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Three-point suture anchor repair of traumatic sternoclavicular joint dislocation Sarah C. O’Reilly-Harbidge and Zsolt J. Balogh Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
Key words dislocation, sternoclavicular joint, surgical technique, suture anchor. Correspondence Professor Zsolt J. Balogh, Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310, Australia. Email: [email protected] S. C. O’Reilly-Harbidge BMed; Z. J. Balogh MD, PhD, FRACS. Accepted for publication 12 June 2013. doi: 10.1111/ans.12403
Abstract Background: Traumatic dislocation of the sternoclavicular joint (SCJ) is a rare injury. Previous techniques are associated with hardware migration, loss of reduction and infectious complications. We aim to describe our preferred surgical technique and summarize our experience with three-point suture technique of acute SCJ dislocation (SCJD). The objective of this study was to describe and assess the safety of three-point suture anchor repair technique in acute traumatic dislocation in the SCJ. Methods: A 7-year retrospective study in a university affiliated level 1 trauma centre. Operative cases and the trauma registry was reviewed to identify all potential cases of SCJD between 2005 and 2011. Inclusion criteria for this study were computed tomography (CT) identification of Allman III SCJD, intra-operative confirmation of the CT findings, acute fixation defined as 60 >60 >60 >60 >60
18 6 5 12 18 12
18 months 5 years 6 months 5 months 3 years 3 months 3 years 2 years
Patient 7 Patient 8
M M
16 16
Rugby Football Rugby Rugby Horseriding Motorbike accident Football Football
Right Right
School Labourer
Anterior Posterior
3 2
>60 >60
12 3
3 years 3 months
Patient Patient Patient Patient Patient Patient
F, female; M, male.
thorough description of the high rate of intra-thoracic injuries, little has been published on the recommended surgical technique and subsequent outcomes. The largest adult study group comprising of eight patients over an 8-year period.15 However, this paper addressed chronic post-traumatic dislocations (as defined as greater than 7 days of dislocation) and patients representing for surgical intervention because of chronic pain. The medial clavicular epiphysis is the last to close, occurring between the ages of 22 and 25;15 therefore, children and adolescents typically present with epiphyseal fractures rather than joint dislocations.6,7 Despite this, physeal fractures and joint dislocations are not routinely divided into different injuries, which is a significant limitation of most research to date and therefore diluting the applicability of suggested treatment algorithms.6,14,16,17 The SCJ is stabilized by a joint capsule, the anterior and posterior sternoclavicular and interclavicular ligaments, and particularly by the costoclavicular ligament,18 with the posterior structures demonstrated as being stronger than the anterior, making posterior SCJDs a less common occurrence than anterior dislocations.2 In this paper, the patients involved had been submitted to significant mechanisms of injury, which may explain the preponderance towards posterior dislocations. The SCJ is difficult to visualize with plain X-rays. Three plain radiographic projections have been described to aid in diagnosing dislocation in addition to the anteroposterior (AP) chest X-ray are: the Hobbs view, the Heinig view and the Serendipity view. None of these projections are widely used and provide satisfactory visualization for acute diagnosis. However the advent of the CT gives greater clarity of the level of injury and the impact on closely associated structures of the superior mediastinum, which may be concomitantly injured,10,14,19 and therefore routinely ordered on patients in this study (Fig. 3). When compared with previous studies of similar power, it demonstrates the reproducibility of the technique when applying it in an acute setting. The technique not only provides coronal plane fixation to stabilize the SCJ with regards to AP movement, it demonstrates that it can successfully stabilize both posterior and anterior dislocations making it a technique that can be utilized regardless of the plane in which the dislocation occurs. This paper supports the safety of the three-point suture anchor technique in the stabilization of a true SCJD in the acute trauma © 2013 Royal Australasian College of Surgeons
Fig. 3. Axial slice computed tomography – posterior dislocation.
setting. It demonstrates the reproducibility of outcome with a simple management algorithm commonly utilized with regard to orthopaedic follow-up. Complications associated with previous fixation methods used in the acutely unstable Grade III SCJD have not been replicated in this series of patients. The only post-operative complaint noted was due to keiloid scarring, which while not compromising the functional capacity of the patient was noted because of the relatively high occurrence in this particular region of the body.8,15,16 The three-anchor suturing technique is demonstrated as a safe, effective and replicatable method of SCJ fixation in this case series in spite of being a rare injury. This study demonstrates the benefit in long-term patient comfort and joint stability with acute phase intervention rather than delaying surgical intervention and relying on delayed reconstructive techniques. Despite this, for this rare injury, only multicenter studies or metaanalyses will lead to a sufficient classification and treatment algorithm. It is felt that the relatively large and repeatable nature of this study will add significantly to a future combined study.
886
References 1. Noda M, Shiraishi H, Mizuno K. Chronic posterior sternoclavicular dislocation causing compression of subclavian artery. J. Shoulder Elbow Surg. 1997; 6: 564–9. 2. Nettles JL, Linscheid RL. Sternoclavicular dislocations. J. Trauma 1968; 8: 158–64. 3. Booth CM, Roper BA. Chronic dislocation of the sternoclavicular joint: an operative repair. Clin. Orthop. Relat. Res. 1979; 140: 17–20. 4. Burrows HJ. Tenodesis of subclavius in the treatment of recurrent dislocation of the sterno-clavicular joint. J. Bone Joint Surg. Br. 1951; 33: 240–3. 5. Lowman CI. Operative correction of old sternoclavicular dislocation. J. Bone Joint Surg. 1928; 10: 740–1. 6. Jaggard MK, Gupte CM, Gulati V, Reilly P. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J. Trauma 2009; 66: 576–84. 7. Goldfarb CA, Bassett GS, Sullivan S, Gordon JE. Retrosternal displacement after physeal fracture of the medial clavicle in children treatment by open reduction and internal fixation. J. Bone Joint Surg. Br. 2001; 83: 1168–72. 8. Lyons FA, Rockwood CA Jr. Migration of pins used in operations on the shoulder. J. Bone Joint Surg. Am. 1990; 72: 1262–7. 9. Ono K, Inagawa H, Kiyota K, Terada T, Suzuki S, Maekawa K. Posterior dislocation of the sternoclavicular joint with obstruction of the innominate vein: case report. J. Trauma 1998; 44: 381–3. 10. Rockwood CJ, Wirth M. Disorders of the sternoclavicular joint. In: Rockwood CJ, Matsen F (eds). The Shoulder, 2nd edn. Philadelphia, PA: WB Saunders, 1998; 555–610.
O’Reilly-Harbidge and Balogh
11. Barber FA, Herbert MA, Hapa O et al. Biomechanical analysis of pullout strengths of rotator cuff and glenoid anchors: 2011 update. Arthroscopy 2011; 27: 895–905. 12. Jhamb A, Goldberg J, Harper W, Butler A, Smitham PJ, Walsh WR. String Theory: An Examination Of The Properties Of ‘High Strength’ Suture Materials. [Cited 30 Sep 2013.] Available from URL: http://www .orthosports.com.au/SiteMedia/w3svc994/Uploads/Documents/ STRING_THEORY_paper.pdf 13. Barber FA, Herbert MA, Coons DA, Boothby MH. Sutures and suture anchors-update 2006. Arthroscopy 2006; 22: 1063.e1–9. 14. Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin. Sports Med. 2003; 22: 359–70. 15. Gobet R, Meuli M, Altermatt S et al. Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation. Emerg. Radiol. 2004; 10: 252–5. 16. Rajaratnam S, Kerins M, Apthorp L. Posterior dislocation of the sternoclavicular joint: a case report and review of the clinical anatomy of the region. Clin. Anat. 2002; 15: 108–11. 17. Macdonald PB, Lapointe P. Acromioclavicular and sternoclavicular joint injuries. Orthop. Clin. North Am. 2008; 39: 535–45. 18. Peter B, MacDonald MD, FRCSCa, Pierre Lapointe, MD, FRCSCb. Acromioclavicular and sternoclavicular joint injuries, Section of Orthopaedic Surgery, PanAm Clinic, University of Manitoba, 75Orthop. Clin. North Am. 2008; 39: 535–45. 19. Carmichael KD, Longo A, Lick S, Swischuk L. Posterior sternoclavicular epiphyseal fracture-dislocation with delayed diagnosis. Skeletal Radiol. 2006; 35: 608–12.
© 2013 Royal Australasian College of Surgeons
Three-point suture anchor repair of traumatic sternoclavicular joint dislocation Sarah C. O’Reilly-Harbidge and Zsolt J. Balogh Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
Key words dislocation, sternoclavicular joint, surgical technique, suture anchor. Correspondence Professor Zsolt J. Balogh, Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Newcastle, NSW 2310, Australia. Email: [email protected] S. C. O’Reilly-Harbidge BMed; Z. J. Balogh MD, PhD, FRACS. Accepted for publication 12 June 2013. doi: 10.1111/ans.12403
Abstract Background: Traumatic dislocation of the sternoclavicular joint (SCJ) is a rare injury. Previous techniques are associated with hardware migration, loss of reduction and infectious complications. We aim to describe our preferred surgical technique and summarize our experience with three-point suture technique of acute SCJ dislocation (SCJD). The objective of this study was to describe and assess the safety of three-point suture anchor repair technique in acute traumatic dislocation in the SCJ. Methods: A 7-year retrospective study in a university affiliated level 1 trauma centre. Operative cases and the trauma registry was reviewed to identify all potential cases of SCJD between 2005 and 2011. Inclusion criteria for this study were computed tomography (CT) identification of Allman III SCJD, intra-operative confirmation of the CT findings, acute fixation defined as 60 >60 >60 >60 >60
18 6 5 12 18 12
18 months 5 years 6 months 5 months 3 years 3 months 3 years 2 years
Patient 7 Patient 8
M M
16 16
Rugby Football Rugby Rugby Horseriding Motorbike accident Football Football
Right Right
School Labourer
Anterior Posterior
3 2
>60 >60
12 3
3 years 3 months
Patient Patient Patient Patient Patient Patient
F, female; M, male.
thorough description of the high rate of intra-thoracic injuries, little has been published on the recommended surgical technique and subsequent outcomes. The largest adult study group comprising of eight patients over an 8-year period.15 However, this paper addressed chronic post-traumatic dislocations (as defined as greater than 7 days of dislocation) and patients representing for surgical intervention because of chronic pain. The medial clavicular epiphysis is the last to close, occurring between the ages of 22 and 25;15 therefore, children and adolescents typically present with epiphyseal fractures rather than joint dislocations.6,7 Despite this, physeal fractures and joint dislocations are not routinely divided into different injuries, which is a significant limitation of most research to date and therefore diluting the applicability of suggested treatment algorithms.6,14,16,17 The SCJ is stabilized by a joint capsule, the anterior and posterior sternoclavicular and interclavicular ligaments, and particularly by the costoclavicular ligament,18 with the posterior structures demonstrated as being stronger than the anterior, making posterior SCJDs a less common occurrence than anterior dislocations.2 In this paper, the patients involved had been submitted to significant mechanisms of injury, which may explain the preponderance towards posterior dislocations. The SCJ is difficult to visualize with plain X-rays. Three plain radiographic projections have been described to aid in diagnosing dislocation in addition to the anteroposterior (AP) chest X-ray are: the Hobbs view, the Heinig view and the Serendipity view. None of these projections are widely used and provide satisfactory visualization for acute diagnosis. However the advent of the CT gives greater clarity of the level of injury and the impact on closely associated structures of the superior mediastinum, which may be concomitantly injured,10,14,19 and therefore routinely ordered on patients in this study (Fig. 3). When compared with previous studies of similar power, it demonstrates the reproducibility of the technique when applying it in an acute setting. The technique not only provides coronal plane fixation to stabilize the SCJ with regards to AP movement, it demonstrates that it can successfully stabilize both posterior and anterior dislocations making it a technique that can be utilized regardless of the plane in which the dislocation occurs. This paper supports the safety of the three-point suture anchor technique in the stabilization of a true SCJD in the acute trauma © 2013 Royal Australasian College of Surgeons
Fig. 3. Axial slice computed tomography – posterior dislocation.
setting. It demonstrates the reproducibility of outcome with a simple management algorithm commonly utilized with regard to orthopaedic follow-up. Complications associated with previous fixation methods used in the acutely unstable Grade III SCJD have not been replicated in this series of patients. The only post-operative complaint noted was due to keiloid scarring, which while not compromising the functional capacity of the patient was noted because of the relatively high occurrence in this particular region of the body.8,15,16 The three-anchor suturing technique is demonstrated as a safe, effective and replicatable method of SCJ fixation in this case series in spite of being a rare injury. This study demonstrates the benefit in long-term patient comfort and joint stability with acute phase intervention rather than delaying surgical intervention and relying on delayed reconstructive techniques. Despite this, for this rare injury, only multicenter studies or metaanalyses will lead to a sufficient classification and treatment algorithm. It is felt that the relatively large and repeatable nature of this study will add significantly to a future combined study.
886
References 1. Noda M, Shiraishi H, Mizuno K. Chronic posterior sternoclavicular dislocation causing compression of subclavian artery. J. Shoulder Elbow Surg. 1997; 6: 564–9. 2. Nettles JL, Linscheid RL. Sternoclavicular dislocations. J. Trauma 1968; 8: 158–64. 3. Booth CM, Roper BA. Chronic dislocation of the sternoclavicular joint: an operative repair. Clin. Orthop. Relat. Res. 1979; 140: 17–20. 4. Burrows HJ. Tenodesis of subclavius in the treatment of recurrent dislocation of the sterno-clavicular joint. J. Bone Joint Surg. Br. 1951; 33: 240–3. 5. Lowman CI. Operative correction of old sternoclavicular dislocation. J. Bone Joint Surg. 1928; 10: 740–1. 6. Jaggard MK, Gupte CM, Gulati V, Reilly P. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system. J. Trauma 2009; 66: 576–84. 7. Goldfarb CA, Bassett GS, Sullivan S, Gordon JE. Retrosternal displacement after physeal fracture of the medial clavicle in children treatment by open reduction and internal fixation. J. Bone Joint Surg. Br. 2001; 83: 1168–72. 8. Lyons FA, Rockwood CA Jr. Migration of pins used in operations on the shoulder. J. Bone Joint Surg. Am. 1990; 72: 1262–7. 9. Ono K, Inagawa H, Kiyota K, Terada T, Suzuki S, Maekawa K. Posterior dislocation of the sternoclavicular joint with obstruction of the innominate vein: case report. J. Trauma 1998; 44: 381–3. 10. Rockwood CJ, Wirth M. Disorders of the sternoclavicular joint. In: Rockwood CJ, Matsen F (eds). The Shoulder, 2nd edn. Philadelphia, PA: WB Saunders, 1998; 555–610.
O’Reilly-Harbidge and Balogh
11. Barber FA, Herbert MA, Hapa O et al. Biomechanical analysis of pullout strengths of rotator cuff and glenoid anchors: 2011 update. Arthroscopy 2011; 27: 895–905. 12. Jhamb A, Goldberg J, Harper W, Butler A, Smitham PJ, Walsh WR. String Theory: An Examination Of The Properties Of ‘High Strength’ Suture Materials. [Cited 30 Sep 2013.] Available from URL: http://www .orthosports.com.au/SiteMedia/w3svc994/Uploads/Documents/ STRING_THEORY_paper.pdf 13. Barber FA, Herbert MA, Coons DA, Boothby MH. Sutures and suture anchors-update 2006. Arthroscopy 2006; 22: 1063.e1–9. 14. Bicos J, Nicholson GP. Treatment and results of sternoclavicular joint injuries. Clin. Sports Med. 2003; 22: 359–70. 15. Gobet R, Meuli M, Altermatt S et al. Medial clavicular epiphysiolysis in children: the so-called sterno-clavicular dislocation. Emerg. Radiol. 2004; 10: 252–5. 16. Rajaratnam S, Kerins M, Apthorp L. Posterior dislocation of the sternoclavicular joint: a case report and review of the clinical anatomy of the region. Clin. Anat. 2002; 15: 108–11. 17. Macdonald PB, Lapointe P. Acromioclavicular and sternoclavicular joint injuries. Orthop. Clin. North Am. 2008; 39: 535–45. 18. Peter B, MacDonald MD, FRCSCa, Pierre Lapointe, MD, FRCSCb. Acromioclavicular and sternoclavicular joint injuries, Section of Orthopaedic Surgery, PanAm Clinic, University of Manitoba, 75Orthop. Clin. North Am. 2008; 39: 535–45. 19. Carmichael KD, Longo A, Lick S, Swischuk L. Posterior sternoclavicular epiphyseal fracture-dislocation with delayed diagnosis. Skeletal Radiol. 2006; 35: 608–12.
© 2013 Royal Australasian College of Surgeons
