Resection arthroplasty of the sternoclavicular joint

Predictors of Clinical Outcomes and Quality of Life After Sternoclavicular Joint Reconstruction With Hamstring Tendon Autograft

BACKGROUND

Anterior instability of the sternoclavicular joint (SCJ) is a rare but potentially devastating pathological condition, particularly when it occurs in young or active patients. SCJ reconstruction using hamstring tendon autograft is a commonly used treatment option, yet to date results are limited to small case series. Studies on baseline, preoperative factors and their association with postoperative outcome are limited.

PURPOSE

To assess the midterm clinical outcomes and survivorship after SCJ reconstruction using hamstring tendon autograft in patients experiencing anterior SCJ instability and to determine whether baseline patient or causative factors are associated with postoperative outcomes or patient satisfaction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent SCJ reconstruction with a hamstring tendon autograft for anterior SCJ instability between October 2005 and October 2020 were included in this retrospective single-center study. At a minimum of 2 years postoperatively, clinical outcomes were collected, including the following patient-reported outcomes (PROs): the 12-Item Short Form Survey (SF-12) score; American Shoulder and Elbow Surgeons (ASES) score; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Single Assessment Numeric Evaluation (SANE) score; and visual analog scale (VAS) pain score. Subjective postoperative satisfaction with the procedure was quantified on a scale from 0 (very unsatisfied) to 10 (very satisfied). The predictive role of patient factors, including age, sex, and injury in dominant arm, on postoperative PROs and satisfaction at short-term follow-up was evaluated using multiple linear regression.

RESULTS

A total of 49 patients (mean age, 29.6 ± 16.2 years; range 13.8-67.1 years; 27 females) were included in the final analysis. At a mean follow-up of 3.9 ± 2.1 years, all PROs had significantly improved, including the mean SF-12 Physical Component Summary score (40.4 ± 6.8 to 52.6 ± 6.9; P < .001), ASES score (54.9 ± 20.4 to 91.0 ± 11.3; P < .001), QuickDASH score (41.2 ± 18.5 to 10.2 ± 9.1; P < .001); SANE score (50.2 ± 21.1 to 88.3 ± 8.8; P < .001), VAS pain score (4.4 ± 2.6 to 0.8 ± 1.4; P < .001), and VAS pain score at its worst (7.4 ± 2.5 to 3.3 ± 2.6; P < .001). The median postoperative satisfaction score was 9 (range, 1-10). Revision-free survivorship was 95.9%. Male patients had a significantly lower VAS pain score at its worst compared with female patients (2.6 ± 2.6 vs 4.1 ± 2.4; P = .045); higher age was significantly correlated with a worse QuickDASH score (correlation coefficient, 0.314; P = .036). Overhead athletes had a significantly lower propensity to return to sport compared with nonoverhead athletes (P = .043), with only 45% of the overhead athletes returning to a level similar to their preinjury level, whereas 81% of the nonoverhead athletes were able to do so.

CONCLUSION

The significant improvements in clinical and sport-specific outcomes and high patient satisfaction after SCJ reconstruction with a hamstring tendon autograft demonstrate the success of this procedure in treating anterior SCJ instability. Male sex and younger patient age are associated with superior outcomes, while overhead athletes have to be counseled about difficulties of returning to preinjury level of sport postoperatively.

Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability: Patient-reported outcomes at a minimum of 2 years

Background

Instability of the sternoclavicular joint (SCJ) is a rare problem that is often treated closed, with few published outcomes of surgical treatment with tendon graft reconstruction.

Methods

We reviewed a consecutive series of patients who underwent tendon graft reconstruction for SCJ instability over a 7-year period. Cases with acute fractures or fewer than 2 years of follow-up were excluded. Pre- and postoperative function and pain were assessed using Single assessment numeric evaluation (SANE), simple shoulder test (SST), and visual analog scale (VAS) outcome measures.

Results

Thirty cases were included, with 27 (90%) available for follow-up at a minimum of 2 years postoperatively. SANE scores improved from a median of 40 to 90. SST scores improved from a median of 3 positive responses to a median of 12 on a 12-point scale. VAS scores decreased from a median of 7 to 0 points. One patient underwent reoperation for recurrent instability and wound dehiscence. Three (11%) patients did not achieve a minimum 30% of maximum possible improvement in SST scores.

Conclusions

Tendon graft reconstruction for SCJ instability is a safe procedure with a low complication rate and statistically and clinically significant improvements in patient-reported outcome measures at 2-year minimum follow-up.

Level of evidence

Level IV: Therapeutic.

Novel sternoclavicular hook plate for the treatment of posterior sternoclavicular dislocation: a retrospective study

BACKGROUND

Controversies regarding the optimal internal fixation method for posterior sternoclavicular dislocation (SCD) exist. Therefore, this study aimed to investigate the clinical efficacy of a new type of sternoclavicular hook plate for treating posterior SCD.

METHODS

Eleven patients (eight men and three women) with posterior SCD who underwent treatment with the new sternoclavicular hook plate from June 2011 to January 2022 were retrospectively analyzed. The patients' ages ranged from 33 to 71 years (54.91 ± 13.58 years). Operation time, blood loss, length of hospital stay, and postoperative complications were recorded. Postoperative joint reduction and healing were evaluated using radiography and computed tomography. The Constant-Murley and Rockwood sternoclavicular joint scores were used to evaluate the functional recovery of the affected limb 12 months after surgery.

RESULTS

All 11 patients were followed up for 12-24 months (18.00 ± 3.74 months). All incisions healed by first intention. The healing time ranged from 9 to 13 days (10.82 ± 1.54 days), and the joint healing time was 3-4 months (3.55 ± 0.52 months). The operation time was 45-75 min (59.55 ± 11.06 min), intraoperative blood loss was 22-58 mL (39.91 ± 11.07 mL), and the length of hospitalization was 6-14 days (9.91 ± 3.27 days). There were no complications such as infections, internal fixation failure, or nerve injury. The Constant-Murley score was 93.64 ± 9.01 at 12 months postoperatively. The Rockwood score was 13.36 ± 1.86, of which nine cases were excellent, one case was good, and one case was fair.

CONCLUSION

The novel sternoclavicular hook plate is effective for the treatment of posterior SCD. This novel device can facilitate early joint functional exercises and good functional recovery.

Atraumatic Sternoclavicular Joint Instability: Prevalence, Etiology, and Management

Sternoclavicular joint instability is a rare complaint in the orthopedic clinic, but patients can experience chronic pain and functional impacts. Causes of instability may be posttraumatic, infectious, autoimmune, degenerative, or secondary to generalized laxity. Conservative treatment is the initial approach to management and involves activity modification, physical therapy, oral nonsteroidal anti-inflammatory drugs, and corticosteroid injections. Surgery is indicated when conservative treatment does not manage symptoms. Figure-of-eight reconstruction techniques provide greatest biomechanical strength but are associated with risk of neurovascular injury. Other reconstruction methods have been shown to mitigate these risks with favorable short-term outcomes.

Current Concepts in Sternoclavicular Joint Injuries

LEVEL OF EVIDENCE

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

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.

Magnetic Resonance Imaging in the Management of Significantly Displaced Adolescent Posterior Sternoclavicular Joint Injuries

BACKGROUND

Computed tomography (CT) scans are the standard imaging modality for the diagnosis and treatment guide for adolescent posterior sternoclavicular joint (SCJ) injuries. However, the medial clavicular physis is not visualized and it is not possible to differentiate between a true SCJ dislocation and a physeal injury (PI). An magnetic resonance imaging (MRI) scan can visualize the bone and the physis.

METHODS

We treated a series of patients with adolescent posterior SCJ injuries diagnosed on CT scan. Patients underwent an MRI scan to differentiate between a true SCJ dislocation and a PI and to further differentiate between a PI with or without residual medial end clavicular bone contact. Patients with a true SCJ dislocation and a PI with no contact underwent an open reduction and fixation. Patients with a PI with contact were treated nonoperatively with repeat CT scans at 1 and 3 months. At final follow-up SCJ clinical function was assessed using Quick-DASH, Rockwood, modified Constant, and single assessment numeric evaluation (SANE) scores.

RESULTS

Thirteen patients (2 female and 11 male) with an average age of 14.9 years (12 to 17) were included in the study. Twelve patients were available at final follow-up (mean 50 mo, 26 to 84). One patient had a true SCJ dislocation and 3 had an off-ended PI and were treated with an open reduction and fixation. Eight patients had a PI with residual bone contact and were treated nonoperatively. For these patients serial CT scans showed that the position was maintained, with a serial increase in callus formation and bone remodeling. The average follow-up was 42.9 months (24 to 62). At final follow-up the mean Quick-disabilities of the arm, shoulder and hand (DASH) was 0.4 (0 to 2.3), Rockwood was 15, modified Constant was 98.8 (89 to 100) and SANE was 99.5% (95 to 100).

CONCLUSION

In this case series of significantly displaced adolescent posterior SCJ injuries MRI scans allowed identification of true SCJ dislocations and off-ended PIs, which were successfully treated by open reduction, and PIs with residual physeal contact which were successfully treated nonoperatively.

LEVEL OF EVIDENCE

Level IV-case series.

Clinical Outcomes and Return to Sports After Open Reduction and Hamstring Tendon Autograft Reconstruction in Patients With Acute Traumatic First-Time Posterior Dislocation of the Sternoclavicular Joint

BACKGROUND

Traumatic posterior dislocations of the sternoclavicular joint (SCJ) are rare. Multiple case reports, case series, and systematic reviews have been published on the treatment of posterior SCJ dislocations. However, they have usually been of small numbers, described a variety of surgical techniques on a mixture of acute and chronic dislocations, and have not focused on functional recovery or return to sports.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the clinical outcomes and return to sports after SCJ open reduction and reconstruction using a hamstring tendon autograft in patients with an acute first-time traumatic posterior dislocation of the SCJ. We hypothesized that SCJ open reduction and reconstruction would result in high survivorship, good clinical outcomes, and a high rate of return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study included all patients who underwent SCJ open reduction and reconstruction within 14 days of sustaining a first-time traumatic posteriorly dislocated SCJ, with a minimum 3-year follow-up. Patient-reported outcomes were assessed by the following scores: short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Rockwood SCJ, modified Constant, and Single Assessment Numeric Evaluation (SANE). Survivorship was defined as no clinical failure, such as instability or recurrent dislocation, and no revision surgery. Return to sports was assessed using a customized questionnaire.

RESULTS

A total of 19 patients who underwent surgery were included, with a mean age of 30.8 years (range, 18-52 years). Seventeen patients were available at final follow-up at a mean 94.5 months (range, 37-155 months). At final follow-up, the mean scores were as follows: QuickDASH, 4.3 (range, 0-20.4); Rockwood, 13.9 (range, 12-15); modified Constant, 94.4 (range, 71-100); and SANE, 92.1 (range, 70-100). The construct survivorship was 96%. Of the 14 patients who participated in sports, 12 (86%) returned to their preinjury levels.

CONCLUSION

After an acute first-time traumatic posterior SCJ dislocation, open reduction and stabilization with a hamstring tendon autograft, undertaken within 14 days of injury, provides good clinical outcomes and high rates of survivorship and return to sports.

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.

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.

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.

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.

Unique Case of Neurogenic Thoracic Outlet Syndrome with Arterial Compression in Patient with Bilateral Cervical Ribs and Osteochondroma of the Ribs

Background: Neurogenic thoracic outlet syndrome typically presents with paresthesia, pain, and impaired strength in the neck, shoulder, and arm, and is typically a diagnosis of exclusion. This condition is caused by compression of the brachial plexus, typically by a bony or soft tissue anomaly present congenitally and influenced by repetitive motion or significant trauma. Treatment typically involves removal of the first rib and anterior scalene to decompress the thoracic outlet and relieve stress to the brachial plexus if the patient has failed conservative treatment with physical therapy and lifestyle modifications. Case Presentation: We present a case of neurogenic thoracic outlet syndrome with arterial compression treated surgically via a transaxillary first rib and cervical rib resection in a patient with bilateral cervical ribs and osteochondromas of the ribs.

Reconstruction of the Sternoclavicular Joint After Excessive Medial Clavicle Resection

Medial clavicle excision is a rarely indicated procedure and may be performed in different pathologies affecting the medial clavicle. Excessive medial clavicle resection with an injury to the costoclavicular ligament often leads to poor postoperative results. The exact surgical treatment used in this kind of pathology when conservative treatment is unsuccessful remains unclear. The aim of this Technical Note is to describe our preferred surgical technique to treat this condition.

Ultrasound-guided sternoclavicular joint injection: technique and case series

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

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.

Management of Vertical Sternal Fracture Nonunion in Elite-Level Athletes

Background:

Sternal fractures are rare, and they can be treated nonoperatively. Vertical sternal fractures have rarely been reported.

Purpose:

To describe the management and surgical treatment of a series of elite-level athletes who presented with symptomatic nonunions of a vertical sternal fracture.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients with an established symptomatic nonunion of a vertical sternal fracture, as diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI), underwent open reduction and internal fixation using autologous bone graft and cannulated lag screws. The patients were assessed preoperatively and at the final follow-up using the Rockwood sternoclavicular joint (SCJ) score; Constant score; and shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. Bony union was confirmed on postoperative CT scan.

Results:

Five patients (4 men and 1 woman) were included; all were national- or international-level athletes (rugby, judo, show-jumping, and MotoGP). The mean age at surgery was 23.4 years (range, 19-27 years), the mean time from injury to referral was 13.6 months (range, 10-17 months), and the mean time from injury to surgery was 15.8 months (range, 11-20 months). The mean follow-up was 99.4 months (range, 25-168 months). There was a significant improvement after surgery in the mean Rockwood SCJ score (from 12.6 to 14.8 [P < .05]), Constant score (from 84 to 96.4 [P < .05]; 80% met the minimal clinically important difference [MCID] of 10.4 points), and QuickDASH (from 6.8 to 0.98 [P < .05]; 0% met the MCID of 15.9 points). Four of the patients were able to return to sport at their preinjury level, and 1 patient retired for nonmedical reasons. All of the fractures had united on the postoperative CT scan. There were no postoperative complications.

Conclusion:

Vertical fractures of the sternum are very rare and tend to behave clinically like an avulsion fracture injury to the capsuloligamentous structure of the inferior SCJ. The requirement of advanced imaging to diagnose this injury means that the actual incidence and natural history are not known. For high-demand athletes, early identification, surgical reduction, and fixation are likely to achieve the best outcome.

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.

Unicortical sternal graft reconstruction for anterior sternoclavicular joint instability

Sternoclavicular joint (SCJ) injury represents 3%-5% of all shoulder girdle injuries, yet can produce significant pain and disability. While conservative management improves symptoms in most cases, surgical intervention may be indicated for patients with symptoms recalcitrant to nonoperative treatment. A wide range of surgical stabilisation techniques is documented in the literature; however, the scarcity of SCJ pathology has hindered development of a 'gold standard'.We present a minimalistic medial clavicle osteoplasty and SCJ reconstruction using semitendinosus autograft anchored with unicortical sternal tunnels in the 54 years old with chronic SCJ instability. This technique can be performed safely, resulting in joint stability and pain reduction, while avoiding risks and complications noted in the literature with other techniques.

A rare case of extensive Staphylococcus aureus sternoclavicular septic arthritis treated without surgical intervention

This is a rare case of a 55 year-old immunocompetent female who developed Methicillin sensitive Staphylococcus aureus sternoclavicular septic arthritis. The infection was not limited to the joint space but extended into adjacent bones and superior mediastinum. However the patient was successfully treated without surgical intervention and preservation of joint function was obtained with only intravenous antibiotic therapy.

Positional anterior sternoclavicular joint dislocation in the acceleration phase of throwing: a case report

Positional anterior sternoclavicular joint (SCJ) dislocation is relatively rare and needs careful treatment. We report our course of treatment and tips for surgery in a case. The patient was a 16-year-old male outfield baseball player. Three years ago, he had 3 recurrent episodes of right shoulder dislocation. During these injuries, there were forward dislocations of the proximal right clavicle edge accompanied by a creaking sound during the throw acceleration period. Thereafter, the anterior dislocation of the SCJ occurred during the acceleration phase of throwing, and the SCJ naturally repositioned on the shoulder resting position. This situation lingered and he often felt shoulder apprehension during throws, so he opted for surgical treatment just 1 month after the first injury. We performed a modified version of the figure-of-8 technique reported by Wang et al, using the ipsilateral palmaris longus (PL) tendon. The bilateral edge of the PL was attached to a Krackow suture and passed through the bone tunnels opened at the proximal clavicle and proximal sternum so that it became a figure of 8 on the anterior of the SCJ. The stability of the SCJ was confirmed after the surgery.

Innovative Surgical Concept for Septic Sternoclavicular Arthritis: Case Presentation of a Simultaneous Joint Resection and Stabilization with Gracilis Tendon Graft Including Literature Review

INTRODUCTION

Septic arthritis of the sternoclavicular joint (SCJ) is a rarity in everyday surgical practice with 0.5 - 1% of all joint infections. Although there are several risk factors for the occurrence of this disease, also healthy people can sometimes be affected. The clinical appearance is very variable and ranges from unspecific symptoms such as local indolent swelling, redness or restricted movement of the affected shoulder girdle to serious consequences (mediastinitis, sepsis, jugular vein thrombosis). Together with the low incidence and the unfamiliarity of the disease among practicing doctors in other specialties, this often results in a delay in the diagnosis, which in addition to a significant reduction in the quality of life can also have devastating consequences for the patient.

PATIENT AND METHOD

According to a stage-dependent procedure, the therapy strategies range from antibiotic administration only to radical resection of the SC joint and other affected structures of the chest wall in severe cases with the following necessity for flap reconstruction. The aspect of possible post-interventional instability after resection of the SCJ receives little or no attention in the current literature. In the present case report of a 51-year-old, otherwise healthy gentleman with isolated monoarthritis of the right SCJ with Escherichia coli (E. coli) shortly after two prostatitis episodes, the possibility of a new surgical approach with a one-stage eradication and simultaneous stabilization of the SCJ is presented. Therefore, a joint resection including extensive debridement is performed while leaving the posterior joint capsule and inserting an antibiotic carrier. In the same procedure, the SCJ is then stabilized with an autologous gracilis tendon graft by using the "figure of eight" technique, which has become well established particularly for anterior instabilities of the SCJ in recent years.

RESULTS AND CONCLUSION

One year after operative therapy, the patient presented symptom-free with an excellent clinical result (SSV 90%, CS89 points, CSM 94 points, TF 11 points, DASH 2.5 points). It is concluded that in selected cases with an infection restricted to the SCJ without major abscessing in the surrounding soft tissues, the demonstrated procedure leads to good and excellent clinical results with stability of the joint. If the focus of infection and germ are known, stabilization using an autologous graft can be carried out under antibiotic shielding. To the best of the authors' knowledge, this surgical procedure has not yet been described in the current literature. Depending on the extent of the resection, an accompanying stabilization of the SCJ should be considered to achieve stable conditions and an optimal clinical outcome.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV case series.

Minimum 5-Year Outcomes and Return to Sports After Resection Arthroplasty for the Treatment of Sternoclavicular Osteoarthritis

BACKGROUND

Osteoarthritis of the sternoclavicular (SC) joint is a rare condition that leads to decreased function and persistent pain, ultimately altering the function of the shoulder and keeping individuals from their desired activities. SC resection in the setting of primary and posttraumatic osteoarthritis is the most common surgical treatment for these patients, but midterm results are lacking.

PURPOSE/HYPOTHESIS

The purpose was to assess the clinical outcomes, pain levels, return to sports rate, and survivorship after open SC joint resection in the setting of painful primary SC joint osteoarthritis. We hypothesized that an SC joint resection of maximum 10 mm would result in a significant improvement in clinical outcomes, decreased pain levels, a high rate of return to sports, and a high survivorship.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent SC joint resection (maximum 10 mm) by a single surgeon between the years 2006 and 2013 with minimum 5-year follow-up were reviewed. The following clinical outcomes were collected prospectively during this time period: 12-Item Short Form Health Survey Physical Component Score (SF-12 PCS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numerical Evaluation (SANE) score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and patient satisfaction. Return to sports and pain were assessed through use of a customized questionnaire. Survivorship of SC joint resection was defined as not requiring further surgery on the affected joint.

RESULTS

A total of 21 SC joints were treated with resection of the medial clavicle and intra-articular disk and capsulorrhaphy for SC joint osteoarthritis in 19 patients with a mean age of 39.4 years (range, 12.5-66.7 years). At minimum 5-year follow-up, 19 SC joint resections were assessed in 16 of 19 patients (84%) with a mean follow-up of 6.7 years (range, 5.0-10.4 years). All outcome scores improved significantly from pre- to postoperative assessments: ASES (from 54 to 90.5; P = .003), SANE (from 61.8 to 90.4; P = .004), QuickDASH (from 43.1 to 13.8; P = .004), and SF-12 PCS (from 39.8 to 51.3; P = .004). Median satisfaction with surgical outcomes was 9 (range, 2-10), and pain levels improved from a score of 8 out of 10 to 3 out of 10 (scale of 0 to 10 with 0 being pain free and 10 worst possible pain). Of the 13 patients who answered the optional sports participation question, 13 (100%) patients had participated in sports before their injury. A total of 14 patients answered the question on sports participation after injury, with 12 (86%) indicating successful return to sports. Pain at its worst (P = .003) and pain with competition (P = .017) significantly decreased pre- to postoperatively. Resection survivorship at final follow-up was 84.2% at 5 years. We found that 3 patients (15%) had recurrent SC joint pain and were treated with revision surgery.

CONCLUSION

Open SC resection arthroplasty with capsulorrhaphy in the setting of pain for SC osteoarthritis results in significant improvement in clinical outcomes, patient satisfaction, return to sports, and pain reduction at minimum 5-year follow-up.

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.

Chronic Posterior Sternoclavicular Dislocation in a Contact Athlete: A Case Report

CASE

Traumatic posterior sternoclavicular dislocation (PSCD) is an uncommon injury that often presents in a delayed fashion and can be difficult to diagnose. Standard treatments include reduction of acute injuries and possible reconstruction for chronic injuries. We describe a 16-year-old male football player with a traumatic PSCD and initial dyspnea and dysphagia. He returned to playing contact sports without undergoing reduction.

CONCLUSIONS

Contrary to the literature that suggests reduction as a primary treatment of PSCD, this case shows that a contact-sport athlete may be able to return to competitive sports with a chronic PSCD.

Surgical Treatment of a Medial Clavicle Fracture Nonunion with Medial Clavicle Resection and Stabilization to the Sternum with Palmaris Longus Graft

Medial end clavicular fractures are a rare occurrence. While most of these fractures can be appropriately managed with a nonoperative treatment, some cases of symptomatic nonunion might be surgically addressed to preserve sternoclavicular joint stability and ensure favorable outcomes. The open reduction and osteosynthesis procedure is a commonly performed procedure to treat clavicular fracture nonunion. However, few revision procedures have been described to address the occasional cases of hardware failure or recurrent nonunion of the medial end. In this report, the authors present a case of symptomatic nonunion of the medial clavicle initially treated with osteosynthesis. Implant failure with hardware migration was then treated by medial clavicle resection and stabilization to the sternum using a palmaris longus autograft and the figure-of-eight lacing technique. Excellent functional outcomes at three years of follow-up were obtained. To the authors' knowledge, this is the first case reporting on a sternoclavicular stabilization with a tendon autograft for such an important bone deficit.

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.

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.

Sports-related sternoclavicular joint injuries

Sports-related injuries to the shoulder are common causes of disability. Injuries to the sternoclavicular joint (SCJ) in sports are more rare, though have been reported in a small number of cases. SCJ injury classification is determined by the degree of joint displacement and direction of clavicular displacement. Direction of displacement is particularly important due to risk of injury to intrathoracic structures, which has the potential to result in fatal outcomes. These injuries are important to identify in athletes and can be difficult to assess on the field. Specific radiographic views and use of ultrasound can improve accuracy of diagnosis. Reduction of acute traumatic SCJ dislocations is recommended and may require open reduction in the case of posteriorly displaced dislocations. Surgical treatment is indicated in cases of persistent pain or significant compression to intrathoracic soft tissue structures. Long-term outcomes are generally favorable, and athletes are able to return to sport without functional limitations.

Chronic Instability and Pain of the Sternoclavicular Joint: Treatment With Semitendinosus Allograft to Restore Joint Stability

Chronic instability of the sternoclavicular (SC) joint is a challenging clinical problem, particularly in a patient population for which nonoperative forms of treatment prove ineffective. Patients present after experiencing recurrent subluxation events and subsequent pain, which commonly result in increasing functional limitation. Recurrent SC joint instability of this nature can lead to damage of the SC joint cartilage and bone, and in cases of posterior subluxation or dislocation, damage to mediastinal structures. While the precise treatment algorithm requires tailoring to individual patients and their respective pathologies, we have demonstrated successful outcomes in correcting chronic SC joint instability by means of SC joint reconstruction with semitendinosus allograft, SC joint capsular reconstruction, and, in cases of arthritic damage, resection of a small portion of the degenerative component of the medial clavicle. The purpose of this Technical Note is to describe a technique that uses a semitendinosus allograft to stabilize the SC joint combined with a capsular reconstruction in patients who have previously failed nonoperative treatment methods.

[Effectiveness analysis of distal radius microplate locking plate for treatment of displaced fracture of medial clavicle]

OBJECTIVE

To investigate and evaluate the effectiveness of the distal radius microplate locking plate for the treatment of displaced fracture of medial clavicle.

METHODS

Between January 2013 and June 2017, 18 cases of obvious displaced fracture of medial clavicle were treated with distal radius microlocking plate. There were 10 males and 8 females, with an average age of 51.4 years (range, 18-88 years). Causes of injury included traffic accident injury in 15 cases, heavy object injury in 3 cases; all of them were closed injury. According to Edinburgh classification, 15 cases were ⅠB1 type and 3 cases were ⅠB2 type. Fracture displacement was 12-21 mm (mean, 16.3 mm). The time from injury to operation was 3-7 days (mean, 4.3 days). After operation, the clinical healing and complications of fracture were observed, and shoulder function was evaluated according to Rockwood's scoring criteria.

RESULTS

No incisional infection, neurovascular injury, or other early complications occurred. All 18 patients were followed up 8-15 months (mean, 12 months). All fractures reached clinical osseous union, and the healing time was 8-24 weeks (mean, 16.6 weeks). Postoperative plate loosening occurred in 1 case, which was removed surgically, while other patients did not suffer from complications such as bone nonunion, displacement, internal fixator loosening, and loss of reduction. At last follow-up, according to Rockwood's scoring criteria, the results were excellent in 12 cases and good in 6 cases.

CONCLUSION

The distal radius microplate locking plate is effective for the treatment of displaced medial clavicle fracture, which has few complications, and is feasible for early functional exercise, and is helpful for the recovery of shoulder joint function.

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.

A novel surgical method for treating medial-end clavicle fractures

The present study examined the effectiveness of the method of inversing the distal clavicle anatomic locking plate to treat medial-end clavicle fractures. This involved retrospectively analyzing six cases of medial-end clavicle fractures treated using the method of inversing the distal clavicle anatomic locking plate between September 2013 and December 2015. These cases included five men and one woman with an average age of 46.3±10.6 years old and a range of 24-66 years old. Among these cases, one was type A, two were type C, and three were type D, based on the Throckmorton type classification. All patients had fresh closed fractures, which were caused by direct injury. A regular postoperative follow-up was performed and the therapeutic efficacy was evaluated systematically with reference to the Rockwood and Disability of the Arm, Shoulder and Hand (DASH) score standards. All six cases had a follow-up visit, which was between 10 and 14 months with an average of 12.0±2.2 months. All patients exhibited osseous healing and functional recovery without incision infection, nerve vascular injury, chest injury, fracture nonunion, or other complications. According to the Rockwood and DASH score standards, evaluation of the curative effect showed that five cases were excellent and one case was good, and the associated rate for achieving good or excellent outcomes was 100%. All of the DASH scores were <10. These results indicated that the effect of the treatment of medial-end clavicle fractures by the method of inversing the distal clavicle anatomic locking plate was reliable, and the functional recovery of patients was good, making this method worthy of clinical promotion.

Sternoclavicular joint

The sternoclavicular joint is a saddle shaped, synovial joint and is the only skeletal articulation between the axial skeleton and the upper limb. Here, a reviewis provided of the anatomy, biomechanics, traumatic and atraumatic conditions, and management options for the various conditions described.

Temporary Sternoclavicular Stabilization Using an Innovative Blocking Technique with Kirschner Wires for the Treatment of Posterior Sternoclavicular Joint Injury in Adolescent Patients: A Report of Two Cases

CASE

A 15-year-old boy with a posterior physeal fracture-dislocation of the medial aspect of the clavicle and a 14-year-old boy with a posterior sternoclavicular joint dislocation were successfully treated with temporary sternoclavicular stabilization using an innovative blocking technique with Kirschner wires.

CONCLUSION

When treating posterior sternoclavicular joint injuries, posterior instability should be securely stabilized. Temporary blocking stabilization of the sternoclavicular joint using Kirschner wires does not rigidly fix the sternoclavicular joint, but it prevents posterior displacement of the proximal aspect of the clavicle. This stabilizing technique is a simple, safe, and viable treatment option for adolescent patients with a posterior sternoclavicular joint injury.

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

[Development and clinical application of a new type of anatomical locking plate for sternoclavicular joint fracture and dislocation]

Objective

To report a new type of anatomical locking plate for sternocalvicular joint, and investigate its effectiveness in treatment of sternoclavicular joint fracture and dislocation.

Methods

A new type of anatomical locking plate for sternoclavicular joint was developed, which accorded with the anatomical features and biomechanical characteristics of Chinese sternoclavicular joint. By adopting the method of clinical randomized controlled study, 32 patients with the sternoclavicular joint fracture and dislocation who met the selection criteria between June 2008 and May 2015 were randomly divided into groups A and B ( n=16), and the patients were treated with new anatomic locking plate and distal radial T locking plate internal fixation, respectively. There was no significant difference between 2 groups in gender, age, injured side, body mass index, cause of injury, type of injury, the time from injury to operation, and preoperative Rockwood grading score ( P>0.05). The operation time, intraoperative blood loss, incision length, hospitalization time, and postoperative complications in 2 groups were recorded, and the effectiveness was evaluated by Rockwood grading score.

Results

The operations of 2 groups completed successfully. The operation time, intraoperative blood loss, and hospitalization time in group A were significantly less than those in group B ( P<0.05), but there was no significant difference in the incision length between 2 groups ( t=0.672, P=0.507). All the patients were followed up 18-30 months (mean, 24 months). In group A, there were 1 case of sternoclavicular joint pain and 2 cases of wound infection; in group B, there were 1 case of sternoclavicular joint pain, 1 case of internal fixation loosening, and 1 case of sternoclavicular joint re-dislocation; there was no significant difference in complication incidence between 2 groups ( P=1.000). The Rockwood grading scores at each time point after operation in 2 groups were significantly higher than those before operation. At 1 month after operation, the Rockwood grading score in group A was significantly higher than that in group B ( t=2.270, P=0.031); but there was no significant difference in the Rockwood grading scores between the 2 groups at 6 months and at last follow-up ( P>0.05). At last follow-up, according to the Rockwood scoring standard, the results of group A were excellent in 13 cases, good in 2 cases, poor in 1 case, the excellent and good rate was 93.75%; the results of group B were excellent in 11 cases, good in 4 cases, poor in 1 case, and the excellent and good rate was 93.75%; there was no significant difference between 2 groups ( Z=-0.748， P=0.455).

Conclusion

The new type of anatomic locking plate accords with the Chinese anatomical characteristics. It has the advantages of easy operative procedure, less surgical trauma, shorter operation time, less intraoperative blood loss, shorter hospitalization time, and it can achieve better results in the treatment of sternoclavicular joint fracture and dislocation.

[Development and biomechanical study of anatomical locking plate of sternoclavicular joint]

Objective

To develop an anatomical locking plate in accordance with the anatomical characteristics of the sternoclavicular joint, which is reliable fixation and easy to operate, so as to provide an ideal internal fixation device for the treatment of sternoclavicular joint dislocation or peripheral fractures.

Methods

Gross measurement and CT measurement were performed on the 8 adult antiseptic and moist cadaver specimens (16 sides) to measure the parameters of surrounding bone structure of the sternoclavicular joint. The parameters included the thickness of presternum, sternal notch width, anteroposterior diameter of proximal 1/3 of clavicle, upper and lower diameters of proximal 1/3 of clavicle, angle between proximal end of clavicle and presternum in coronal plane, and angle of thoracoclavicular joint at anatomic position forward. According to the anatomical parameters and biomechanical properties of the specimens, the anatomical locking plate was designed and developed. The sternoclavicular ligament and joint capsule of all the specimens were completely cut off to make the sternoclavicular joint dislocation model. The left and right sternoclavicular joint of each specimen were randomly divided into experimental group (anatomic locking plate fixation) and control group (oblique T shape locking plate fixation). The sternoclavicular joint activity and common force mechanism was simulated on the universal mechanical testing machine, and the clavicular distal load test, sternoclavicular joint torsion test, and anti-pulling of steel plate manubrium part test were performed.

Results

The differences between the anatomical parameters of gross measurement and CT measurement were not significant ( P>0.05). In the clavicular distal load test, when the anatomical position perpendicular to the distal clavicle back loading to 20 N, the displacement of loading point in the experimental group was (8.455±0.981) mm, which was significantly less than that in control group [(10.163±1.379) mm] ( t=-3.012, P=0.020); the distal clavicle displacement of loading point of experimental group and control group were (5.427±1.154) mm and (6.393±1.040) mm, respectively, showing no significant difference ( t=-1.459, P=0.188)。In the sternoclavicular joint torsion test, the torque of experimental group was significantly greater than that of control group when the clockwise torsion angle was at 2, 4, 6, 8, and 10 degrees and the counterclockwise torsion angle was at 4, 6, 8, and 10 degrees ( P<0.05). The torsional stiffness in the experimental group under clockwise and counterclockwise condition was 0.122 and 0.108 N·m/° respectively, which were significantly higher than those in the control group (0.083 and 0.078 N·m/° respectively) ( F=67.824, P=0.000; F=20.992, P=0.002). In the anti-pulling of steel plate manubrium part test, the maximum pullout force of experimental group [(225.24±16.02) N] was significantly higher than that in control group [(174.40±21.90) N] ( t=5.785, P=0.001).

Conclusion

The new type of anatomical locking plate can realize the sternoclavicular joint three-dimensional fixation, and has the advantages of reliable fixation, simple operation, less trauma, superior biomechanical properties, and earlier functional exercise. It may be an ideal internal fixation device in clinical treatment of sternoclavicular joint dislocation or peripheral fractures.

Arthroscopic Sternoclavicular Joint Diskectomy for Acute and Chronic Tears

PURPOSE

To describe the results and functional scores in a group of patients who underwent arthroscopic excision of a symptomatic sternoclavicular joint (SCJ) disk tear with a minimum follow-up period of 2 years.

METHODS

Between April 2010 and December 2014, 14 patients underwent arthroscopic excision of a torn SCJ disk. Patients whose intended surgery was an isolated diskectomy and underwent that surgery only, with no additional procedure, were included. The minimum follow-up period was 24 months. All patients underwent an arthroscopic SCJ diskectomy. Postoperatively, no immobilization was required, and the patients were encouraged to mobilize as pain permitted. The patients were assessed preoperatively and at final follow-up with the visual analog scale score for pain, Rockwood score, and QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) score.

RESULTS

The average age at surgery was 29.4 years (range, 19-39 years). Ten of the patients had been symptom free before a specific incident, after which SCJ symptoms developed. The other 4 patients reported a gradual onset of symptoms and were considered to have chronic tears. The average duration of symptoms was 22.8 months (range, 6-48 months). At a mean follow-up of 33.4 months (range, 24-59 months), a significant improvement in the Rockwood score was noted, from 7 (range, 5-9; standard deviation [SD], 1.4) to 13.6 (range, 9-15; SD, 1.9) (P = .001) (minimal clinically important difference not described). The mean QuickDASH score improved from 23.7 points (range, 6.8-40.9 points; SD, 11.8 points) to 8 points (range, 0-29.5 points; SD, 9 points) (P = .0024) (minimal clinically important difference, 13.4 points). There were no reported complications and specifically no instability.

CONCLUSIONS

The results of this series suggest that arthroscopic SCJ diskectomy is a safe and reproducible procedure for the treatment of patients with symptomatic SCJ disk tears.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic Excision of the Sternoclavicular Joint

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

[Chronic acromioclavicular joint injury of Rockwood V type with concomitant chronic anterior sternoclavicular instability]

Bipolar dislocation of the clavicle is rare. In the literature, every reported bipolar dislocation of the clavicle is caused by a traumatic injury with loss of function of the affected shoulder. Currently, there is no recommendation to treat. A conservative treatment can be tried first to achieve adequate shoulder function. If this cannot be achieved, surgical treatment will be indicated. In the literature, many options for surgical treatment are described. This article presents a case of a chronic Rockwood V injury with chronic anterior sternoclavicular joint instability. The special feature of this case was the arthroscopically assisted stabilization of the acromioclavicular joint (ACJ) with the ipsilateral semitendinosus tendon graft and the open stabilization of the sternoclavicular joint (SCJ) with the ipsilateral gracilis tendon graft. A lateral fracture of the clavicle in the course of the postoperative treatment was treated with a plate osteosynthesis. At follow-up after six months, the postoperative shoulder function was restored. The ACJ and the SCJ were stable in clinical and radiographic examination. This case report shows the first surgical treatment using two tendon grafts for combined stabilization of the ACJ and SCJ.

Possibilities for arthroscopic treatment of the ageing sternoclavicular joint

AIM

To investigate if there are typical degenerative changes in the ageing sternoclavicular joint (SCJ), potentially accessible for arthroscopic intervention.

METHODS

Both SCJs were obtained from 39 human cadavers (mean age: 79 years, range: 59-96, 13 F/26 M). Each frozen specimen was divided frontally with a band saw, so that both SCJs were opened in the same section through the center of the discs. After thawing of the specimens, the condition of the discs was evaluated by probing and visual inspection. The articular cartilages were graded according to Outerbridge, and disc attachments were probed. Cranio-caudal heights of the joint cartilages were measured. Superior motion of the clavicle with inferior movement of the lateral clavicle was measured.

RESULTS

Degenerative changes of the discs were common. Only 22 discs (28%) were fully attached and the discs were thickest superiorly. We found a typical pattern: Detachment of the disc inferiorly in connection with thinning, fraying and fragmentation of the inferior part of the disc, and detachment from the anterior and/or posterior capsule. Severe joint cartilage degeneration ≥ grade 3 was more common on the clavicular side (73%) than on the sternal side (54%) of the joint. In cadavers < 70 years 75% had ≤ grade 2 changes while this was the case for only 19% aged 90 years or more. There was no difference in cartilage changes when right and left sides were compared, and no difference between sexes. Only one cadaver - a woman aged 60 years - had normal cartilages.

CONCLUSION

Changes in the disc and cartilages can be treated by resection of disc, cartilage, intraarticular osteophytes or medial clavicle end. Reattachment of a degenerated disc is not possible.

Minimum 2-year outcomes and return to sport following resection arthroplasty for the treatment of sternoclavicular osteoarthritis

HYPOTHESIS

The aim of this study was to assess the effect of open resection arthroplasty for osteoarthritis of the sternoclavicular (SC) joint on pain levels, functional outcomes, and return to sport.

METHODS

Patients from a single surgeon's practice who underwent open resection arthroplasty (maximum 10-mm resection) for SC osteoarthritis or prearthritic changes between November 2006 and November 2013 were retrospectively reviewed. This was an outcomes study with prospectively collected data. Preoperative and postoperative American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score, Single Assessment Numeric Evaluation score, several pain scores, and level of sport intensity were assessed.

RESULTS

Seventeen SC joints in 16 patients (9 female, 7 male) met inclusion criteria. Mean age at time of surgery way 41.1 years (range, 12-66 years). One patient refused participation in the study. Three SC joint resections (17.7%) required SC joint revision surgery. Minimum 2-year outcomes data were available for 11 of the remaining 13 SC joints (84.6%). The mean time to follow-up was 3.3 years (range, 2.0-8.8 years). Pain at its worst (P = .026), pain at competition (P = .041), the Quick Disabilities of the Arm, Shoulder, and Hand score (P = .034), and the ability to sleep on the affected shoulder (P = .038) showed significant improvement postoperatively. The average postoperative American Shoulder and Elbow Surgeons score was 83.3. The level of sports participation (P = .042) as well as strength and endurance when participating in sport (P = .039) significantly increased postoperatively.

CONCLUSION

Resection arthroplasty of the medial end of the clavicle in patients with osteoarthritis of the SC joint without instability results in pain reduction, functional improvement, and a high rate of return to sport at midterm follow-up.

Bilateral Posterior Sternoclavicular Dislocations

We present the case of a professional horse jockey with chronic, bilateral, posterior sternoclavicular dislocations. Traumatic dislocation of the sternoclavicular is a relatively rare but potentially devastating injury. Posterior sternoclavicular dislocations occur less frequently than anterior dislocations and require careful and complete evaluation because of the potential for serious complications including respiratory distress, brachial plexus injury, and vascular injury. Our patient was treated with excision of the medial end of the clavicle on her symptomatic side.