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

The Ultrasound Perspective for Sternoclavicular Joint in Spondyloarthritis

Spondyloarthritis (SpA) is a prevalent genetic disorder that significantly impairs mobility, particularly in the spine, sacroiliac, and peripheral joints. Recent evidence highlights early involvement of the sternoclavicular joint in SpA, which may serve as an initial indicator. Diagnosis often relies on CT and MRI, neglecting ultrasound's potential in identifying SpA-related sternoclavicular arthritis. This review focuses on the joint's anatomy, exploring ultrasound's diagnostic and therapeutic role in SpA-related sternoclavicular arthritis, aiming to provide insights for future ultrasound applications in SpA management.

Instabilities and Osteoarthritis of the Sternoclavicular Joint

Injury to the sternoclavicular joint (SCG) is very rare, accounting for 3% of shoulder injuries and < 1% of instabilities. Consequently, both the treatment of acute instabilities and their subsequent states (chronic instabilities/SCG arthrosis) are controversial. While treatment has so far been mostly conservative, in recent years there has been a trend towards surgical therapy.Considerable violence, such as that found in traffic accidents or contact sports, can tear the extremely stable ligaments between the medial clavicle and sternum. While anterior dislocation is easier to reduce in most cases, instability remains in up to 50% of cases. In most cases, posterior instability requires rapid reduction, particularly due to the anatomical proximity to important cardio-pulmonary structures. If this succeeds, the rate of persistent instabilities is low. For chronic instability, reconstruction/augmentation of the ligament apparatus with tendon grafts in the "Figure of 8 configuration" has proven to be the standard technique in recent years.

Current Concepts in Sternoclavicular Joint Injuries

LEVEL OF EVIDENCE

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

Clinical Outcome after Clavicular Hook Plate Fixation for Displaced Medial-End Clavicle Fractures

Background

Surgery of the medial end of the clavicle remains a challenge for orthopedic surgeons. Moreover, there is no standard surgical procedure for treating displaced fractures or dislocation of the medial clavicle. Thus, the present study aimed to evaluate the safety and efficacy of using a hook plate for treating medial-end clavicular fractures and present functional outcomes.

Methods

We retrospectively investigated 18 patients who underwent surgery with a hook plate from July 2016 to December 2021. There were 14 men and 4 women with a mean age of 57.4 years. Fracture union was assessed at follow-up by computed tomography (CT). Other outcome parameters were complications, including implant failure, infection, nonunion, osteolysis of sternal manubrium, and migration of the hook portion. Range of motion (ROM), visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH), and American Shoulder and Elbow Society (ASES) scores were evaluated 6 months postoperatively and at the last follow-up.

Results

The mean operation time was 43.8 minutes (range, 35-50 minutes) and the mean follow-up was 22.8 months (range, 12-42 months). Bone union was confirmed in all cases. The mean union time was 6.2 months (range, 6-7 months). Implant removal was performed routinely according to the clinical course in 17 cases. The mean implant removal time was 10.0 months (range, 6-14 months). Clinical and functional outcomes measured at the last follow-up were significantly improved compared to those at 6 months postoperatively (p < 0.05). Regarding complications, there were 6 cases (33.3%) of osteolysis of the sternal manubrium. Although the anteroposterior length of the manubrium and hook depth showed significant differences between the non-osteolysis group and the osteolysis group (p = 0.024), ROM, VAS, Quick DASH, and ASES scores were not significantly different between the two groups (all p > 0.05).

Conclusions

Clavicle hook plating can be a safe and effective method that can be easily applied with good outcomes if it is used with appropriate surgical planning and technique for medial-end clavicle fracture. CT scans are useful for preoperative planning and postoperative evaluation of bone union or complications.

Acromioclavicular Joint Anatomy and Biomechanics: The Significance of Posterior Rotational and Translational Stability

The shoulder girdle extends from the sternoclavicular joint to the scapular stabilizing muscles posteriorly. It consists of 3 joints and 2 mobile regions. The shoulder girdle is statically stabilized by the acromioclavicular and coracoclavicular capsuloligamentous structures and dynamically stabilized by the trapezius, deltoid, and deltotrapezial fascia. During humerothoracic elevation, the clavicle elevates, protracts, and rotates posteriorly through the sternoclavicular joint while the scapula tilts posteriorly and rotates upward. The purpose of this article is to review the anatomy and biomechanics of the acromioclavicular joint and the shoulder girdle.

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.

Dynamic evaluation of the sternoclavicular and acromioclavicular joints using an upright four-dimensional computed tomography

In the analysis of the shoulder complex, the sequential changes occurring in the sternoclavicular and acromioclavicular joints during active shoulder motion are challenging to track. This study aimed to investigate the in vivo sternoclavicular and acromioclavicular joint motions during active elevation, including the sequential changes in these joint spaces using upright four-dimensional computed tomography (4DCT). Bilateral shoulders of 12 healthy volunteers upright 4DCT were obtained during active elevation similar to a "hands up" motion. The sternoclavicular and acromioclavicular rotation angles, joint distances, and closest points on the clavicle relative to the thorax and scapula were evaluated during 10°-140° of humerothoracic elevation. During humerothoracic elevation, the clavicle elevated, retracted, and rotated posteriorly relative to the thorax, whereas the scapula rotated upwardly, internally, and posteriorly relative to the clavicle. All the sternoclavicular and acromioclavicular joint rotation angles were significantly different at ≥ 30°-50° of humerothoracic elevation compared with 10° of humerothoracic elevation. The mean sternoclavicular and acromioclavicular joint distances were 2.2 ± 1.1 mm and 1.6 ± 0.9 mm, respectively. The closest points were located on the anteroinferior part of the medial and lateral clavicle in the sternoclavicular and acromioclavicular joints, respectively. Significant differences were observed in the acromioclavicular joint distance and anterior/posterior movements of the closest points in the sternoclavicular and acromioclavicular joints compared with 10° of humerothoracic elevation. Our sternoclavicular and acromioclavicular closest point results indicate that the impingement tends to occur at the anteroinferior part of the medial and lateral aspects of the clavicle and may be related to osteoarthritis.

The Incidence of Symptomatic Mediastinal Compromise Following Medial Clavicle Fractures

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [Orthopedics. 202X;XX(X):xx-xx.].

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.

Anatomical study of the sternoclavicular joint using high-frequency ultrasound

OBJECTIVES

The purpose of the present study was to determine whether ultrasound enables assessment of sternoclavicular structures.

METHODS

A preliminary study in 3 cadavers was followed by an ultrasound study, performed by 2 musculoskeletal radiologists working in consensus, in 59 patients without history of trauma, surgery or pain in the sternoclavicular joint. The visibility, echogenicity and thickness of the sternoclavicular structures were assessed.

RESULTS

The anterior sternoclavicular ligament and the interclavicular ligament could be seen in all patients (mean thickness: 1.4 mm and 1.3 mm, respectively). The articular disc was clearly seen in 66.1% of cases, and shoulder antepulsion enabled analysis in an additional 20.3%. Intra-articular joint gas was frequent (33.89% of cases), preventing analysis of the disc in 2 patients. Only the superficial anterior aspect of the clavicular and sternal articular cartilages could be assessed. Joint effusion was seen in 6.8% of cases. Clavicular osteophytes, sternal osteophytes and bone irregularities at the anterior sternoclavicular ligament insertion were detected in 33.9%, 16.9% and 16.9% of cases, respectively.

CONCLUSION

The anterior sternoclavicular ligament, interclavicular ligament and anterior intra-articular structures can be visualized by ultrasound. This means of assessment may have clinical applications, particularly in patients with trauma or microtrauma.

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.

What Are the Functional Outcomes and Pain Scores after Medial Clavicle Fracture Treatment?

BACKGROUND

Medial clavicle fractures are uncommon, occurring in older and multiply injured patients. The management of these fractures and the factors that predispose toward poor outcomes are controversial. Furthermore, the functional outcomes of treatment are not well characterized or correlated with fracture patterns.

QUESTIONS/PURPOSES

(1) To determine minimum 1-year functional outcomes using QuickDASH scores and pain scores after medial clavicle fractures and (2) to identify factors associated with these outcome variables.

METHODS

In an institutional review board-approved, retrospective study, we identified adult patients with medial clavicle fractures at two tertiary care referral centers in a single metropolitan area in the United States from January 2010 to March 2019. Our initial query identified 1950 patients with clavicle fractures, from which 74 adult patients with medial clavicle fractures and at least 1 year of follow-up were identified. We attempted to contact these eligible patients by telephone for functional outcomes and pain scores. Twenty-six patients were deceased according to the most recent Social Security Death Index data and public obituaries, three declined participation, and 14 could not be reached, leaving 42% of the total (31 of 74) and 65% (31 of 48) of living patients included in the analysis. Demographic characteristics, fracture characteristics, and clinical and radiographic union as assessed by plain radiography and CT were collected through record review. Twenty-nine patients were treated nonoperatively and two patients underwent open reduction internal fixation. Sixty-eight percent (21 of 31) of the included patients also had radiographic follow-up at least 6 weeks postoperatively; two patients had persistent nonunion at a mean of 5 ± 3 years after injury. Our primary response variable was the QuickDASH score at a minimum of 1 year (median [range] 5 years [2 to 10]). Our secondary response variable was the pain score on a 10-point Likert scale. A bivariate analysis was performed to identify factors associated with these response variables. The following explanatory variables were studied: age, gender, race, dominant hand injury, employment status, manual labor occupation, primary health insurance, social deprivation, BMI, diabetes mellitus, smoking status, American Society of Anesthesiologists physical status classification, Charlson Comorbidity Index, nonisolated injury, high-energy mechanism of injury, nondisplaced fracture, fracture comminution, superior-inferior fracture displacement, medial-lateral fracture shortening, and surgical treatment of the medial clavicle fracture.

RESULTS

The mean QuickDASH score was 12 ± 15, and the mean pain score was 1 ± 1 at a mean of 5 ± 3 years after injury. The mortality rate of the cohort was 15% (11 of 74) at 1 year, 22% (16 of 74) at 3 years, and 34% (25 of 74) at 5 years after injury. With the numbers available, no factors were associated with the QuickDASH score or pain score, but it is likely we were underpowered to detect potentially important differences.

CONCLUSION

Medial clavicle fractures have favorable functional outcomes and pain relief at minimum 1-year follow-up among those patients who survive the trauma, but a high proportion will die within 3 years of the injury. This likely reflects both the frailty of a predominantly older patient population and the fact that these often are high-energy injuries. The outcome measures in our cohort were not associated with fracture displacement, shortening, or comminution; however, our sample size was underpowered on these points, and so these findings should be considered preliminary. Further studies are needed to determine the subset of patients with this injury who would benefit from surgical intervention.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Long-term results for traumatic sternoclavicular joint dislocation treated with a sternoclavicular joint-specific plate

BACKGROUND

The treatment of traumatic sternoclavicular joint (SCJ) dislocation (SCJD) with internal fixation has been reported with good short-term results, but data on its long-term results are scarce.

METHODS

Patients with traumatic SCJD treated with an SCJ-specific plate between January 2003 and January 2018 were evaluated retrospectively. All implants were routinely removed. Data from radiography, the American Shoulder and Elbow Surgeons score, the visual analogue scale and abduction and forward elevation of the shoulder were collected and evaluated before the index surgery, at implant removal and at the latest follow-up.

RESULTS

A total of 22 patients were included in this study with a mean follow-up period of 94.8 months. All patients maintained good reduction after the index surgery and implant removal. The visual analogue scale significantly improved from 7.1 ± 1.3 before the index surgery to 0.9 ± 1.0 at implant removal (P < 0.001) and to 1.0 ± 1.1 at the latest follow-up (P < 0.001); the American Shoulder and Elbow Surgeons score significantly improved from 37.9 ± 10.1 to 90.8 ± 7.8 (P < 0.001) and to 86.7 ± 8.6; and both abduction and forward elevation of the shoulder significantly improved at the latest follow-up (P < 0.001). There was no significant difference in the clinical results after implant removal.

CONCLUSION

Traumatic SCJD treated with an SCJ-specific plate appeared to be efficient, with satisfactory clinical and radiological results at long-term follow-up.

Balser Plate Stabilization for Traumatic Sternoclavicular Instabilities or Medial Clavicle Fractures: A Case Series and Literature Review

OBJECTIVE

This study was performed to observe the effect of internal Balser plate fixation for treating unstable sternoclavicular joints (SCJ) and displaced medial clavicle fractures.

METHODS

From April 2009 to September 2016, 17 consecutive patients who underwent open reduction and internal Balser plate fixation for SCJ dislocations or medial clavicle fractures were retrospectively reviewed. There were 11 male and six female patients, with a mean age of 45.6 ± 15.5 years. Standardized treatment procedures consisted of reduction, creating a space posterior dorsal osteal face of the sternal manubrium, an inverted Balser plating, and postoperative immobilization. At follow-up, plain radiographs were assessed for fracture union, implant loosening, degenerative changes, and joint congruity. Clinical evaluation included: completion of the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire; determination of the Constant and Murley score and visual analog scale (VAS) score; and assessment of intraoperative and postoperative complications.

RESULTS

All patients were followed up, at a mean follow-up of 20.1 ± 7.9 months, each fracture had a solid union, and each dislocation showed no sign of recurrent dislocation. The mean shoulder forward flexion was 162.9° ± 8.1°. The mean DASH score was 5.2 ± 5.2 points. The mean Constant and Murley joint function score was 93.7 ± 7.9 points, with 15 excellent cases and two good cases. The mean VAS score was 1.1 ± 1.4 points, showing significant improvement compared with the VAS score preoperatively. Postoperative complications included one wound hematoma which was healed after a debridement and one recurrent instability due to hook migration, which underwent revision reconstruction. All patients were satisfied with their treatment outcome at the final follow-up.

CONCLUSION

Sternoclavicular joints dislocation or medial clavicle fractures can be treated successfully with Balser plate fixation. This technique permits early functional exercise while preserving the SCJ.

[Injuries of the sternoclavicular joint]

Injuries of the sternoclavicular joint (SCJ) are rare accounting for 3% of all injuries to the shoulder girdle and are often overlooked. The SCJ is surrounded by tight ligamentous structures, thus substantial energy with corresponding force vectors is needed to cause dislocation. Causative are mostly high-energy traumas. Anterior dislocation is most common but in rare cases potentially life-threatening posterior dislocation occurs, which requires immediate reduction. The established gold standard is 3D reconstruction in contrast-enhanced computed tomography (CT) for depiction of neurovascular structures. Low-grade instability can initially be treated conservatively. For unsuccessful attempts at reduction, high-grade instability and chronic instability various surgical techniques are established. Next to retentive augmentation with suture materials, in acute cases with chronic instability biological tendon augmentation is preferred. In cases of posttraumatic instability arthritis SCJ resection with or without additive biological augmentation can be carried out. Various study groups have shown good to very good midterm outcome.

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.

Editorial Commentary: Sternoclavicular Joint Osteoarthritis Surgical Treatment Offers Benefits as Well as Risks

Sternoclavicular (SC) joint surgical procedures have risks as well as benefits and should be performed by experienced surgeons with a good understanding of the neurovascular anatomy and with a thoracic surgeon on call. Computed tomography angiograms to evaluate the proximity of the SC joint to the blood vessels are essential for preoperative planning. Care must be taken to exclude instability as a cause of SC joint symptoms, and surgeons must avoid causing iatrogenic instability. Both arthroscopic and open approaches can result in excellent clinical outcomes for patients with symptomatic SC arthritis. We prefer an open approach because an arthroscopic approach may have a greater risk of complications. In our experience, after surgical treatment of SC arthritis, 67% of patients return to sport at 2-year minimum follow-up.

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.

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.

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.].

[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.

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.

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.

Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint

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

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.

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.

Biomechanical Comparison of Surgical Techniques for Resection Arthroplasty of the Sternoclavicular Joint

BACKGROUND

The optimal location and extent of medial clavicle resection for sternoclavicular (SC) joint resection arthroplasty are unknown.

HYPOTHESIS

Resection of the intra-articular disc alone cannot reliably decompress the SC joint, and a parallel resection technique will decompress the SC joint significantly more compared with the same amount with an oblique resection technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Force transmission through the SC joint was measured in 7 matched-pair human cadaveric SC joints in a dynamic tensile testing machine. The specimens were randomized to either a parallel or an oblique resection technique. An 80-N axial load was applied on the lateral clavicle toward the SC joint in each of the following 4 conditions: (1) intact joint, (2) after resecting the intra-articular disc, (3) after resecting 5 mm of the medial clavicle, and (4) after 10-mm resection.

RESULTS

Complete discectomy of all SC joints resulted in a significant reduction of force transmitted through the SC joint (P = .002). However, the varying anatomy of the disc was accompanied by a varying amount of joint decompression (95% CI, 29.8%-65.4%). Resecting 5 mm of the SC joint with the parallel technique decompressed the SC joint by a mean (±SD) of 76.7 ± 22.1 N compared with 37.8 ± 24.8 N with the oblique technique (P = .02). Decompression did not significantly differ between the groups after 10-mm resection (P = .18) using the parallel technique (89.4 ± 24.1 N) compared with the oblique technique (68.2 ± 31.6 N). Furthermore, 5-mm resection of the medial end of the clavicle with the parallel technique decompressed the SC joint by an amount similar to 10-mm resection with the oblique technique.

CONCLUSION

Resection of the disc alone did not reliably decompress each SC joint. Resection of 5 mm of the medial end of the clavicle with the parallel resection technique reliably decompressed the SC joint better than with the oblique resection technique.

CLINICAL RELEVANCE

This study provides baseline data on SC joint resection techniques and their mechanical effects. This knowledge can be implemented in clinical practice to treat patients with symptomatic posttraumatic arthritis of the SC joint.

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.