Safe surgical technique: reconstruction of the sternoclavicular joint for posttraumatic arthritis after posterior sternoclavicular dislocation
© Stahel et al.; licensee BioMed Central Ltd. 2013
Received: 5 December 2013
Accepted: 26 December 2013
Published: 31 December 2013
Posttraumatic sternoclavicular arthritis related to chronic ligamentous instability after posterior sternoclavicular dislocation represents a rare but challenging problem. The current article in the Journal’s “Safe Surgical Technique” series describes a successful salvage procedure by partial resection of the medial clavicle and ligamentous reconstruction of the sternoclavicular joint with a figure-of-eight semitendinosus allograft interposition arthroplasty.
Since the first description of a traumatic posterior sternoclavicular dislocation 170 years ago , several anecdotal case reports have been published on this rare injury pattern [2–8]. While uncommon, posterior sternoclavicular dislocations represent potentially life-threatening injuries due to the close proximity of the posterior mediastinal structures [9, 10]. Aside from the risk of a vascular injury , tracheal tears and esophageal compression have been described, which lead to acute dyspnea and dysphagia . Additional associated injuries include a traumatic vocal cord palsy  and brachial plexus injury . Establishing an early diagnosis is difficult since these injuries are frequently missed [5, 15, 16]. Clinically, patients with traumatic posterior sternoclavicular dislocations are in significant pain, potentially associated with venous congestion, shortness of breath, and dysphagia. The medial end of the clavicle is typically palpable lateral to the jugular notch, and when displaced posteriorly, the corner of the sternum is exposed to palpation. As the clinical examination frequently remains equivocal, radiographic studies are required to establish the diagnosis [5, 16, 17]. Conventional radiographs are not sensitive for posterior sternoclavicular dislocations, and computed tomography (CT) represents the imaging modality of choice [18, 19].
Acute management strategies
Due to the proximity of the sternoclavicular joint to vulnerable structures in the superior mediastinum, dislocations must be reduced as early as possible . Forty to fifty percent of all posterior sternoclavicular joint dislocations are successfully managed by closed reduction [21, 22]. The most frequently described reduction maneuver consists of an ‘abduction/traction’-technique with the patient placed in supine position with a bump or sandbag between the shoulders, and gradual traction applied to the abducted arm, with slow progression to extension . If the reduction maneuver is successful, the clavicle reduces with an audible ‘popping’ sound. Some authors recommend the use of a percutaneous sterile towel clip to grasp the medial clavicle with lateral and anterior traction . About 50% of all closed reduction attempts are unsuccessful and place the patient at risk of additional harm . Severe complications have been reported after closed reduction maneuvers. As an example, a “near miss” complication has been described in which the medial clavicle perforated the right pulmonary artery, and surgical exploration revealed that acute bleeding was prevented by the clavicle compressing the artery . In this circumstance, a closed reduction maneuver would have likely resulted in unforeseen disaster. Thus, multiple authors recommend the early open surgical treatment of posterior sternoclavicular dislocations [26–29]. The ‘classic’ operative technique described by Burrows in 1951 consists of a subclavius tenodesis for stabilization of the sternoclavicular joint . Multiple additional surgical techniques have more recently been described, including fixation with cannulated screws , bridge plating [31, 32], cable fixation , artificial ligament reconstruction , and tendon reconstruction of the disrupted capsular/ligamentous complex [35, 36]. Of note, the use of Kirschner wires has been abandoned due to the risk of pin migration resulting in delayed penetration of vascular structures [37, 38]. Interpositional arthroplasty utilizing the sternal head of the sternocleidomastoid muscle has been recommended in conjunction with resection of the medial clavicle . Resection of the medial clavicle alone, however, has been associated with poor outcomes, particularly in cases with residual ligamentous instability [40–42].
Applied surgical anatomy
Meticulous care has to be taken not to plunge across the far cortex of the medial clavicle, due to the close proximity of posterior vascular structures, and not to extend the resection more than 1 cm laterally in order to preserve the insertion of the costoclavicular ligament. A malleable retractor is placed posterior to the clavicle to protect from the tip of the drill bit, and the osteotomy across the far cortex is carefully completed by the use of an osteotome. The resected part of the medial clavicle should not extend beyond 1 cm in length (small insert in Figure 8).
The antero-posterior drill holes are placed at a distance of 1 cm medial to the lateral sternal border, and 1 cm lateral to the site of the medial clavicular resection, to ensure no breach of the residual cortical bridge. We recommend using consecutive drill bit sizes in ascending order of 2.5 mm, 3.5 mm, and 4.5 mm to ensure adequacy of placement of the intraarticular drill holes for the ligament transfer. A drill hole of 4.5 mm diameter is the minimum requirement for successful passing of the semitendinosus tendon graft.
Temporary sutures are passed through the sternum to mark the drill holes and facilitate passage of the tendon graft (Figure 9B). The medullary canal of the clavicle is then drilled with a 4.5 mm drill bit and opened with a curette (Figure 9C). A temporary suture is passed through the clavicular drill holes, exiting the medullary canal (Figure 9D). The semitendinosus allograft is secured on a braided non-absorbable suture (e.g. Fiberwire®, Arthrex, Naples, FL) and passed through the medullary canal of the clavicle (Figure 10). The tendon graft is then passed in a figure-of-eight position through the tagged drill holes in the clavicle and sternum (Figure 11).
It is important to hold the sternoclavicular joint reduced in anatomic position prior to tying two consecutive knots with the ends of the tendon within the residual joint space. The knot of the tendon within the joint space serves as a ‘spacer’ for the resection arthroplasty of the medial clavicle (Figure 11).
✓ Posterior sternoclavicular dislocations are rare injuries which are frequently missed. Delayed diagnosis may relate to the fact that a plain chest radiograph is not sensitive in detecting this injury pattern (Figure 3). The ‘gold standard’ for establishing diagnosis is by clinical examination and CT scan (Figure 4).
✓ Many authors recommend the early open reduction and surgical fixation of posterior sternoclavicular dislocations due to limited proven success of closed reduction, and the potential for iatrogenic injuries associated with attempted closed reduction maneuvers [26–29]. The use of Kirschner wires for joint transfixation is strongly discouraged due to the risk of pin migration with penetration into the great vessels in the upper mediastinum [37, 38].
✓ Locked plate fixation represents a feasible new treatment option for the acute management of traumatic posterior sternoclavicular dislocations, by restoring joint stability and allowing early functional rehabilitation . The success of this technique is confirmed by the present case report, in which the patient had an excellent and uneventful postoperative recovery after locked plate fixation.
✓ Preemptive hardware removal after locked plate fixation, specifically within less than 3 months postoperatively, should be strongly discouraged due to the risk of recurrent joint instability as a root cause of early symptomatic posttraumatic arthritis. In analogy to the established plate fixation across joints in other anatomic locations (e.g. pubic symphysis plating), the consideration should be made of maintaining implants for lifetime in asymptomatic patients.
✓ Multiple reconstruction techniques have been described for restoring stability of the sternoclavicular joint in cases of posttraumatic arthritis related to chronic ligamentous instability. The resection of the medial clavicle alone is associated with poor long-term outcomes and therefore discouraged in cases with residual ligamentous instability [40–42].
✓ The surgical technique described herein consists of anterior ligamentous complex reconstruction by tendon tissue woven in a figure-of-eight intraarticular interposition technique. This is performed in conjunction with partial resection of the medial clavicular head proximal to the insertion of the costoclavicular ligament. This technique appears to represent the treatment modality of choice for addressing chronic joint instability in conjunction with posttraumatic arthritis, based on the results of the present case report and the current peer-reviewed literature [42, 43].
Written informed consent was obtained from the patient for publication of this article.
The patient agreed with publication of this case report, including the publication of medical data, radiological imaging, and intraoperative pictures. The authors acknowledge Judy Powell (medical illustrator, Naval Medical Center, San Diego, CA) for contributing the graphic artwork in Figures 1 & 2.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
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