Sternoclavicular reconstruction with gracilis autograft in a pediatric patient
Click Here to Manage Email Alerts
An 11-year-old left hand-dominant boy with no medical or surgical history presented to the pediatric orthopedic surgery clinic approximately 5 months after falling off a trampoline and falling directly onto his right shoulder.
He felt something “pop out, then pop back in.” Initially, he was seen by an orthopedic surgeon at an outside institution who diagnosed him with a sternoclavicular joint dislocation and treated him non-weight-bearing in a sling for 10 weeks. After the trial of immobilization, he was pain-free; however, he continued to feel gross instability when moving his shoulder certain ways. He was treated with several weeks of physical therapy, which did not improve his instability.
On presentation, physical examination demonstrated mild atrophy of the right shoulder girdle. He had mild tenderness over the right sternoclavicular joint and no tenderness around the distal clavicle or acromioclavicular joint. He had full range of motion of the right shoulder, with painless subluxation of the sternoclavicular joint at terminal range of forward flexion and abduction. He could actively anteriorly dislocate the joint with minimal elevation of his shoulder with his arm at his side by contracting his trapezius, which reduced with an audible clunk with relaxation (Figures 1a and 1b).
Source: Michele Cerasani, MD; Bradley Lezak; Cody Perskin; and Andrew Price, MD
Initial plain radiographs of the right shoulder did not demonstrate any fracture, dislocation or osseous lesion. MRI of the chest wall demonstrated normal alignment of sternoclavicular joints bilaterally, mild hyperintensity in the medial aspect of the right clavicle, which may demonstrate minimal marrow edema, and no physeal widening (Figure 2).
What are the next best steps in management of this patient?
See answer below.
Sternoclavicular reconstruction with gracilis autograft
Due to the failure of nonoperative management and significant bothersome instability of his sternoclavicular joint, the patient was indicated for sternoclavicular figure-of-eight reconstruction technique with a gracilis autograft.
Surgical technique
Surgery was performed under general anesthesia with the patient in a supine position. First, we harvested a gracilis autograft from the ipsilateral lower extremity and prepared it in standard fashion with Krakow whipstitches on both ends using 2-0 FiberWire (Arthrex), tubularizing the graft to a diameter of 4 mm. An upside-down “L” incision was then made along the medial clavicle and down over the manubrium. Dissection was carried out down through the subcutaneous tissue, and the medial clavicle and manubrium were exposed through a longitudinal capsulotomy through the anterior sternoclavicular capsule. Using a 4-mm drill bit, two drill holes were made at the superior and inferior aspect of the medial clavicle aimed convergently at a 45° angle through the anterior cortex. These were made lateral to the medial clavicular physis and approximately a centimeter from the sternoclavicular joint and a centimeter apart from each other. The two holes were connected using a towel clamp.
Similar holes were made in the manubrium aimed 45° toward each other and the clavicle through only the anterior cortex. The holes were connected using a towel clamp to create one contiguous hole. We passed the tendon through the medial clavicle tunnels using a shuttling 0 PDS suture (Ethicon) to pass the whipstitch sutures of the gracilis autograft (Figure 3a). The graft was then passed through the manubrium transosseous tunnel using a figure-of-eight technique (Figure 3b). The sternoclavicular joint was then held firmly reduced and the two ends of the graft tied and reinforced using 2-0 sutures (Figure 3c). The anterior joint capsule was repaired over the reconstruction. After completion (Figure 4), the shoulder was taken through full range of motion, which did not elicit any instability in the sternoclavicular joint. A sling and swathe were applied.
Postoperative rehabilitation
The patient was made non-weight-bearing in his right upper extremity and instructed to remain in the sling at all times with no shoulder range of motion. At 2 weeks, he was instructed to complete gentle Codman’s exercises and to remain non-weight-bearing. He began a formal physical therapy program at 3 weeks and began both passive and gentile active range of motion.
At 6 weeks postoperatively, he returned to the office with full, painless right shoulder range of motion and strength. However, he did have mild tenderness to palpation over the sternoclavicular joint and mild pain with push-ups in his pectoral region. At 6 weeks, he was made weight-bearing as tolerated, but was instructed to remain out of athletic activities until 3 months.
Discussion
Clinical instability of the sternoclavicular joint represents a difficult clinical problem. Overall, sternoclavicular joint dislocations are rare, representing about 1% of all dislocations, with anterior being more common than posterior. Despite favorable responses to nonoperative management with low risk of sequelae in most cases, persistent sternoclavicular joint instability often necessitates surgical intervention. The intricate structure of the diarthrodial sternoclavicular junction, coupled with concurrent degenerative alterations in the sternoclavicular joint and its proximity to neurovascular structures, presents a formidable surgical obstacle.
The surgical technique represented in this paper, a figure-of-eight reconstruction technique with a gracilis autograft, has been previously documented to provide promising biomechanical and clinical outcomes. During the description of the technique, drill holes are to be placed in the medial clavicle and sternum in an anterior-posterior direction. Frank Martetschläger, MD, PhD, and colleagues described using a gracilis autograft in a well-described figure-of-eight technique, describing meticulous placement of the medial clavicle and sternal drill holes in an oblique direction from the anterior cortex toward the articular surface to prevent damage to posterior neurovascular structures and the posterior capsule, which is a major concern during sternoclavicular joint reconstruction given the close proximity. In their small cohort of five patients with a mean of 12 months follow-up, there were no intraoperative or postoperative complications.
There are several techniques described in the literature for reconstruction of an unstable sternoclavicular joint, including suture tendon grafts, suture anchors and plates; however, biomechanical testing supports use of the figure-of-eight method using tendon autograft. Edwin E. Spencer Jr., MD, and John E. Kuhn, MD, investigated biomechanical aspects of sternoclavicular joint reconstruction techniques, highlighting the figure-of-eight method with hamstring graft as the most stable at time zero. In a separate study, Lucca Lacheta, MD, and colleagues reported positive clinical outcomes and 90% survivorship at a minimum 5-year follow-up for sternoclavicular joint reconstruction using hamstring tendon autograft. Klaus Bak, MD, and Kamille Fogh, MS, observed improved functional outcomes in 27 patients with sternoclavicular joint reconstruction using hamstring tendon autograft but noted 7% of patients required revision surgery and 37% reported persistent discomfort. A smaller case series of six patients undergoing sternoclavicular joint reconstruction with semitendinosus hamstring autograft in a figure-of-eight fashion published by Justin J. Guan, BSE, and Brian R. Wolf, MD, MS, showed improved functional outcomes with no residual instability at a mean 3-year follow-up. Overall, these studies suggest that tendon autografts, particularly in a figure-of-eight configuration, result in biomechanical stability and positive clinical outcomes for sternoclavicular joint reconstruction, albeit with some instances of revision or persistent discomfort.
In our case, it is important to consider that our patient was 11 years old and skeletally immature. In addition, preoperative MRI revealed the absence of any medial clavicular physeal injury. Previous literature has reported that 80% of the growth comes from the medial clavicular physis, and it does not fuse until 23 to 25 years of age. Therefore, it is paramount not to disrupt the physis in patients younger than 26 years old during surgical sternoclavicular joint reconstruction. Particular attention is required while drilling the medial clavicle.
In conclusion, addressing chronic instability in the sternoclavicular joint poses significant challenges, often requiring surgical intervention due to persistent dislocations and the complex nature of the joint. The figure-of-eight reconstruction technique with a gracilis autograft, as discussed in this paper, has demonstrated promising biomechanical and clinical outcomes.
Key points:
- Sternoclavicular dislocations may result in chronic instability warranting surgical treatment;
- Use of tendon graft in a figure-of-eight technique is deemed a successful surgical option for chronic sternoclavicular joint instability; and
- Avoidance of the medial clavicular physis during sternoclavicular reconstruction is important in young patients, as the physis provides 80% of clavicular growth and remains open until age 25 years old.
- References:
- Apostolakos JM, et al. Arthrosc Tech. 2023;doi:10.1016/j.eats.2023.03.019.
- Bak K, et al. J Shoulder Elbow Surg. 2014;doi:10.1016/j.jse.2013.05.010.
- De Jong KP, et al. J Orthop Trauma. 1990;4:420-423.
- 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.
- Jit I, et al. Indian J Med Res. 1976;64:773-782.
- Lacheta L, et al. Am J Sports Med. 2020;doi:10.1177/0363546519900896.
- Martetschläger F, et al. Knee Surg Sports Traumatol Arthrosc. 2016;doi:10.1007/s00167-015-3570-3.
- Pandya NK, et al. J Am Acad Orthop Surg. 2013;doi:10.5435/JAAOS-20-08-498.
- Spencer EE, et al. J Bone Joint Surg Am. 2004;doi:10.2106/00004623-200401000-00015.
- For more information:
- Michele Cerasani, MD; Bradley Lezak; Cody Perskin and Andrew Price, MD, can be reached at the department of orthopedic surgery at NYU Langone Orthopedic Hospital in New York. Cerasani’s email: michele.cerasani@nyulangone.org. Lezak’s email: bradley.lezak@nyulangone.org. Perskin’s email: cody.perskin@nyulangone.org. Price’s email: andrew.price@nyulangone.org.
- Edited by Andrew Bi, MD, and Pooja Prabhakar, MD. Bi is a chief resident in the department of orthopedic surgery at NYU Langone. He will pursue a fellowship in sports medicine at Rush University Medical center following residency completion. Prabhakar is a chief resident in the department of orthopaedic surgery at the University of Washington. She will pursue a fellowship in foot and ankle surgery at Baylor University Medical Center following residency completion. For more information on submitting Orthopedics Today Grand Rounds cases, please email orthopedics@healio.com.
Collapse
Read more about
Click Here to Manage Email Alerts