS

A total of 22 shoulders that underwent SC joint reconstruction, with a mean patient age of 31.3 years (range, 15.8-57.0 years) at the time of surgery, were included. At the final evaluation, 18 shoulders, with a mean follow-up of 6.0 years (range, 5.0-7.3 years), completed a minimum 5-year follow-up. All clinical outcome scores improved significantly from preoperatively to postoperatively: ASES (50.0 to 91.0; P = .005), SANE (45.9 to 86.0; P = .007), QuickDASH (44.2 to 12.1; P = .003), and SF-12 PCS (39.4 to 50.9; P = .001). Median postoperative satisfaction was 9 (range, 7-10). The construct survivorship was 90% at 5-year follow-up. There were 2 patients with failed treatment at 82 and 336 days postoperatively because of instability or pain who underwent revision SC joint reconstruction and capsulorrhaphy. Another patient had a superficial wound infection, which was debrided once and resulted in a good clinical outcome. Of the patients who answered optional sports activity questions, 15 (17 shoulders, 77%) participated in recreational or professional sports before the injury. At final follow-up, 14 patients (16 of 17 shoulders, 94%) returned to their preinjury level of sports. The visual analog scale score for pain today (P = .004) and pain at its worst (P = .004) improved significantly from preoperatively to postoperatively.

CONCLUSION

SC joint reconstruction with a hamstring tendon autograft for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and 90% survivorship at midterm follow-up. Furthermore, 94% of this young and high-demand patient population returned to their previous level of sports. Concerns in terms of advanced postinstability arthritis were not confirmed because a significant decrease in pain was found after a minimum 5-year follow-up.

The management of Salter-Harris type II fracture with associated posterior sternoclavicular joint displacement using a locking compression plate: A 14-year-old adolescent's case report

RATIONALE

Posterior sternoclavicular joint dislocations (PSCJDs) are particularly rare injuries, accounting for 3% to 5% of sternoclavicular joint dislocations. With very few cases reported in the literature, these injuries are often misdiagnosed and imaging is not always clear, thus making physicians often unaware of them. The present case report aims to investigate a rare case involving a clavicular Salter-Harris II fracture with associated posterior displacement of the diaphysis, a term coined a "pseudodislocation."

PATIENT CONCERNS

We present a case of a 14-year-old adolescent who sustained a traumatic injury to the shoulder while falling during a soccer match. His main concern was about recovery time and the return to daily life activities.

DIAGNOSES

Multiple imaging studies imaging (X-rays, computed tomography, magnetic resonance imaging) revealed a Salter-Harris II fracture of the right clavicle with posterior displacement of the diaphysis.

INTERVENTIONS

The patient underwent primary surgery to reduce the fracture, using an articular locking compression plate, and secondary surgery to remove the hardware.

OUTCOMES

Following the removal of the hardware at 60 days after the initial surgery and a number of cycles of physiotherapy the patient reported a pain-free range of motion with slight limitation at extremes. Full return to recreational and everyday life activities were achieved at 3 months from the initial surgery.

LESSONS

The PSCJDs are challenging injuries, as they are surrounded by delicate structures inside the mediastinum. Attention must be taken while diagnosing and treating these injuries as the risk of complications and iatrogenic injuries is high. To the author's knowledge, this case is one of the first of its kind described in the literature where we have a Salter-Harrys type II fracture associated with a posterior pseudodislocation of the lateral clavicle. Given the positive results of the case, we recommend the above-mentioned treatment protocol in PSCJD with associated Salter-Harris II fractures in adolescent patients.

Intra-articular injection of steroids in the early postoperative period does not have an adverse effect on the clinical outcomes and the re-tear rate after arthroscopic rotator cuff repair

PURPOSE

The purpose of this study was to compare clinical outcomes and structural integrity following arthroscopic rotator cuff repair, either with intra-articular injection of corticosteroids in the early postoperative period using ultrasound guidance or without it.

METHODS

This study included 318 patients who underwent arthroscopic repair for either a partial-thickness or small-to-medium-sized full-thickness rotator cuff tear from 2012 to 2015. Patients were divided into two groups based on the administration of an intra-articular corticosteroids injection at 3 months after the surgery: group A (with corticosteroid injection, n = 56) and group B (without corticosteroid injection, n = 262). Functional outcomes were evaluated using the visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, and active range of motion (ROM). Postoperative magnetic resonance arthrography (MRA) was performed 6 months postoperatively to assess structural integrity.

RESULTS

At the 2-year follow-up, both groups showed no significant differences in VAS pain score (group A/B, 1.1 ± 0.9/1.1 ± 1.1), functional scores including SSV (88.5 ± 10.8/88.3 ± 10.0), ASES (90.8 ± 6.6/90.4 ± 6.9), and UCLA scores (30.2 ± 5.6/30.7 ± 5.2), and active ROM including forward flexion (151° ± 8°/153° ± 7°), external rotation (54° ± 5°/55° ± 7°), and internal rotation (10 ± 1/10 ± 2). Follow-up MRA imaging collected 6 months after surgery showed no significant difference in the re-tear rate (n.s.) between group A and B (n = 10/56, 17.9% and 45/262, 17.2%, respectively).

CONCLUSIONS

Intra-articular corticosteroids injection in the early postoperative period after arthroscopic rotator cuff repair provided satisfactory pain relief and ROM improvement without increasing the re-tear rate or deteriorating clinical outcomes at the 2-year follow-up.

LEVEL OF EVIDENCE

III.

Sternoclavicular joint replacement case report

INTRODUCTION

This report describes the first known sternoclavicular joint (SCJ) replacement with a custom-made prosthesis.

HISTORY

A 42-year-old male who presented post left medial clavicular excision with significant pain and limited range of motion impeding his daily activities and ability to work. The patient subsequently underwent a left SCJ arthroplasty with a custom-made prosthesis. Postoperatively, the patient suffered an anterior dislocation of the prosthetic joint which was successfully rectified and stabilized with soft tissue reconstruction, creating a pseudo-capsule from adjacent tissues of the joint. Thereafter, the patient required a final procedure to remove prominent sutures.

RESULTS

Currently, the patient has regained full range of motion and is pain free during most activities and has now returned to work, with a plan to review his progress in 1 year. These initial promising results post SCJ replacement with the custom-made prosthesis could potentially lead SCJ reconstruction in an exciting new direction.

DISCUSSION

More research should be encouraged regarding this nascent operative option, in order to identify the indications, parameters, and effectiveness of SCJ arthroplasty.

Figure-of-eight Reconstruction of the Sternoclavicular Joint: Outcomes of Sport and Work

Instability of the sternoclavicular joint is a challenging condition given the proximity of neurovascular structures and minimal osseous constraint, and little is known regarding return to activity. A prospectively maintained institutional registry was retrospectively queried for all sternoclavicular joint reconstructions performed from 2005 to 2016. All included patients were asked to answer questions from a previously established survey to assess return to sport, work, and satisfaction following surgery. Ten patients (12 shoulders) were available for long-term follow-up (71.4%; range, 26-145 months). There were significant improvements in both visual analog scale (-2.3±3.0) and American Shoulder and Elbow Surgeons (+29.7±29.6) scores (P<.001, respectively). Seven patients reported good to excellent satisfaction, and all patients reported they would undergo the surgery again in hindsight. Regarding sports, 4 of 9 (44.4%) were able to return to sport, 1 of 9 (11.1%) was able to return to same or better intensity, and 4 of 8 (50%) were able to perform a push-up having done so prior to injury. In total, 3 of 7 (42.9%) returned to work, with 1 of 7 (14.3%) returning to same or better intensity. None of the heavy-duty workers were able to return to their preinjury level of duty. Although figure-of-eight reconstruction of the sternoclavicular joint provides consistent clinical improvement and acceptable levels of patient satisfaction, most patients were unable to return to preinjury activity. Patients should be counseled preoperatively regarding appropriate expectations. Workers with strenuous responsibilities should be advised to find alternative employment opportunities. [Orthopedics. 2019; 42(4):205-210.].

Sternoclavicular Joint Reconstruction Fracture Risk Is Reduced With Straight Drill Tunnels and Optimized With Tendon Graft Suture Augmentation

Background:

Despite the rare entity of sternoclavicular joint (SCJ) instability, a variety of different reconstruction techniques for SCJ dislocations have been described. A technique with oblique drilling has been proposed to reduce intraoperative risks.

Purpose:

To biomechanically investigate different cerclage reconstruction techniques and the benefit of additional reinforcement using suture tape.

Study Design:

Controlled laboratory study.

Methods:

Reconstructed artificial bone specimens were mounted on a mechanical testing machine. They were subjected to anterior and posterior translation, analyzing ultimate strength, displacement, stiffness, and elongation. For stage 1, different angulations of the drill tunnels through the sternum and clavicle were compared. Straight drill tunnels from anterior to posterior were compared with 45° oblique drill tunnels. For stage 2, three different materials for cerclage reconstruction were compared: (1) suture tape alone (FT group), (2) tendon graft alone (tendon group), and (3) tendon graft with suture tape augmentation (tendon+FT group).

Results:

For the FT group, in the anterior and posterior directions, straight drill holes resulted in a significantly higher load to failure (936.9 ± 122.5 N) compared with oblique ones (434.5 ± 20.2 N) (P < .0001). During cyclic testing, all specimens with straight drill holes survived the 5- to 550-N step, while all specimens with oblique ones failed during the 5- to 450-N step. Analyzing the graft material choice, the mean load to failure was 556.6 ± 174.3 N for the tendon group, 936.9 ± 122.5 N for the FT group, and 767.0 ± 110.7 N for the tendon+FT group (P = .089). The stiffness of the tendon+FT group was significantly lower than that of the FT group and significantly higher than that of the tendon group.

Conclusion:

Oblique tunnel placement during SCJ reconstruction, while reducing the intraoperative risk, results in decreased primary stability of the construct. Tendon graft reconstruction with suture tape augmentation leads to enhanced stability and optimizes biomechanical properties of the construct.

Clinical Relevance:

The surgical technique with straight drill holes has superior initial biomechanical properties and may likewise produce superior clinical outcomes in the treatment of SCJ instability. Suture tape augmentation can provide additional stability to reconstruction procedures.

Chronic anterior sternoclavicular instability: technique and results of corrective clavicular osteotomy

BACKGROUND

Chronic anterior sternoclavicular (SC) instability is a rare but potentially disabling condition. It can arise in conjunction with trauma or hyperlaxity, or both. Numerous surgical techniques have been described, but no gold standard exists. SC instability is often position-dependent and can be reduced with the arm in a specific position.

METHODS

To directly address this issue, we used a technique of corrective osteotomy of the clavicle with the goal to reorient the articular portion of the medial end of the clavicle so that it remains stable in all functional positions of the arm. To illustrate the technique and the correction in space, we performed postoperative 3-dimensional computed tomography analyses of the shoulder girdle of 4 patients. Clinical scores were obtained at the final follow-up and compared with preoperative scores.

RESULTS

Mean follow-up was 64 months (range, 19-191 months). The mean Constant score improved from 58 (range, 45-68) preoperatively to 73 (range, 69-84) postoperatively and the Subjective Shoulder Value from 42 (range, 15-80) to 79 (range, 50-100). All patients reported good or very good stability of the SC joint at the last follow-up. We recorded no intraoperative or direct postoperative complications. During follow-up, 3 patients underwent removal of the plate, 1 of them for plate breakage. The mean postoperative correction for combined rotations is given as a 3-dimensional angle and averaged 28.0° (range, 8.6°-39.7°).

CONCLUSION

In this pilot study, medial corrective clavicular osteotomy using the described technique treated anterior SC instability with improvement of clinical shoulder function scores and good patient satisfaction. The technique appears simple and safe and deserves further evaluation.

Joint reconstruction using sternocleidomastoid tendon autograft as a treatment for traumatic posterior dislocation of sternoclavicular joint: A case report

Introduction

Posterior sternoclavicular joint dislocations are extremely rare and emergent injuries.

Presentation of case

We presented a case of a seventeen-year-old male patient who was diagnosed with traumatic posterior dislocation. He underwent joint reconstruction using sternocleidomastoid tendon autograft, and the operation went well.

Discussion

At four-week and fourteen-week follow-up post-operatively revealed a surgical wound that healed well, regained stable sternoclavicular joint that was marked by a normal left sternoclavicular notch, full range of movement of the left shoulder and the pain subsided.

Conclusion

These findings provide evidence that the method of joint reconstruction and augmentation may produce good outcome for posterior dislocation of the sternoclavicular joint.

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

Locking plate for treating traumatic sternoclavicular joint dislocation: a case series

Background

Traumatic sternoclavicular joint dislocations are rare; closed reduction is the primary treatment. The failure of closed reduction or a prominent insult to the skin may require surgery to ensure the best possible outcome.

Methods

The records of 5 patients operated at our institution for sternoclavicular joint dislocation were reviewed. All patients were treated with open reduction and single 3.5-mm locking plate was used for fixation. Outcomes were evaluated with the Constant Shoulder Score (CSS) and Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Intraoperative and postoperative complications were recorded.

Results

All the patients had an average follow-up of 14 months (range, 11–16 months). At the final follow-up, the mean CSS score was 89.5 (range, 78–98) and the mean DASH score was 9.0 (range, 4–16). There were no early complications, including wound infection or neurologic or vascular deficits; there were also no broken or loosened screws or plates. No case of redislocation or arthrosis was observed.

Conclusion

Our study indicates that open reduction and fixation with a single locking plate for the treatment of traumatic sternoclavicular joint dislocation is a safe, relatively simple surgical procedure that can lead to satisfactory outcomes.

Sternoclavicular Joint Reconstruction in the Setting of Medial Comminuted Clavicle Fracture

A dislocation of the sternoclavicular joint is a particularly threatening injury given the close proximity of neighboring vital structures. Moreover, a traumatic injury resulting in a comminuted fracture of the medial clavicle in addition to joint instability results in even greater complexity. In the setting of sternoclavicular joint instability, definitive treatment that will lead to complete resolution of symptoms is necessary. Various treatment methods, both conservative and operative, with positive treatment outcomes have been described. The aim of this Technical Note is to describe our preferred surgical technique to treat a medial comminuted clavicle fracture with anterior sternoclavicular joint instability.

Repair of sternoclavicular joint dislocations with FiberWire®

PURPOSE

Up to 50% of traumatic sternoclavicular joint (SCJ) dislocations need open reduction and fixation to prevent long-term complications and complaints. We present our preferred surgical approach for acute as well as chronic SCJ dislocations, including their outcome.

METHODS

Five consecutive male patients with a median age of 27 (range 20-49) were treated for traumatic anterior (n = 2) or posterior (n = 3) SCJ dislocation. Open reduction and surgical fixation were achieved by a modified figure-of-eight sutures using Fiberwire^®. In anterior dislocations, an additional reconstruction of the costoclavicular ligament was performed. Median follow-up was 11 months (range 9-48) and included clinical evaluation and the use of the DASH questionnaire.

RESULTS

Open surgical reduction and SCJ repair were successfully achieved in all patients without complications. Repair resulted in very good functional outcomes in all five patients with DASH scores of 0, 8 (n = 3) and 5, 8 (n = 2), respectively.

CONCLUSIONS

The presented technique allowed simple, effective, and durable repair of the SCJ joint in patients with SCJ dislocations with excellent functional outcomes.

Outcomes and complications following graft reconstruction for anterior sternoclavicular joint instability

PURPOSE

Publications describing tendon graft reconstruction for anterior sternoclavicular joint (SCJ) instability are rare and usually refer to small patient numbers. The aim of this study was to systematically review the literature regarding outcomes and complications following tendon graft reconstruction techniques for anterior SCJ instability.

METHODS

An online database was systematically searched to identify studies on graft reconstruction for anterior SCJ instability. Reported outcome scores were graded as excellent, good, fair and poor to summarize the study results. All reported complications were recorded.

RESULTS

Five articles with a total of 80 patients met the inclusion criteria. Reported outcomes were excellent in 10 %, good in 89 % and fair in 1 %. Recurrent instability was found in 10 % of the patients, and 5 % underwent revision surgery due to persistent impairment of shoulder function related to SCJ instability or osteoarthritis.

CONCLUSION

Surgical stabilization techniques for the SCJ using autologous tendon grafts have shown to be safe and reliable and make better patients' pain situation and shoulder function. However, a certain amount of impairment might persist, which needs to be discussed with patients. Severe complications were rare and revision rates were as low as 5 %. Therefore, graft reconstruction techniques should be considered for patients with chronic anterior SCJ instability after a course of failed conservative treatment. This study is valuable for clinicians in daily clinical practice when dealing with this difficult-to-treat pathology and can help surgeons to better predict the clinical outcomes and complications following SCJ graft reconstruction. It should, however, not lead to underestimation of the potential risks of the procedure.

LEVEL OF EVIDENCE

Systematic review, Level IV.

A three-stage procedure using bone transportation for the treatment of sternoclavicular infectious arthritis

Background

Sternoclavicular joint (SCJ) infectious arthritis is a rare disease. A standard treatment for SCJ infection has not been established. This study aimed to assess the clinical outcomes of a three-stage procedure with bone transportation (BT) for treating SCJ infectious arthritis.

Methods

Six patients (mean age 39.5 years) with chronic SCJ infectious arthritis were included in the study. The patients underwent a three-stage treatment between January 2009 and December 2012, and results were analyzed retrospectively. Following debridement, immediate flap closure was conducted, and BT of the clavicle was performed to fill the gap using a monolateral external fixator. SCJ reconstruction with a tendon autograft was performed, and the external fixator was finally removed. Clinical outcomes were evaluated using Disabilities of the Arm, Shoulder, and Hand (DASH) scores and Constant scores. The average follow-up period was 16 months (range 12–36 months).

Results

The DASH scores decreased from 53.6 ± 4.9 preoperatively to 24.4 ± 3.1 postoperatively. The Constant scores for pain, activity level, positioning, strength, and range of motion were significantly high after the treatment. The total Constant score improved from 32.5 ± 5.8 preoperatively to 76.7 ± 6.4 postoperatively. All patients were satisfied with the therapeutic effect. No complications occurred.

Conclusions

The three-stage procedure with BT improves shoulder function and movement and relieves pain. It is an effective and safe method for treating SCJ infectious arthritis.

Posterior dislocation of the sternoclavicular joint: report of two cases

The authors report the cases of two young patients who had suffered a sporting accident with posterior traumatic dislocation of sternoclavicular joint. In one of the patients closed reduction was accomplished by keeping the limb in a sling. The second patient, after reduction was done, presented recurrence of the dislocation, thus requiring surgical treatment. It is important to observe the relevance of computed tomography to help diagnosing, as well as monitoring the reduction procedure. The objective of this study was to demonstrate two different types of treatment in a rare injury such as the posterior dislocation of sternoclavicular joint.

Novel technique for sternoclavicular joint reconstruction using a gracilis tendon autograft

Surgical treatment of sternoclavicular joint instability can be challenging and carries the inherent risk of damaging vital structures if the posterior capsule is violated during surgery. In the current manuscript, a novel and easy technique for open reduction and tendon graft stabilization of the unstable sternoclavicular joint is presented. Analogous to other techniques, the graft is passed through drill holes in a figure-of-eight configuration. However, for this technique, the drill holes are placed in oblique direction from the anterior cortex towards the articular surface of the sternum, respectively the medial clavicle. By doing so, graft reconstruction is achieved without any need for retrosternal dissection and mobilization of the posterior capsule, thus minimizing the risk of severe intraoperative complications.

LEVEL OF EVIDENCE

V.

Clinical outcomes after autograft reconstruction for sternoclavicular joint instability

BACKGROUND

Instability of the sternoclavicular (SC) joint is a rare condition. However, in some cases, SC joint instability may lead to persistent pain and impairment of shoulder function that requires surgical management. This study evaluated clinical outcomes after SC joint reconstruction with hamstring tendon autograft in patients with SC joint instability.

METHODS

From December 2010 to January 2014, 21 reconstructions of the SC joint with hamstring tendon autograft were performed. Outcomes data were prospectively collected and retrospectively reviewed. Data analyzed included American Shoulder and Elbow Surgeons score, Quick Disability of the Arm, Shoulder and Hand, physical component of the Short Form 12, and Single Assessment Numeric Evaluation scores. Pain with activities of daily living, work, and sleep were separately analyzed along with painless use of arm for activities. Patients were also questioned regarding postoperative satisfaction.

RESULTS

Nine women and 10 men (2 bilaterals), with a mean age of 30 years (range, 15-56 years), were monitored for a mean of 2 years (range, 12-36 months) postoperatively. Mean American Shoulder and Elbow Surgeons, Quick Disability of the Arm, Shoulder and Hand, and Single Assessment Numeric Evaluation scores significantly improved (P < .001). Pain scores also improved over preoperative baselines, including pain with activities of daily living, work, and sleep (P < .001). Median satisfaction at final follow-up was 8.5 (range, 7-10). There were no intraoperative or postoperative complications and no cases of recurrent instability.

CONCLUSION

Free hamstring tendon autograft reconstruction for SC joint instability resulted in significantly improved clinical outcomes with high patient satisfaction and no intraoperative or postoperative complications.

cVEMP morphology changes with recording electrode position, but single motor unit activity remains constant

Cervical vestibular evoked myogenic potentials (cVEMPs) recorded over the lower quarter of the sternocleidomastoid (SCM) muscle in normal subjects may have opposite polarity to those recorded over the midpoint. It has thus been suggested that vestibular projections to the lower part of SCM might be excitatory rather than inhibitory. We tested the hypothesis that the SCM muscle receives both inhibitory and excitatory vestibular inputs. We recorded cVEMPs in 10 normal subjects with surface electrodes placed at multiple sites along the anterior (sternal) component of the SCM muscle. We compared several reference sites: sternum, ipsilateral and contralateral earlobes, and contralateral wrist. In five subjects, single motor unit responses were recorded at the upper, middle, and lower parts of the SCM muscle using concentric needle electrodes. The surface cVEMP had the typical positive-negative polarity at the midpoint of the SCM muscle. In all subjects, as the recording electrode was moved toward each insertion point, p13 amplitude became smaller and p13 latency increased, then the polarity inverted to a negative-positive waveform (n1-p1). Changing the reference site did not affect reflex polarity. There was a significant short-latency change in activity in 61/63 single motor units, and in each case this was a decrease or gap in firing, indicating an inhibitory reflex. Single motor unit recordings showed that the reflex was inhibitory along the entire SCM muscle. The cVEMP surface waveform inversion near the mastoid and sternal insertion points likely reflects volume conduction of the potential occurring with increasing distance from the motor point.

Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair

INTRODUCTION

Although arthroscopic rotator cuff repair is minimally invasive, there is still considerable postoperative pain, especially during the first 48 hours. The present study assessed the short-term efficacy and safety of multimodal analgesic (MMA) injection associated to corticosteroids in arthroscopic rotator cuff tear surgery.

MATERIAL AND METHOD

A single-center prospective randomized study included 50 patients undergoing arthroscopic rotator cuff tear surgery. The study group received subacromial injection of a mixture of morphine, ropivacaine and methylprednisolone associated to intra-articular injection of morphine plus methylprednisolone; the control group received only isotonic saline. All patients had had 24 hours self-administered morphine associated to standard analgesia. Postoperative data were recorded at 30 minutes and 1, 2, 4, 6, 12, 18 and 24 hours: pain intensity, morphine intake and side effects, and also time to first morphine bolus and additional analgesic intake. Constant, ASES and SST functional scores were recorded at 3 months.

RESULTS

Postoperative pain was significantly less intense in the MMA group than in controls at 30 min, H1, H4, H6, H12, H18 and H24 (P<0.05). A rebound at D10 occurred in both groups. During the first 24 hours, MMA significantly reduced cumulative resort to morphine (P<0.05 at H1/2, P<0.001 at H1-24). Mean time to first bolus was significantly longer in the MMA group (71.6 vs. 33 min; P<0.05). The rate of opioid-related side effects was similar between groups. At last follow-up, functional scores were similar between groups. There were no cases of infection or delayed skin healing.

CONCLUSION

MMA associated to corticosteroids after arthroscopic rotator cuff tear surgery provided immediate benefit in terms of analgesia and morphine sparing, without apparent risk of infection. The practice is presently little known in France and deserves longer-term assessment, especially as regards functional rehabilitation and tendon healing.

LEVEL OF EVIDENCE

2.

[Acute posterior dislocation of the sternoclavicular joint: Reduction, fixation by endobutton system and alternative procedures]

Acute posterior dislocation of the sternoclavicular (SC) joint is rare but can lead to life-threatening vascular injuries of the mediastinum; however, diagnosis is difficult and the injury can be initially overlooked so that surgical treatment is delayed. Although a variety of different treatment modalities have been published, the ideal fixation technique has not yet been identified. We report the case of a patient suffering from a locked posterior SC joint dislocation caused by a skiing accident. The injury was treated by transarticular endobutton fixation. This article describes the technique and highlights its advantages and disadvantages in comparison to previously published treatment options.

Sternoclavicular dislocation: case report and surgical technique

Sternoclavicular dislocations account for less than 5% of all dislocations of the scapular belt. Most cases of anterior dislocation of the sternoclavicular joint do not present symptoms. However, some patients may develop chronic anterior instability and remain symptomatic, and surgical treatment is indicated in these cases. There is a scarcity of reports in the literature relating to reconstruction using the long palmar tendon in cases of traumatic anterior instability. Although rare, these injuries deserve rapid diagnosis and efficient treatment in order to avoid future complications. The aim of this report was to report on a case of a motocross competitor who developed chronic traumatic anterior instability of the sternoclavicular joint and underwent surgical reconstruction using the autogenous long palmar tendon.

The patient was a 33-year-old man with a history of anterior dislocation of the sternoclavicular subsequent to a fall during a maneuver in a motocross competition. Conservative treatment was instituted initially, consisting of use of a functional sling to treat the symptoms for 3 weeks, along with physiotherapeutic rehabilitation for 3 months. We chose to use a modification of the “figure of eight” technique based on the studies by Spencer and Kuhn. A longitudinal incision of approximately 10 cm was made at the level of the sternoclavicular joint. The graft from the ipsilateral long palmar tendon was passed through the orifices in the form of a modified “figure of eight” and its ends were sutured together. The patient was immobilized using an American sling for 4 weeks. After 6 months of follow-up, the patient no longer presented pain or instability when movement of the sternoclavicular joint was required. Minor discomfort and slight prominence of the sternoclavicular joint continued to be present but did not affect the patient's activities. Thus, the patient was able to return to racing 6 months after the operation. Our study presented a case of chronic anterior dislocation of the sternoclavicular joint that was successfully treated by using a modification of the “figure of eight” reconstruction technique. This technique was shown to be safe and effective, and it allowed the patient to fully return to his sports activities.

Double figure-of-eight reconstruction technique for chronic anterior sternoclavicular joint dislocation

Sternoclavicular joint dislocations account for <5 % of all dislocations of the shoulder girdle. Whereas most cases of anterior dislocation do not experience symptoms, some patients with anterior instability remain symptomatic and require reconstructive surgery to stabilize the sternoclavicular joint. We present the case of a 57-year-old male diagnosed with sternoclavicular joint anterior dislocation and unusual swallowing difficulty while bending the neck forward. The patient was treated using a new and effective surgical technique of sternoclavicular joint reconstruction named "double figure-of-eight" using the ipsilateral gracilis tendon. Surgical outcome was successful, based on the Rockwood SC joint rating scale, and the patient maintained excellent stability even after 2 years. This new surgical technique offers superior stability, without harvest site morbidity, to patients with rare, severe, and chronic sternoclavicular joint dislocation. Level of evidence IV.

Chronic posterior sternoclavicular joint fracture dislocations in children and young adults: results of surgical management

BACKGROUND

Posterior sternoclavicular joint (SCJ) fracture dislocations in children and young adults can be missed on initial examination or could fail closed treatment. We hypothesize that surgical interventions (open reduction and ligamentous reconstruction or medial clavicle resection depending on the clinical scenario) are safe treatment options in patients with symptomatic chronic posteriorly displaced SCJ injuries.

METHODS

A retrospective review was conducted of all patients younger than 25 years of age who underwent surgical treatment for chronic posteriorly displaced SCJ injuries at our institution from January 1, 1999 to December 31, 2011. Chronic injuries were defined as those presenting and/or treated at a minimum of 6 weeks from the causative injury. Indications for surgery included symptomatic posterior SCJ dislocations or posteriorly angulated physeal fractures that did not remodel and were refractory to nonoperative treatment. Subjective patient outcomes were obtained by mailed survey and telephone contact. Outcomes included a Disabilities of the Arm, Shoulder and Hand score, patient-rated levels of pain and/or disability, SCJ stability, and symptom improvement.

RESULTS

Seven patients met the inclusion criteria and all patients reported postoperative improvement or complete resolution of pain at last clinical follow-up (mean, 13 mo). At average 5.5 years follow-up, all respondents (n=4) reported that their injury did not interfere with normal social activities or daily activities. No patients reported difficulty with employment; however, all patients reported mild difficulty with return to their level of athletic activity before SCJ fracture dislocation. Patients rated their level of pain or disability as 1.5 on a 10-point scale.

CONCLUSIONS

Surgical intervention can reliably provide pain relief and facilitate successful return to activities including work in patients with symptomatic chronic posterior SCJ fracture dislocations. However, patients must be counseled that they may experience persistent symptoms with return to their previous level of sport performance.

LEVEL OF EVIDENCE

Therapeutic Study-Investigating the Results of Treatment: Level IV.

[Surgical treatment of sternoclavicular joint instability with tenodesis]

BACKGROUND

Instability of the sternoclavicular joint is a very uncommon disorder of the shoulder girdle. Acute traumatic dislocations are commonly treated nonoperatively. But severe displacement or chronic instability with recurrent symptomatic subluxation may require surgical intervention. We present our results with open reduction and internal fixation through an autologous gracilis tendon transplant or fiber tape in 8 patients treated surgically. The operative stabilisation of the sternoclavicular joint reduces pain level and improves function of the shoulder. This technique provides an effective surgical procedure for treatment of symptomatic sternoclavicular joint instability.

OBJECTIVE

Restoration of the function and aspect of the sternoclavicular joint.

INDICATIONS

Chronic and painful instabilities.

CONTRAINDICATIONS

Local infection, tumor.

SURGICAL TECHNIQUE

The gracilis tendon graft is harvested as previously described by Petersen. Direct incision over the sternoclavicular joint. Sharp dissection of the periostal sleeve and partial release of sternocleidomastoideus and pextoralis muscle. Resection of osteophytes. Careful placement of a raspatorium under the proximal clavicle and sternum to protect the mediastinal structures. Application of 2.5 or 3.2 mm drill holes to the sternum and the proximal clavicle. The gracilis tendon or the fiber tape is pulled through the drill holes in a figure of eight and then sutured. Recontruction of the joint capsule, closure of the wound.

POSTOPERATIVE MANAGEMENT

Gilchrist brace for 3-5 days, functional physiotherapy with a maximum abduction of 90° for 6 weeks. No carrying or lifting of weights greater than 5 kg for 3 months.

RESULTS

During the period from January 2006 to December 2010, 8 patients with sternoclavicular instability were treated. Four patients were treated with fiber tape and four were treated with a gracilis tendon autograft. Postoperative all patients described a reduction of pain and improved shoulder function. The Constant score was 72 points, the DASH 58 points.

A rare case of floating clavicle and a novel technique for stabilizing the sternoclavicular joint

We present the first ever case report of a floating clavicle with a unique combination of a posterior sternoclavicular joint dislocation and an associated grade III acromioclavicular joint dislocation. We treated this injury surgically by stabilizing both ends of clavicle using a polyester surgical mesh device (LockDown™; Mandaco 569 Limited, Redditch, UK; previously called the Nottingham Surgilig).

Assessment of the function and resistance of sternoclavicular ligaments: A biomechanical study in cadavers

BACKGROUND

Few biomechanical studies have assessed the resistance of the ligamentous structures of the sternoclavicular joint, and none have reproduced the physiological movements of the joint. Determining the structures that are injured in sternoclavicular dislocations is important for the surgical planning of acute or chronic ligament reconstruction.

METHODS

Forty-eight joints from 24 human cadavers were studied, and they were divided into 4 groups of 12 joints each (retraction, protraction, depression and elevation). Biomechanical testing assessed primary and secondary failures. The mechanical resistance parameters between movements that occurred on the same plane (depression versus elevation, protraction versus retraction) were compared.

RESULTS

The posterior sternoclavicular ligament was the most injured structure during the protraction test, but it was not injured during retraction. The anterior sternoclavicular ligament was the most affected structure during retraction and depression. The costoclavicular ligament was the most affected structure during elevation. Joint resistance was significantly greater during protraction movements when compared to retraction (P<0.05).

CONCLUSION

The anterior sternoclavicular ligament was the most affected structure during retraction and depression movements. During protraction, lesions of the posterior sternoclavicular ligament were most frequent during elevation, and the costoclavicular ligament was the most frequently injured ligament. The resistance of the sternoclavicular joint was significantly greater during protraction movement when compared to retraction.

LEVEL OF EVIDENCE

IV, basic science, biomechanics, cadaver model.

Instability and degenerative arthritis of the sternoclavicular joint: a current concepts review

BACKGROUND

Injuries to the sternoclavicular (SC) joint typically occur with high-energy mechanisms such as those obtained in automobile accidents or contact sports. Many disorders of the SC joint can be treated nonoperatively. However, surgical treatment may be indicated for locked posterior dislocations; symptomatic, chronic instability; or persistent, painful osteoarthritis that fails nonoperative therapy.

PURPOSE

To provide an updated review on the current diagnosis and management of instability and degenerative arthritis of the SC joint.

STUDY DESIGN

Current concepts review.

METHODS

A preliminary PubMed database search using the terms sternoclavicular instability, dislocation, arthritis, resection, and stabilization was performed in August 2012. All anatomic and biomechanical studies, review articles, case reports, case series, and technique papers that were relevant to the topic were included.

RESULTS

The search identified 929 articles, 321 of which, after screening of the titles and abstracts, were considered potentially relevant to this study. Of the 321 articles, 30 were anatomic or imaging studies, 2 were biomechanical studies, 69 were review papers, 189 were case series or reports, and 31 were technique papers. The majority of these studies were classified as evidence level 4, with a few scattered level 3 studies. Because the level of evidence obtained from this search was not adequate for systematic review (or meta-analysis), a current concepts review of the diagnosis and management of SC joint instability and degenerative arthritis is presented.

CONCLUSION

Injuries to the SC joint are uncommon. Recognition and classification of these injuries are critical to proper management, thus minimizing potential long-term sequelae such as posttraumatic arthritis and recurrent instability. Although nonoperative therapy is the modality of choice in anterior dislocations, posterior dislocations require special attention because of the presence of vulnerable posterior hilar structures. Surgical management of chronic instability and degenerative arthritis of the SC joint includes resection arthroplasty of the medial clavicle with or without reconstruction of the sternoclavicular ligaments with graft material. Although resection is typically performed open, an arthroscopic technique is described that theoretically decreases operating and recovery times while also decreasing the risk of iatrogenic injury. Currently, when reconstruction is needed for stability, a figure-of-8 graft reconstruction is the recommended method based on biomechanical data and small clinical series.

Posterior sternoclavicular dislocations: a brief review and technique for closed management of a rare but serious injury

Posterior sternoclavicular dislocations are rare but serious injuries. The proximity of the medial clavicle to the vital structures of the mediastinum warrants caution with management of the injury. Radiographs are the initial imaging test, though computed tomography and magnetic resonance imaging are essential for diagnosis and preoperative planning. This paper presents an efficient diagnostic approach and effective technique of closed reduction of posterior sternoclavicular dislocations with a brief review of open and closed reduction procedures.

A novel technique for ligamentous reconstruction of the sternoclavicular joint

The technique presented is a departure from previous attempts to standardize the treatment of sternoclavicular dislocations. It offers stability without requiring extra dissection around vital intrathoracic structures and greatly decreases the risk of migration of the implant used for fixation.

Artificial ligament reconstruction of sternoclavicular joint instability: report of a novel surgical technique with early results

Symptomatic instability of the sternoclavicular (SC) joint is an uncommon problem. The majority of patients respond well to nonoperative measures, although a small number require reconstructive surgery for symptomatic instability, with varying surgical techniques reported in the literature. We report a series of 5 operations (in 4 patients) with chronic SC joint instability treated by reconstruction of SC and costoclavicular ligaments using an artificial ligament weave (LARS: Ligament Augmentation and Reconstruction System). Preoperative and postoperative disabilities of the Arm, Shoulder, and Hand (DASH) Scores and Oxford Shoulder Scores were collected to evaluate the outcomes. The patients had a mean age of 20 years (range, 17 to 22 y), with 2 male and 2 female patients. Three of the patients had traumatic dislocation of the SCJ and 1 patient had bilateral symptomatic atraumatic instability. Anterior instability was observed in 4 joints and posterior instability in 1 joint. In all cases, reconstruction was achieved with a 30 mm LARS ligament. Postoperative follow-up was for an average of 29 months (range, 19 to 41 mo). The DASH Score improved from 51.7 points (range, 24.2 to 75.0) preoperatively to 13.7 points (range, 8.3 to 20.8) postoperatively. The Oxford Shoulder Scores improved from 20.6 preoperatively (range, 15 to 32) to 41.8 postoperatively (range, 39 to 47). All patients returned to full activity including competitive sports. In conclusion, stabilization of the SC joint using a LARS ligament with a weave technique is a feasible option for young, active patients with symptomatic SC joint instability after failure of nonoperative treatment.

Reconstruction of the chronic anterior unstable sternoclavicular joint using a tendon autograft: medium-term to long-term follow-up results

BACKGROUND

Chronic symptomatic anterior sternoclavicular (SC) instability is a rare condition with sparse treatment options. Owing to the rarity of the condition and the potential risk of fatal complications, only a few reports on treatment of this condition have been published. We evaluated a prospective series of patients with chronic anterior SC instability who underwent minimally open reconstruction with an autologous tendon graft.

METHODS

From 2002 to 2010, 32 consecutive patients underwent minimally open SC ligament reconstruction using a tendon autograft. A palmaris longus was used in 7 patients and a gracilis tendon autograft was used in 25. All patients with at least 2 years of follow-up were reviewed. Five were lost to follow-up. The remaining 27 patients (84.4%) were a median age of 35 years (range, 11-61 years) at surgery. Patients were evaluated with the Western Ontario Shoulder Instability (WOSI) score preoperatively and at follow-up at a median 54 months (range, 24-120 months) postoperatively.

RESULTS

The total WOSI score improved from a median of 44% (range 6%-62%) preoperatively to 75% (range, 13%-93%) at follow-up (P = .0001). Two failures (7.4%) occurred; after revision, both patients remained stable. After the operation, 17 of 25 patients (68%) complained of donor site morbidity, and 10 (40%) still had some discomfort at follow-up. No infections or local vascular complications occurred.

CONCLUSIONS

Miniopen SC joint reconstruction using a tendon autograft results in prolonged improvement in shoulder function in most patients with symptomatic anterior SC instability.

Surgical technique: Results of stabilization of sternoclavicular joint luxations using a polydioxanone envelope plasty

BACKGROUND

Surgical treatment options for sternoclavicular joint luxations described in the literature are numerous, although all have limitations. Therefore, there is no favorable surgical treatment for sternoclavicular luxations when nonoperative treatment has failed.

DESCRIPTION OF TECHNIQUE

We developed the polydioxanone (PDS) envelope plasty, a modification of the figure-of-eight technique, using a PDS ligament.

METHODS

We retrospectively reviewed 39 patients (40 joints), treated with a PDS envelope plasty for invalidating sternoclavicular luxations. The minimum followup was 10 months (average, 52 months; range, 10-171 months). The Simple Shoulder Test (SST), Constant-Murley shoulder score, and subjective categorical results were recorded preoperatively and postoperatively.

RESULTS

In most patients, postoperative functional shoulder scores were excellent (mean Constant-Murley score, 90, range, 52-100; mean SST, 10; range, 2-12). Ninety percent of patients had an improvement of shoulder function at followup. Only minor complications occurred. Thirteen percent of patients had spontaneous postoperative subluxations. However, the postoperative shoulder function improved in all these patients.

CONCLUSIONS

The PDS envelope plasty is a simple procedure, a modification of the best-reported technique. We have promising results with high shoulder scores.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reconstruction for anterior sternoclavicular joint dislocation and instability

BACKGROUND

Sternoclavicular joint (SCJ) instability is relatively rare. Surgical treatment may be considered for severely displaced dislocations or symptomatic recurrent anterior instability. The purpose of this study was to describe an SCJ ligament reconstruction technique and retrospectively evaluate its safety and effectiveness for treating anterior SCJ dislocations and instability.

MATERIALS AND METHODS

A retrospective review of demographics, medical history, injury characteristics, and pretreatment pain and functional levels was performed. A soft-tissue graft woven in a Roman numeral X pattern through clavicular and sternum subcortical bone tunnels was used. Patients were evaluated with postoperative visual analog scale (VAS) and functional scores, and their ability to return to normal preoperative sports and activities was determined.

RESULTS

Six patients were evaluated with a mean follow-up of 40 months (range, 24.5-58 months). Injury mechanisms included acute trauma (3 patients), minor trauma (1 patient), and chronic atraumatic instability (2 patients). The mean preoperative symptom duration was 11 months (range, 0.5-27.5 months). Autograft hamstring graft was used in all cases with no resulting surgical complications. All 6 patients had full range of motion with no instability after treatment. Five patients had no pain (0 of 10 on VAS), whereas one patient had mild pain (1 to 3 of 10 on VAS). All 6 patients had improved functional scores. All returned to preoperative activities and participation in sports. No recurrent instability occurred. In 1 case, failure occurred at 4 years with recurrent pain, and revision was performed.

CONCLUSIONS

The results of our study indicate that reconstruction for anterior SCJ dislocation is safe with results comparable to previously described surgical stabilization techniques. This technique provides a surgical treatment option for symptomatic anterior SCJ dislocation and instability.

Anterior sternoclavicular dislocation associated with clavicular fracture: a case report and review of the literature

Although clavicle fractures are common, fracture dislocations of the medial end are rare. We report on a case of a 17-year-old patient who presented with a fracture of the medial clavicle with an associated anterior dislocation of the sternoclavicular joint. The patient underwent successful surgical management resulting in fracture union, restoration of shoulder stability and full functional range of motion at latest follow-up.