Hamstring autograft reconstruction treats anterior sternoclavicular joint instability
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Sternoclavicular joint injury is rare and accounts for about 3% of all shoulder girdle injuries. Due to the strong support of the surrounding ligamentous structures, dislocation requires a large force.
Mechanism of injury can be either by direct or indirect force, and motor vehicle accidents and athletic injuries account for more than 80% of injuries to the sternoclavicular (SC) joint. The type of injury can range from a sprain to frank dislocation. Anterior dislocations are more common and can generally be treated nonoperatively. Posterior dislocations are potentially life-threatening events due to potential compression of the posterior structures that can result in shortness of breath, dysphagia, decreased circulation to the ipsilateral extremity, cardiovascular collapse and brachial plexus palsy or injury.
First-line treatment for an acute dislocation, either anterior or posterior, is a closed reduction under general anesthesia. Failed closed reduction of posterior dislocation is an indication for acute open reduction with cardiothoracic surgery available due to the potential for injury to the posterior cardiovascular structures. Chronic dislocations can result in SC joint osteoarthritis, and medial clavicle excision with possible stabilization of the remaining medial clavicle is an option for treatment if symptoms are refractory to nonoperative management.
Injuries to the joint can cause chronic anterior instability or recurrent subluxation events. Furthermore, atraumatic anterior instability and subluxation has been described. This chronic instability can lead to pain and dysfunction for patients, especially active patients who wish to participate in dynamic movements of the shoulder girdle. Treatment has historically been conservative and consists of activity modification, patient education, physical therapy and bracing. For patients who fail extensive conservative management, SC joint reconstruction is an option. This article describes our preferred technique for SC joint reconstruction with hamstring autograft in a patient with chronic anterior instability who had failed extensive conservative measures.
Preoperative history
The patient is a 19-year-old right-hand dominant man. He noticed an acute onset of sternal pain approximately 2 years earlier. This resulted from what was described as a hyperadduction moment of the right upper extremity while swinging a baseball bat. After resolution of the initial injury and swelling, he described having continued symptoms in the form of SC joint instability with mechanical symptoms with upper extremity movement and referred pain into the anterior neck and through the shoulder girdle. He attempted extensive conservative management with physical therapy and NSAIDs with no improvement in his symptoms for 2 years. Exam was significant for slight anterior subluxation of the SC joint at rest in a supine position. Range of motion was symmetric to the contralateral side. There was hypermobility of the SC joint anteriorly through range of motion which reproduced symptoms. Radiographs demonstrated no obvious findings. Chest CT was remarkable for calcifications around the SC joint indicating prior injury.
Surgical technique
The patient is placed supine on a radiolucent table with a bump placed directly between the scapula at the level of the sternum. The sternum and medial clavicle are palpated and a longitudinal incision is planned centered directly over the SC joint. It is extended medially to the midbody of the sternum. Laterally, it is extended over the longitudinal axis of the clavicle as far as necessary for complete observation of the joint and medial clavicle. An intraoperative X-ray or sterile needle can be used to identify the SC joint if bony landmarks are not easily identified.
The ipsilateral leg is also prepped and draped to allow for hamstring autograft harvest. A small 3-cm incision is made longitudinally along the middle of the medial face of the tibia over the pes anserine insertion. Sartorial fascia is incised and the gracilis and semitendinosis tendons are identified. In this case, the gracilis tendon was small, so the semitendinosis was harvested in standard fashion. It was whip-stitched on both ends in a Krackow fashion with #2 suture to allow for later handling and passage.
SC joint capsule incision
The incision is made longitudinally, first through the skin and subcutaneous tissue. The platysma can either be taken as a separate layer or as one with the periosteum. This sharp dissection is taken down onto bone and the periosteum is elevated superiorly and inferiorly off the medial clavicle from lateral to medial along the clavicle until the SC joint is identified. The goal is to establish full-thickness periosteal flaps and identify the superior and inferior borders of the clavicle. Next, the capsule of the SC joint is incised longitudinally in similar fashion. The dissection is carried over onto the sternum where part of the ipsilateral sternocleidomastoid is elevated superiorly with the periosteum until the superior sulcus of the sternum is identified. It has been recommended by the original authors of this technique that the dissection be carried at least 3-cm medially onto the sternum for the adequate exposure necessary for future bone tunnels.
Once fully exposed, the joint is debrided and the disc removed. Once debrided, the joint can be reduced with light posterior pressure. Next, the graft is sized. We determined the need to drill 4.5-mm bone tunnels, which were drilled about 1.5 cm to 2 cm away from the SC joint to allow a bony bridge of more than 1 cm between the tunnels and the joint. Tunnels are drilled unicortically on the anterior superior surface and anterior inferior surface of the clavicle and sternum. A burr is used to widen the aperture of the drill holes to allow for easier passage of the graft. After this, a series of curved curettes are used to connect the tunnels and dilate adequately for graft passage (Figure 1).
Source: Gregory L. Cvetanovich, MD
Care is taken throughout to recognize and maintain an intact posterior cortex. The advantage of this unicortical anterior inferior and anterior superior connected tunnel technique is maintenance of the posterior cortex which allows protection from deep neurovascular structures posterior to the SC joint.
Graft passage
In preparation for graft passage, two free sutures are passed through the clavicle and sternal tunnels independently with a free needle to help facilitate later double passage of the graft. Next, the graft is passed through the sternal tunnel and both ends are brought to an equal length. The inferior limb from the sternal tunnel is then passed through the clavicular tunnel from superior to inferior. That superior limb from the sternal tunnel is then passed in similar fashion using the previously passed free suture through the clavicular tunnel from inferior to superior, creating a “X” configuration over the SC joint. After this, the inferior limb of the clavicular tunnel is passed from inferior to superior through the sternal tunnel using the previously placed free suture (Figure 2). The resulting two free ends of the autograft that are exiting the superior sternal and clavicular tunnels are tensioned to ensure reduction of the joint. While tension is maintained, these two ends are laid down over the previously passed portions and several #2 reinforced sutures are used to secure and lock the autograft in position (Figures 3 and 4).
The area is irrigated. A layered closure is performed. A 0-Vicryl suture is used to close a deep fascial layer, if possible. After this, 2-0 Vicryl suture is used to close the subdermal layer. A running 4-0 Monocryl suture is used to approximate the subcutaneous edges. Steristrips and a dry dressing are applied.
The patient is kept non-weight-bearing in a sling for 6 weeks. Gentle therapy is started at 2 weeks for shoulder, elbow and wrist range of motion. The sling is discontinued at 6 weeks postoperatively. Therapy is progressed to shoulder and core strengthening once full range of motion of the shoulder is obtained. Between 6 and 12 weeks, aggressive strengthening is avoided. At 3 months, activity and therapy can be progressed in an as-tolerated fashion. At 6 months postoperatively, the patient can return to sports activities assuming they have reached full shoulder strength and range of motion without any pain or clinical symptoms of instability at the SC joint.
Click here to watch video of this technique.
- References:
- Groh GI, et al. J Am Acad Orthop Surg. 2011;doi:10.5435/00124635-201101000-00001.
- Guan JJ, et al. J Shoulder Elbow Surg. 2013;doi:10.1016/j.jse.2012.07.009.
- Higginbotham TO, et al. J Am Acad Orthop Surg. 2005;doi:10.5435/00124635-200503000-00007.
- Singer G, et al. J Shoulder Elbow Surg. 2013;doi:10.1016/j.jse.2012.02.009.
- For more information:
- Julie Bishop, MD, is professor of orthopedic surgery, shoulder and sports medicine; Gregory L. Cvetanovich, MD, is associate professor of orthopedic surgery, shoulder and sports medicine; and Dane Swinehart, MD, is orthopedic sports medicine fellow at Jameson Crane Sports Medicine Institute at The Ohio State University Wexner Medical Center. They can be reached at 2835 Fred Taylor Drive, Columbus, OH 43202. Bishop’s email: julie.bishop@osumc.edu. Cvetanovich’s email: gregory.cvetanovich@osumc.edu. Swinehart’s email: steven.swinehart@osumc.edu.
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