72.1 Goals of Procedure

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  Improve pain and functional limitations.

  
  
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  Ideally, restore full range of motion as well as return to preinjury sporting and daily activities.

72.2 Advantages

This technique is a biologic reconstruction, allowing avoidance of complications associated with hardware such as prominence and potential need for removal or possibly lethal migration as has been reported. This type of construct utilizing graft material, and its variations, has been shown to be superior to other techniques (i.e., subclavius tendon reconstruction and intramedullary ligament reconstruction) by biomechanical studies ¹ and to have satisfactory clinical outcomes via various case reports. ^{2 – 5}

72.3 Indications

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  Posterior dislocations as they are potentially life threatening due to the proximity of the medial clavicle to adjacent vital anatomic structures.

  
  
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  Severely displaced or irreducible anterior dislocations.

  
  
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  Recurrent symptomatic anterior instability or subluxations that have failed nonoperative treatment.

72.4 Contraindications

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  No previous trial of closed reduction and/or sling immobilization.

72.5 Preoperative Preparation/Positioning

Proper imaging is important prior to surgical intervention. Diagnosis is frequently missed; in one series, over 70% were undiagnosed in the primary care or emergency setting. ⁶ Standard X-rays will miss displacement of the medial clavicle. The “serendipity view” can be performed with the X-ray beam tilted 40 degrees cephalad in order to better assess anterior or posterior translation of the clavicle at the sternoclavicular joint (SCJ). CT scans are most reliable to assess both direction and magnitude of displacement. Alternatively, MRA can help assess the proximity of the mediastinal vessels.

The patient may be positioned supine, or in a modified beach-chair position with chest elevated approximately 30 to 60 degrees and a rolled towel or gel pad between the scapulae. The entire operative extremity including the anterior chest is prepped and draped ( Fig. 72.1 ). The arm may be placed in an arm holder or left free supported on an arm board or a Mayo stand.

72.6 Operative Technique

An incision is made over the proximal clavicle and is carried to the mid-sternum. After dissecting through the subcutaneous tissue, the platysma is incised and raised as a separate layer in line with the incision. Periosteum is reflected off the clavicle superiorly and inferiorly. The capsule of the SCJ is also reflected superiorly and inferiorly, thus exposing the intra-articular disc, which is removed to allow for passage of our graft through the SCJ. In some patients, this disc has been torn, causing pain. Arthroscopic instruments are useful to complete the resection. Periosteum is then elevated off the sternum as well as the insertion of the ipsilateral sternocleidomastoid superiorly in order to visualize the sulcus of the superior sternum ( Fig. 72.2 ). In dissecting the soft tissues off the clavicle and sternum, try to create a layer that can be reapproximated to the SCJ. Dissection of both the sternum and the clavicle should be sufficient to allow for passage of your soft-tissue graft. Our graft of choice is allograft semitendinosus; alternatively, gracilis or palmaris longus can be used, either auto- or allograft. The graft is prepared at either end with a no. 2 braided suture in a whip stitch fashion and each end is sized. Guide pins and cannulated drills can be used to make uni- or bicortical drill holes for graft passage, but we prefer to use a pneumatic burr in a unicortical fashion for both increased control and safety. Holes are made approximately 10 mm lateral to the SCJ on the clavicle and 10 mm medial to the SCJ on the sternum ( Fig. 72.3 ). They are typically 3 to 4.5 mm in size, depending on the size of the graft. These holes are connected with a sharp curette to form subcortical tunnels ( Fig. 72.4 ). No posterior dissection is required unless significant scarring is present. Shuttling sutures or devices can be used to assist in graft passage. The graft is passed in a simple figure-of-8 fashion passing anteriorly or if desired passing through the SCJ ( Fig. 72.5 ).

If subluxed or dislocated, the SCJ should be reduced, taking care not to over-reduce and posteriorly displace the clavicle. The articular surfaces of the SCJ should be aligned. If reduction is not possible, the clavicle can be shortened to allow reduction. Fixation is achieved when sutures are placed between the free ends of the graft as well as at any points the graft crosses itself ( Fig. 72.6 ). Augmentation of fixation is an option with the addition of tenodesis screws, analogous to CC joint reconstruction, which may minimize the amount of potentially prominent suture material anteriorly. ⁷ Periosteum and joint capsule are then repaired using a no. 0 nonabsorbable suture, followed by the platysma, subcutaneous tissue, and skin in layers.