Injuries of the Sternoclavicular Joint - An Innovative Approach in the Management of a Rare Injury: Tight Rope Fixation of the Costo-Clavicular Ligament

Two cases of sternoclavicular joint replacement arthroplasty: A case report. A novel prosthesis and surgical technique for recalcitrant instability, arthropathy of the sternoclavicular joint with medial clavicular bone loss

Instability arthropathy of the sternoclavicular joint is most commonly managed by rehabilitation, injection, and either arthroscopic or open debridement with or without interposition arthroplasty. When these options fail to achieve symptom relief, excision arthroplasty is an option. This is associated with a risk of persistent instability and incomplete pain relief. We describe two cases in which custom sternoclavicular joint replacement was performed for painful insufficiency of scapular suspension. Although the prostheses remained secure in both cases, the first case was complicated by persistent instability due to insufficient reconstruction of the intrinsic sternoclavicular capsular ligaments. This was recognised and corrected for in the second case, in which stability of the sternoclavicular joint replacement has been noted on more than a 5-year review. We conclude that sternoclavicular joint replacement is an option for patients in whom instability arthropathy remains an intrusive problem in daily life after other conventional treatments have not controlled symptoms. Stability of the joint remains a concern. We offer one method of achieving stability through an iterative design process including the ability to reconstruct the intrinsic capsular ligaments around the articulation.

Anterior dislocation of sternoclavicular joint: A novel surgical technique

INTRODUCTION

Anterior sternoclavicular joint dislocation (SCJ) is a relative rare injury, related to high energy trauma. The objective of the present study is to present a novel suture technique for treatment of anterior SCJ traumatic dislocation and to report clinical outcomes from a small case series undergoing this procedure.

PATIENTS AND METHODS

Patients presenting with traumatic anterior SCJ disruption in our institution were eligible to participate. Surgical technique consisted of two bone tunnels drilled in vertical direction from the anterior to the posterior cortex of the manubrium. Analogous to the sternal side of the clavicle, two vertical bone tunnels were drilled from the anterior cortex towards the posterior cortex. A non-absorbable suture was passed though the four holes in a parallel configuration. Then, by pulling the free suture edges the posterior translation of the clavicle was performed. Two additional drill holes, the first in manubrium and the second in clavicle were performed from the anterior cortex to the posterior between the previous bone tunnels. A non-absorbable suture was placed in a simple configuration in order to stabilize the SCJ in the superior-inferior direction. The final follow up was 28.2 months. The mean QuickDASH was used for functional assessment.

RESULTS

Seven patients (6 males and 1 female) with average age of 34,8 years were included in the present study. Two patients suffered from concomitant medial clavicle fracture. At final follow-up (none of the patients had experienced any symptoms of instability of SCJ, no side-to-side difference was observed, while the Mean QuickDASH score was 4.85.

CONCLUSION

The reported technique for SCJ reconstruction in traumatic anterior SCJ dislocations with two sutures has theoretical advantages, since it stabilizes the SCJ in the antero-posterior, as well as the supero- inferior direction. Outcomes from this small case series are favorable. However, more research is desirable to compare different techniques and to conclude to the optimal surgical treatment.

Monopolar and Bipolar Combination Injuries of the Clavicle: Retrospective Incidence Analysis and Proposal of a New Classification System

Clavicle injuries are common, but only few case reports describe combined clavicular injuries (CCI). CCI include combinations between clavicular fractures and acromioclavicular/sternoclavicular joint dislocations (SCJD). We present the first general therapeutic recommendations for CCI based on a new classification and their distribution. A retrospective, epidemiological, big data analysis was based on ICD-10 diagnoses from 2012 to 2014 provided by the German Federal Statistical Office. CCI represent 0.7% of all clavicle-related injuries (n = 814 out of 114,003). SCJD show by far the highest proportion of combination injuries (13.2% of all SCJD were part of CCI) while the proportion of CCI in relation to the other injury entities was significantly less (p < 0.023). CCIs were classified depending on (1) the polarity (monopolar type I, 92.2% versus bipolar type II, 7.8%). Monopolar type I was further differentiated depending on (2) the positional relationship between the combined injuries: Ia two injuries directly at the respective pole versus Ib with an injury at one end plus an additional midshaft clavicle fracture. Type II was further differentiated depending on (3) the injured structures: IIa ligamento-osseous, type IIb purely ligamentous (rarest with 0.6%). According to our classification, the CCI severity increases from type Ia to IIb. CCI are more important than previously believed and seen as an indication for surgery. The exclusion of further, contra-polar injuries in the event of a clavicle injury is clinically relevant and should be focused.

Acromioclavicular and sternoclavicular joint dislocations indicate severe concomitant thoracic and upper extremity injuries in severely injured patients

Preliminary studies show that clavicle fractures (CF) are known as an indicator in the severely injured for overall injury severity that are associated with relevant concomitant injuries in the thorax and upper extremity. In this regard, little data is available for the rarer injuries of the sternoclavicular and acromioclavicular joints (SCJ and ACJ, respectively). Our study will answer whether clavicular joint injuries (CJI), by analogy, have a similar relevance for the severely injured. We performed an analysis from the TraumaRegister DGU (TR-DGU). The inclusion criterion was an Injury Severity Score (ISS) of at least 16. In the TR-DGU, the CJI were registered as one entity. The CJI group was compared with the CF and control groups (those without any clavicular injuries). Concomitant injuries were distinguished using the Abbreviated Injury Scale according to their severity. The inclusion criteria were met by n = 114,595 patients. In the case of CJI, n = 1228 patients (1.1%) were found to be less severely injured than the controls in terms of overall injury severity. Compared to the CF group (n = 12,030; 10.5%) with higher ISS than the controls, CJI cannot be assumed as an indicator for a more severe trauma; however, CF can. Concomitant injuries were more common for severe thoracic and moderate upper extremity injuries than other body parts for CJI. This finding confirms our hypothesis that CJI could be an indicator of further specific severe concomitant injuries. Despite the rather lower relevance of the CJI in the cohort of severely injured with regard to the overall injury severity, these injuries have their importance in relation to the indicator effect for thoracic concomitant injuries and concomitant injuries of the upper extremity. A limitation is the collective registration of SCJ and ACJ injuries as one entity in the TR-DGU. A distorted picture of the CJI in favor of ACJ injuries could arise from the significantly higher incidence of the ACJ dislocation compared to the SCJ. Therefore, these two injury entities should be recorded separately in the future, and prospective studies should be carried out in order to derive a standardized treatment strategy for the care of severely injured with the respective CJI.

The unicortical sternoclavicular joint reconstruction using synthetic graft

Sternoclavicular joint injuries represent 5% of all injuries to the shoulder complex. We report a safe and reproducible technique for reconstruction of anterior sternoclavicular joint dislocations, employing a synthetic graft using a unicortical technique with minimal dissection anterior to the joint.

Medial injuries of the clavicle: more prevalent than expected? A big data analysis of incidence, age, and gender distribution based on nationwide routine data

Purpose

Although shoulder-girdle injuries occur frequently, injuries of the medial part remain widely unexplored. This study overviews these rare injuries with a focus on incidence, age, and sex distribution in Germany.

Methods

The data are based on diagnoses according to ICD-10 in all German hospitals provided by the German Federal Statistical Office. ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD) were evaluated in detail between 2012 and 2014.

Results

We identified 14,264 cases with medial clavicle injuries (MCIs). MCFs occurred more often (11.6% of all clavicle-related shoulder-girdle injuries vs. 0.6% for SCJD). Mean ages of MCI were significantly different between males (43.7 years) and females (57.1 years) (p < 0.01). Age demonstrated a bimodal distribution with peaks at 20 and 50 years, which were predominantly associated with males. Females showed more injuries at age beyond 70 years. This applies to both SCJD and MCF. The incidence rate of these shoulder-girdle injuries was 47.0 per 100,000 person-years, for MCIs overall 5.9 (4.1 for men, 1.8 for women). This indicates disparity with a significant predominance of male patients over females as for all shoulder-girdle injuries (p < 0.01). Among children (< 16 years old), the incidence rate showed no significant difference in gender ratio.

Conclusion

MCIs appear more frequently than estimated so far and are distinguished from other clavicle fractures in that they occur more at higher age and peaking around 50 years. Further work on possible prevention strategies should focus on the most frequently affected groups of men around 20 and 50 years old.

Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data

Introduction

Although shoulder girdle injuries are frequent, those of the medial part are widely unexplored. Our aim is to improve the knowledge of this rare injury and its management in Germany by big data analysis.

Methods

The data are based on ICD-10 codes of all German hospitals as provided by the German Federal Statistical Office. Based on the ICD-10 codes S42.01 (medial clavicle fracture, MCF) and S43.2 (sternoclavicular joint dislocation, SCJD), anonymized patient data from 2012 to 2014 were evaluated retrospectively for epidemiologic issues. We analyzed especially the concomitant injuries and therapy strategies.

Results

A total of 114,003 cases with a clavicle involving shoulder girdle injury were identified with 12.5% of medial clavicle injuries (MCI). These were accompanied by concomitant injuries, most of which were thoracic and craniocerebral injuries as well as injuries at the shoulder/upper arm. A significant difference between MCF and SCJD concerning concomitant injuries only appears for head injuries (p = 0.003). If MCI is the main diagnosis, soft tissue injuries typically occur as secondary diagnoses. The MCI are significantly more often associated with concomitant injuries (p < 0.001) for almost each anatomic region compared with lateral clavicle injuries (LCI). The main differences were found for thoracic and upper extremity injuries. Different treatment strategies were used, most frequently plate osteosynthesis in more than 50% of MCF cases. Surgery on SCJD was performed with K-wires, tension flange or absorbable materials, fewer by plate osteosynthesis.

Conclusions

We proved that MCI are rare injuries, which might be why they are treated by inhomogeneous treatment strategies. No standard procedure has yet been established. MCI can occur in cases of severely injured patients, often associated with severe thoracic or other concomitant injuries. Therefore, MCI appear to be more complex than LCI. Further studies are required regarding the development of standard treatment strategy and representative clinical studies.

Sports-related sternoclavicular joint injuries

Sports-related injuries to the shoulder are common causes of disability. Injuries to the sternoclavicular joint (SCJ) in sports are more rare, though have been reported in a small number of cases. SCJ injury classification is determined by the degree of joint displacement and direction of clavicular displacement. Direction of displacement is particularly important due to risk of injury to intrathoracic structures, which has the potential to result in fatal outcomes. These injuries are important to identify in athletes and can be difficult to assess on the field. Specific radiographic views and use of ultrasound can improve accuracy of diagnosis. Reduction of acute traumatic SCJ dislocations is recommended and may require open reduction in the case of posteriorly displaced dislocations. Surgical treatment is indicated in cases of persistent pain or significant compression to intrathoracic soft tissue structures. Long-term outcomes are generally favorable, and athletes are able to return to sport without functional limitations.

[Treatment of traumatic anterior dislocation of sternoclavicular joint with allogeneic tendon of "W" type knit]

OBJECTIVE

To investigate effectiveness of allogeneic tendon of "W" type knit in repair of traumatic anterior dislocation of sternoclavicular joint.

METHODS

Between June 2013 and June 2017, 12 patients with traumatic anterior dislocation of sternoclavicular joint after poor conservative treatment were treated with allogeneic tendon of "W" type knit. Of them, 10 were males and 2 were females, aged from 25 to 58 years (mean, 42 years). All injuries were caused by traffic accidents. The time from injury to operation was 4-12 weeks (median, 6 weeks). All of them were closed injuries. The patients had no fracture around the shoulder, or blood vessels, nerves, and other adjacent limb joint injuries. The operation time, intraoperative blood loss, incision healing, and complications were recorded. The sternoclavicular joint was observed by X-ray film and CT at 1 year after operation. Visual analogue scale (VAS) score, University of California Los Angeles (UCLA) score, Rockwood score, modified Hospital for Special Surgery (HSS) score, and Constant-Murley score were used to evaluate the function of shoulder joint after operation.

RESULTS

The operation time was 60-80 minutes (mean, 70 minutes). The intraoperative blood loss was 50-100 mL (mean, 60 mL). Primary healing of incision was obtained in all patients without complications. All the patients were followed up 12-24 months (mean, 18 months). At 1 year after operation, X-ray film and CT examination showed that the position of sternoclavicular joint was satisfactory. At 1 year after operation, the Rockwood score was 12-14 (mean, 13). The UCLA score was 28-34 (mean, 31). The VAS score was significant lower than that before operation ( P<0.05), and the Constant-Murley score and modified HSS score were significantly higher than those before operation ( P<0.05).

CONCLUSION

The repair of traumatic anterior dislocationr of sternoclavicula joint with allogeneic tendon of "W" type knit can effectively reconstruct the stability of the joint, retain the physiological fretting, and obtain satisfactory results.