Open management of atraumatic disorders of the sternoclavicular joint: Indications, techniques, and outcomes

Introduction

Like other diarthrodial joints, the sternoclavicular (SC) joint is also susceptible to the normal spectrum of inflammatory and degenerative diseases, as well as a number of other disorders that are specific to the SC joint. Such disorders can present either acutely or insidiously with localized pain, swelling, and even subluxation or enlargement of the joint.

Spontaneous subluxation or dislocation (anterior and posterior)

As with glenohumeral joint instability, the importance of distinguishing between traumatic and atraumatic instability of the SC joint must be recognized if complications are to be avoided. Fig. 27.1 demonstrates a case of spontaneous anterior subluxation of the right SC joint. Rowe described several patients who had undergone one or more unsuccessful attempts to stabilize the SC joint. In all cases, the patient could voluntarily dislocate the clavicle after surgery.

Crosby and Rubino reported a case of spontaneous atraumatic anterior dislocation secondary to pseudarthrosis of the first and second ribs. Despite a 6-month course of conservative treatment, this 14-year-old girl was still experiencing pain. A three-dimensional computed tomography (CT) scan of the chest revealed a pseudarthrosis anteriorly between the first and second ribs lying adjacent to the posterior aspect of the medial clavicle. Resection of the anterior portion of the first and second rib pseudarthrosis relieved her symptoms and allowed her to return to her normal activities.

Spontaneous posterior subluxation or dislocation has only been noted in a few isolated case reports. Martin et al. described a case of spontaneous atraumatic posterior dislocation of the SC joint. This occurred in a 50-year-old, previously healthy woman who awoke one morning with a painful SC joint. A CT scan confirmed the posterior dislocation. She later developed dysphagia, and a closed reduction was unsuccessful. After 1 year without any other treatment, she had resumed playing golf and was asymptomatic. More recently, Martinez et al. described a 19-year-old woman with a symptomatic spontaneous posterior SC subluxation who was managed surgically. The posteriorly displaced medial clavicle was stabilized with a figure-of-eight soft tissue reconstruction using a gracilis autograft. At the 12-month follow-up, the patient was pain free; however, a repeat CT scan demonstrated recurrent posterior subluxation of the medial clavicle, with erosion of the clavicle and manubrium. Rockwood and Odor previously reviewed 37 cases and reported a high incidence of operative complications, including recurrent instability and persistent or worsening pain. Conversely, Moreels et al. described the results of nonoperative management for 23 patients with atraumatic SC dislocation. At an average of nearly 4 years of follow-up, subluxation events had become less common and outcome scores were good. The authors suggest that a “wait-and-see” program of nonoperative management can be successful for this problem.

Surgical management of the unstable, post-traumatic SC joint is discussed in detail in Chapter 29 .

Infection

Infections of the SC joint are managed as they are in other joints, except that during aspiration and surgical drainage, great care and respect must be directed to the vital structures that lie posterior to the joint. A high suspicion of SC septic arthritis should be maintained for patients who have recently undergone tracheostomy or breast surgery and present with a painful, swollen, and erythematous SC joint. Patients with sickle cell disease may present with atypical septic arthritis caused by Salmonella . Intravenous drug users are also at high risk for SC septic arthritis; the majority of these infections in recent years are caused by Staphylococcus aureus rather than Pseudomonas . Magnetic resonance imaging (MRI) may be useful in differentiating infectious arthritis from other forms of inflammation, as septic joints will show greater capsular distension, extracapsular fluid collection, periarticular muscle edema, and larger areas of bone erosion ( Fig. 27.2 ). Medical management alone, with administration of antibiotics, may be considered for patients in poor health and without associated abscess formation, although these patients should be monitored closely. If aspiration demonstrates purulent material in the joint, or the orthopedist has a high index of suspicion, formal arthrotomy is carried out. Early treatment is critical due to the significant risk of abscess formation in up to 20% of cases and the concern for subsequent spread of the infection to the mediastinal structures. Care should be taken to preserve all supporting ligamentous structures when possible; only necrotic tissue is debrided. Occasionally, the infection arises in the medial end of the clavicle or the manubrium, or there is spread of the infection from the joint space into the adjacent bone, which necessitates resection of any necrotic bone. ^, Depending on the status of the wound after debridement, one can either (1) close the wound primarily; (2) pack the wound open, followed by daily wound care (i.e., secondary intention) with or without negative-pressure wound therapy ; or (3) close the wound at a later time (i.e., tertiary intention).

In 2002, Song et al. presented seven patients who had SC joint infections. Predisposing factors included diabetes mellitus, HIV infection, immunosuppression, and pustular skin disease. All patients had local symptoms, including a medial clavicular mass and swelling. Antibiotic therapy and simple drainage and debridement were generally ineffective, with recurrence of infection in five patients. The patients were subsequently treated by resection of the SC joint and the involved portions of adjacent ribs with an advancement flap from the pectoralis major muscle. The response to therapy was excellent in all patients, and there were no wound complications. More recently, Joethy et al. described a classification of postresection SC joint defects and proposed a reconstructive algorithm based on the residual defect and vascularity of the wound bed.

Arthritis

Management of patients with osteoarthritis (OA), rheumatoid arthritis (RA), condensing osteitis, and other inflammatory arthropathies can usually be accomplished with nonoperative treatment, including rest and activity modification, heat, and antiinflammatory agents (oral nonsteroidal antiinflammatory drugs [NSAIDs] and image-guided corticosteroid injections ). Spontaneous resolution of pain can be expected over the course of several months in many cases. ^, The patient must be thoroughly evaluated to rule out other conditions that mimic degenerative changes in the SC joint (e.g., tumor, stress fracture, infection, sarcoid or crystalline arthropathy, collagen disorders). A minority of patients will have persistent pain in the SC joint that is recalcitrant to nonoperative measures; in these cases, a minimalistic resection, as described below, can be effective.

Evaluation

Physical examination of the patient with SC joint arthritis will often reveal varying degrees of swelling at the affected SC joint, often with exquisite tenderness to palpation. Van Tongel et al. noted this prominence to be caused by a combination of medial clavicular widening and anterior subluxation. Active scapular protraction may cause pain localized to the SC joint. The patient is asked to demonstrate provocative maneuvers, if known, and the SC joints are palpated as they actively shrug, protract, and retract the scapula. The senior author (W.J.W.) routinely examines the patient supine and palpates the SC joint while passively protracting and retracting the scapula. The clavicular shaft can also be grasped and an attempt made to circumduct it. These maneuvers can reveal crepitus and pain; in rare cases, instability can be elicited when contrasted to the unaffected side.

Plain radiographs often provide limited information regarding the extent of disease. Our routine practice is to obtain a fine-cut CT scan of the upper chest with three-dimensional reconstructions of the sternum, bilateral clavicles, and scapulae ( Fig. 27.3 ). Patients with RA often have characteristic findings on MRI with bone marrow edema, synovitis, and periarticular erosions ( Fig. 27.4 ).

Surgical indications

Patients with SC joint arthritis who have not responded to a course of nonoperative management, with persistent pain and dysfunction limiting his/her quality of life and daily activities, are considered for surgery. All patients are thoroughly informed regarding the expected degree of pain relief and potential life-threatening complications.

Applied anatomy

The medial clavicle is usually covered with cartilage at its anteroinferior surface, with broad extension of the interclavicular ligament across the superior aspect of the clavicle ( Fig. 27.5 A; also see Chapter 25 ). Degenerative changes can affect the clavicular and sternal joint surfaces but are typically more advanced at the clavicular side ( Fig. 27.5 B).

Authors’ preferred surgical technique

The patient is placed supine on a radiolucent table in the event an intraoperative radiograph is required. Care is taken to avoid placing a bolster or bump between the scapulae, which is not necessary and may be a cause of postoperative upper back discomfort. A foam donut is used for the head to decrease neck flexion and ease access to the SC joint region with the neck in slight extension. Arms are padded and tucked at the sides as arm boards are removed to allow the surgeons to stand closer to the midline of the body ( Fig. 27.6 ). Large towel drapes (1010) are used around the middle of the neck, extending along the trapezius and posterior acromion. After skin preparation with chlorhexidine, an adhesive U-drape is placed from above the umbilicus centrally to the acromia laterally, followed by the use of another U-drape extending inferiorly from the neck, leaving the thyroid cartilage visible ( Fig. 27.7 A). Usually a thyroid drape is used to isolate the field and cut to extend laterally if needed ( Fig. 27.7 B). If there is concern for concomitant SC joint instability, the ipsilateral lower extremity is prepped and draped, and a proximal tourniquet applied in the standard fashion, in the event an autograft tendon is required for joint reconstruction.