Abstract
Background:
Sternoclavicular joint (SCJ) dislocations may occur as the result of traumatic injury, ligamentous laxity, or chronic arthropathy. While initial management of anterior sternoclavicular dislocations is typically nonoperative treatment, patients with symptomatic chronic dislocation may benefit from reconstruction. In this video, we describe the sternal docking technique for SCJ reconstruction using a semitendinosus allograft augmented with a biologic collagen scaffold.
Indications:
Current indications for SCJ reconstruction include acute posterior dislocations, symptomatic chronic anterior dislocations, and cases of symptomatic arthropathies of the SCJ.
Technique Description:
In a lazy beach-chair position, a curvilinear incision is made over the anterior SCJ centered over the inferior portion of the joint. After exposure of the joint, the intra-articular disc and 5 mm of medial clavicle are resected. A 4-mm bur is used to open the intramedullary canal on the articular facet of the manubrium and the medial clavicle. Additional perforations to act as tunnels are made on the anterior aspects of the manubrium and medial clavicle both superiorly and inferiorly, and a small curved curette is used to widen the tunnels and connect them to their respective intramedullary canals to allow for graft passage. The semitendinosus graft is whipstitched to a biologic collagen shoestring scaffold and passed through the tunnels. The joint is reduced, and the graft is sutured together over the top of the medial clavicle with appropriate tension.
Results:
The sternal docking technique was successfully implemented for the reconstruction of a chronic anterior SCJ dislocation and allowed the patient to return to full pain-free activity by 16 weeks.
Discussion:
Chronic anterior SCJ dislocations may fail to respond to conservative treatment measures necessitating operative reconstruction. The sternal docking technique using semitendinosus allograft augmented with a biologic shoestring scaffold described here is a safe and effective reconstructive technique.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
Overview
In this video, we present a surgical technique for sternoclavicular joint (SCJ) reconstruction with a semitendinosus allograft augmented with a biologic collagen scaffold using a sternal docking technique. While there are a number of configurations and fixation options for SCJ reconstruction, we present a centralized graft position, which minimizes residual SCJ subluxation and the need to dissect and drill posteriorly. Additionally, we provide surgical technique pearls and pitfalls for this approach. We also review our postoperative management and rehabilitation protocol, as well as functional outcomes.
Background
SCJ dislocations can occur as the result of traumatic injury, ligamentous laxity such as in Ehler-Danlos syndrome, or chronic degenerative processes, including inflammatory arthritis or osteoarthritis. While first-line treatment is typically conservative, joint reconstruction is indicated in acute posterior SCJ dislocations, symptomatic chronic anterior dislocations, or cases of symptomatic arthropathy that have failed to respond to nonoperative management. Surgical treatment options for symptomatic chronic sternoclavicular instability and painful arthritis include medial clavicle resection, ligamentous reconstruction, or temporary internal fixation, all of which have acceptable patient-reported outcomes.3-5 SCJ reconstruction can vary in terms of graft and technique, with options including autografts (subclavius, sternocleidomastoid, hamstring) and allografts. Techniques include the intramedullary and figure-of-8 reconstruction, with the most common being the figure-of-8 technique using a hamstring autograft or allograft. 7 However, the anterior graft tying in the figure-of-8 technique can lead to anterior displacement of the clavicle relative to the sternum. Additionally, the anterior knot of the graft can result in a bulky and cosmetically unappealing reconstruction. The potential complication profile is also higher as dissection and drilling posteriorly is in the direction of the great vessels. The sternal docking technique for SCJ reconstruction allows for ligamentous reconstruction with a centralized intramedullary graft position between the clavicle and the sternum. 6 This works to minimize anterior translation of the SCJ and allows for easier graft passage through the sternum while avoiding the need for retrosternal dissection and drilling, thus increasing the safety of the procedure.
Case Presentation
Our case involves a 46-year-old left hand–dominant woman with chronic left shoulder pain that started after a collision on a water slide 2 years prior to presentation. She was noted to have an acute left anterior SCJ dislocation at the time of injury, which was initially managed nonoperatively by an outside provider. Her symptoms were worse with overhead activities and while performing activities of daily living with poor preoperative functional outcomes. Despite a trial of extensive physical therapy, activity modification, and anti-inflammatories, the patient continued to have pain located at her left SCJ 2 years out from injury.
On physical examination, she had no open wounds or abrasions. SCJ deformity with asymmetry was noted with tenderness to palpation. She had near full active and passive range of motion of the left shoulder. She had full rotator cuff strength. She demonstrated significant pistoning of the SCJ with upper extremity movement, as well as anterior and medial translation of the medial clavicle with shoulder forward flexion, abduction, and cross-body adduction.
Axial and coronal magnetic resonance images of the chest demonstrate a chronic anterior dislocation of the left SC joint. Three-dimensional computed tomography reconstructions similarly demonstrate this chronic left SC joint deformity.
Preoperative Planning
The patient was indicated for surgical reconstruction given that her symptomatic chronic anterior SCJ instability had failed to adequately respond to conservative treatment measures and continued to significantly interfere with her activities of daily living and desired recreational activities.
Technique Description
The patient is placed in the supine position on the operating room table. After administration of general anesthesia and endotracheal incubation, the patient is brought up into a lazy beach-chair position to about 30°. A pneumatic arm holder is used for arm positioning throughout the case.
Using a No. 15 blade knife, a curvilinear incision is made overlying the anterior aspect of the left SCJ centered across the inferior portion of the joint. Careful dissection through the underlying subcutaneous tissues and platysma is carried out down to bone. A Key elevator is used to gently lift muscle from the medial clavicle and the manubrium to adequately expose the left SCJ. The intra-articular disc between the clavicle and sternum is identified and removed. The medial end of the clavicle may appear to be bulbous and abnormal in chronic cases.
A microsagittal saw is then used to remove about 5 mm of bone from the sternal end of the clavicle. This osteotomy is performed perpendicular to the long axis of the clavicle. A reduction trial is then performed by applying a posteriorly directed force to the medial clavicle. Here the reduction was felt to be appropriate after the osteotomy. At this point, the medial aspect of the clavicle is identified. A 4-mm burr is used to open the medial end of the clavicular endosteal canal. An anterosuperior tunnel is then created 10 to 15 mm from the resected end of the clavicle, followed by an anteroinferior tunnel. A small angled curette is then used to clear cancellous bone and connect these cortical tunnels to the intramedullary canal. Attention is then turned to the sternum. The sternal facet of the SC joint is identified and an oblong perforation into this facet is performed to create a tunnel into the intermedullary canal of the manubrium to a depth of about 8 to 10 mm. Two additional perforations for tunnel creation are prepared on the anterior cortex of the manubrium, 1 proximal and 1 distal. A small angled curette is then used to connect these 2 tunnels to the original oblong tunnel and to clear cancellous bone and widen the holes enough to allow for graft passage. At this point, the length of the graft is determined by passing a suture in the same configuration as the graft, starting from the anteroinferior clavicular tunnel, through the anteroinferior sternal tunnel, followed by the anterosuperior sternal tunnel, and finally through the anterosuperior clavicular tunnel. On the back table, a semitendinosus tendon allograft is measured to length and split in half longitudinally. A biologic shoestring scaffold is then whipstitched to the allograft using a No. 2 Ethibond (Ethicon) suture. Using the suture tails, the graft is then passed starting from the anteroinferior sternal tunnel, through the anterosuperior sternal tunnel, followed by the anterosuperior clavicular tunnel, and finally through the anteroinferior clavicular tunnel. The joint is then reduced. The 2 limbs of the graft are pulled taut, and side-by-side suture repair of the graft limbs is performed using a No. 2 Ethibond suture in a figure-of-8 fashion. The SCJ stability and reduction is reassessed. The joint is noted to be well reduced with robust fixation and appropriate graft tension. The excess suture, tendon, and scaffold are excised.
The surgical site is copiously irrigated. Vancomycin powder is placed in the deep surgical site for infection prophylaxis. A 0-Vicryl (Ethicon) suture is used to reapproximate the platysma as a deep layer to cover the suture stacks and limit the dead space for hematoma formation. A 2-0 Vicryl suture is used to reapproximate the subcutaneous skin edges and 3-0 Monocryl is then used in a running subcuticular fashion followed by Dermabond (Ethicon) glue and a dry dressing. The patient is placed in an abduction pillow sling.
Postoperative Rehabilitation
Postoperatively, the patient is kept in an abduction pillow sling at all times and with restricted glenohumeral passive range of motion and scapular active range of motion for 6 weeks. From 6 to 12 weeks, the patient is weaned from her sling and progressed to passive shoulder range of motion, active assisted range of motion, and active range of motion in all planes. From 13 to 16 weeks postoperatively, the patient begins shoulder and scapular strengthening with physical therapy along with proprioception and neuromuscular control training. After 16 weeks, the patient progresses to advanced strengthening and returns to all reactional activities at full capacity.
Results and Discussion
Return-to-play outcomes following graft reconstruction for anterior SCJ instability are limited; however, functional outcomes have been encouraging. In a retrospective review, Bae et al 1 reported functional outcomes of surgical treatment of anterior SCJ instability. This study assessed 15 patients and reported a mean American Shoulder and Elbow Surgeons score of 85 and Simple Shoulder Test score of 10.9 after an average follow-up of 55 months, with 60% experiencing stable, pain-free joints without complications or revision procedures. 1 Similarly, Guan and Wolf 2 retrospectively evaluated 6 patients treated with a soft tissue graft and found full range of motion without instability postoperatively, with 5 patients reporting no pain and all returning to preoperative activities. Lastly, Willinger et al 8 reviewed 5 studies involving 80 patients and found that tendon graft reconstruction for anterior SCJ instability yielded excellent results in 10% of cases, good results in 89%, and fair results in 1%, with a low recurrence of instability (10%) and a 5% revision surgery rate due to persistent issues. Overall, the literature supports the safety and effectiveness of SCJ reconstruction in the setting of chronic symptomatic instability.
Several pearls and pitfalls are critical to consider when performing a sternoclavicular reconstruction using the sternal docking technique. One must ensure that the bone tunnels are appropriately dilated to allow for easy graft passage while also minimizing the risk of bone bridge fracture. The graft size should be no larger than 5 mm in width to allow for easy passage. The medial aspect of the clavicle must likely be excised prior to tunnel placement. It is critical to carefully elevate the SCJ capsule and associated soft tissue to avoid plunging into critical vascular structures posterior to the sternum and clavicle. A biologic scaffold can be used to augment the reconstruction, increase time zero construct strength, and facilitate healing. Finally, ensure that the joint is maintained in a reduced position with appropriate graft tension prior to securing the graft limbs.
In summary, chronic anterior SCJ dislocations can be a source of chronic pain and may require surgical reconstruction if conservative treatment measures fail to adequately control symptoms. The sternal docking technique utilizing a semitendinosus allograft augmented with a biologic shoestring scaffold is a safe and effective technique that allows for easy graft passage while avoiding the need to pass the graft behind or completely through the sternum and potentially resisting anterior translation of the SCJ.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: M.T.H. was a paid consultant for Smith & Nephew and Tornier/Stryker; received intellectual property royalties from Smith & Nephew; was an unpaid consultant for Conmed, Ossio, and Sparta; and received research support from Conmed, Ossio, and Reparel. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
