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Resection Arthroplasty of the Sternoclavicular Joint

C. A. ROCKWOOD, JR., G. I. GROH, M. A. WIRTH and F. A. GRASSI
J Bone Joint Surg Am. 1997;79:387-93.

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 Copyright 1997 by The Journal of Bone and Joint Surgery, Incorporated

Resection Arthroplasty of the Sternoclavicular Joint*

BY C. A. ROCKWOOD, JR., M.D.f, G. I. GROH, M.D4, M. A. WIRTH, M.D.t, AND F. A. GRASSI, M.D.§, SAN ANTONIO, TEXAS

Investigation performed at the Department of Orthopaedics, Shoulder Service,

The University of Texas Medical School at San Antonio, San Antonio

ABSTRACT: The results of resection of the medial Since then, a number of authors have described the
end of the clavicle to treat a painful sternoclavicular importance of this ligament in opposing the cephalad
joint in fifteen patients were retrospectively reviewed. pull on the medial portion of the clavicle imparted by
The patients fell into two groups: eight patients who the sternocleidomastoid muscle and various movements
had had a primary arthroplasty of the sternoclavicular of the shoulder5'611'24-2932-35.
joint in which the costoclavicular ligament was left The purpose of the present report was to review
intact (group I), and seven patients who had had revi- the results of resection of the medial portion of the
sion of a failed arthroplasty of the sternoclavicular clavicle in two groups of patients who had been man-
joint and in whom the costoclavicular ligament had to aged between 1972 and 1990. In the first group of pa-
be reconstructed (group II). The results for these two tients (group I), the medial portion of the clavicle was
groups were compared at an average of 7.7 years post- resected, with maintenance of the costoclavicular liga-
operatively. All eight patients in group I had an excel- ment. In the second group (group II), a previous failed
lent result. In sharp contrast, three patients in group II arthroplasty of the sternoclavicular joint was revised,
had an excellent result, three had a fair result, and one with reconstruction of the costoclavicular ligament.
had a poor result. We conclude that preservation or
reconstruction of the costoclavicular ligament is essen- Materials and Methods
tial at the time of resection of the medial portion of We retrospectively analyzed two groups of patients
the clavicle in order to obtain a satisfactory result. who had had resection of the medial end of the clavicle
to treat problems related to the sternoclavicular joint
Sir Astley Cooper, in 1832, was probably the first to (Table I). The sternoclavicular joint was evaluated with
describe resection of the medial end of the clavicle to routine radiographs and a computed tomography scan
treat posterior dislocation of the sternoclavicular joint10. in order to compare it with the contralateral, normal
Since that time, numerous authors have described vari- joint.
ous operative procedures for the treatment of an unsta-
ble or degenerative sternoclavicular joint3,12-16-17'24-27'31. Group I
In any type of operative procedure on the sterno- Group I consisted of eight patients, six men and two
clavicular joint, it is necessary to preserve, repair, or women, in whom a primary resection of the medial end
reconstruct the costoclavicular ligament (the rhomboid of the clavicle with maintenance of the costoclavicular
ligament) to maintain the stability of the medial por- ligament had been performed by the senior one of us
tion of the clavicle in relation to the manubrium. In (C. A. R., Jr.). The diagnosis was post-traumatic degen-
1954, Abbott and Lucas described the importance of erative joint disease of the sternoclavicular joint in two
the costoclavicular ligament with regard to the treat- patients, chronic unreduced posterior dislocation of the
ment of problems related to the sternoclavicular joint1. clavicle in two, chronic anterior dislocation following a
Those authors pointed out that resection of the me- fracture-dislocation in two, chronic posterior disloca-
dial portion of the clavicle resulted in cephalad dis- tion following a fracture-dislocation in one, and trau-
placement and instability of the remaining portion of matic anterior subluxation in one. All of the patients had
the clavicle if the resection included a portion of the chronic pain in the affected sternoclavicular joint as
clavicle that was lateral to the costoclavicular ligament. well as grinding, popping, and crepitus with movement
of the shoulder. The average age at the onset of the
symptoms was thirty years (range, fourteen to forty-five
*No benefits in any form have been received or will be received years), and the average age at the time of the operation
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study. was thirty-five years (range, twenty-three to forty-six
tDepartment of Orthopaedics, The University of Texas Medical years).
School at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas
78284-7774. Please address requests for reprints to Dr. Rockwood.
tBlue Ridge Bone and Joint Clinic, 129 McDowell Street, Ashe-
Group II
ville, North Carolina 28801. Group II consisted of seven patients, five men and
§Clinica Ortopedica e Traumatologica, II Facolta di Medicina
e Chirurgia, Universita di Pavia — Sede di Varese, Ospedale Del two women, who had had resection of the medial end
Ponte, 21100 Varese, Italy. of the clavicle with reconstruction of the costoclavic-

VOL. 79-A, NO. 3, MARCH 1997 387

 388 C. A. ROCKWOOD, JR., G. I. GROH, M. A. WIRTH, AND F. A. GRASS1

TABLE I
DATA ON THE PATIENTS

Duration Score on Rating Scale (Pilints)

Gender, Preoperative Previous of Range of Limi- Subjective Total
Case Age Diagnosis Treatment Follow-up Pain Motion Strength tation Result Score*
(Yrs.) (Yrs.)
Group I
1 M,38 Chronic unreduced 2.0 3 3 3 3 3 15
posterior dislocation
2 M,36 Post-traumatic 5.3 2 3 3 2 3 13
degenerative joint
disease
3 F,30 Traumatic anterior 4.8 2 3 3 2 3 13
subluxation
4 M,27 Chronic anterior 1.7 3 3 3 2 3 14
dislocation following
fracture-dislocation
5 M,23 Chronic anterior 14.5 3 3 3 3 3 15
dislocation following
fracture-dislocation
6 M,31 Chronic unreduced 5.4 3 3 3 3 3 15
posterior dislocation
7 F,46 Post-traumatic 10.0 3 3 3 3 3 15
degenerative joint
disease
8 M,45 Chronic posterior 2.0 3 3 3 3 3 15
dislocation following
fracture-dislocation
Group II
9 M,20 Anterior dislocation Open reduction and 18.3 3 3 2 3 3 14
following fracture- internal fixation
dislocation with threaded pin
10 M,33 Traumatic anterior Resection of medial 10.0 2 2 1 1 2 8
subluxation portion of clavicle
11 M,18 Traumatic anterior Open reduction and 10.5 1 2 2 1 2 8
dislocation internal fixation
with pin, resection
of medial portion
of clavicle
12 F,34 Post-traumatic Resection of medial 7.3 3 3 2 2 3 13
degenerative joint portion of clavicle
disease x2
13 M,30 Spontaneous atraumatic Resection of medial 5.0 1 2 1 1 1 6
anterior dislocation portion of clavicle
14 F,34 Spontaneous atraumatic Resection of medial 3.3 1 2 2 2 2 9
anterior dislocation portion of clavicle
15 M,42 Traumatic anterior Open reduction and 16.3 2 3 3 2 3 13
dislocation internal fixation
with pins

*A total score of 13,14, or 15 points indicates an excellent result; 10,11, or 12 points, a good result; 7, 8, or 9 points, a fair result; and less than 7
points, a poor result.

ular ligament. They had been referred to the senior Rating Scale
one of us because of persistent pain and deformity in As we were not aware of any published data on the
the sternoclavicular joint after a failed arthroplasty results of arthroplasty of the sternoclavicular joint, we
of the joint performed elsewhere without maintenance developed a rating scale with which to evaluate our
or reconstruction of the costoclavicular ligament. The patients (Table II). A maximum of 3 points each was
diagnosis was traumatic anterior dislocation or sub- assigned for pain, range of motion, strength, limitation,
luxation in three patients, spontaneous atraumatic an- and the subjective result. According to this scale, a total
terior dislocation in two, anterior dislocation following score of 13,14, or 15 points indicated an excellent result;
a fracture-dislocation in one, and post-traumatic degen- 10,11, or 12 points, a good result; 7, 8, or 9 points, a fair
erative joint disease in one. The average age at the onset result; and less than 7 points, a poor result.
of the symptoms was thirty years (range, fifteen to forty-
two years), and the average age at the time of the op- Anatomy of the Sternoclavicular Joint
eration was thirty years (range, eighteen to forty-two The sternoclavicular joint is diarthrodial and is the
years). only true articulation between the upper extremity and

THE JOURNAL OF BONE AND JOINT SURGERY

 RESECTION ARTHROPLASTY O F T H E STERNOCLAVICULAR JOINT 389

the axial skeleton. The articular surface of the clavicle TABLE II

RATING SCALE USED TO EVALUATE THE RESULTS OF
is much larger than the articular facet on the sternum,
ARTHROPLASTY OF THE STERNOCLAVICULAR JOINT*
and both surfaces are covered with fibrocartilage. The
enlarged bulbous medial end of the clavicle is concave Category Score
(Points)
front-to-back and convex vertically, creating a saddle-
type joint with the curved clavicular notch of the ster- Pain
None 3
num2728. The joint surfaces are not congruent. Slight 2
Because less than half of the medial portion of the Moderate 1
clavicle articulates with the cephalad angle Of the ster- Severe (at rest) 0
num, the sternoclavicular joint has the distinction of Range of motion
having the least amount of osseous stability of the major Normal . 3
Slight restriction (<25%) 2
joints of the body2728. If a finger is placed in the superior Moderate restriction (25-50%) 1
sternal notch, one can feel that, with motion Of the upper Severe restriction (>50%) 0
extremity, a large part of the medial portion of the clav- Strength
icle is completely cephalad to the articulation with the Normal 3
sternum. There is so much joint incongruity that the in- Slight weakness (<25%) 2
Moderate weakness (25-50%) 1
tegrity has to come from the surrounding ligaments,
Severe weakness (>50%) 0
including the intra-articular disc ligament, the extra-
Limitation
articular costoclavicular ligament, the capsular liga- None 3
ment, and the interclavicular ligament (Fig. 1). Slight 2
Moderate 1
Operative Technique Severe 0
Subjective result
The surgeon must be totally familiar with the anat-
Excellent 3
omy immediately cephalad and posterior to the sterno- Good 2
clavicular joint before the operation. Additionally, we Fair 1
suggest that a thoracic surgeon be available or be a Poor 0
part of the surgical team in the event of vascular com- *A total score of 13,14, or 15 points indicates an excellent result;
plications. The risk of this potentially fatal complication 10,11, or 12 points, a good result; 7, 8, or 9 points, a fair result; and less
is particularly high with chronic unreduced posterior than 7 points, a poor result.
dislocations.
With the patient supine on the operating table, surface of the manubrium (Fig. 2). A deep incision is
three or four towels, or a small sandbag, are placed be- made along the medial four to five centimeters of the
tween the scapulae. The skin incision, which is approxi- clavicle across the capsular ligament and caudad onto
mately eight to ten centimeters long, begins cephalad the manubrium (Fig. 3). The periosteum is dissected
to the superior border of the medial aspect of the clav- carefully off the medial portion of the clavicle with
icle and extends to the notch of the manubrium and care being taken to preserve the periosteum for later
then caudad three to four centimeters onto the anterior closure and to preserve the costoclavicular ligament

Interclavicular Ligament

Lateral
Articular Cavity
Costoclavicular
Intra-articular Ligament
Disc Ligament Capsular
Medial Ligament
Articular Cavity

Synchondrosis
of Manubrium
and 1st Rib

FIG. 1
Illustration demonstrating the ligaments of the sternoclavicular joint, including the intra-articular disc ligament, the interclavicular ligament,
the costoclavicular ligament, and the capsular ligament.

VOL. 79-A, NO. 3, MARCH 1997

390 C. A. ROCKWOOD, JR., G. 1. G R O H , M. A. WIRTH, AND F. A. GRASS1

be removed. The caudad aspect of the osteotomy site

must be placed medial to the stabilizing costoclavicular
ligament to allow resection of 1.5 centimeters of the
medial portion of the clavicle. Care is taken to avoid
injury of the stabilizing costoclavicular ligament. Exci-
sion of the medial portion of the clavicle is facilitated
by placement of a series of holes through both corti-
ces of the clavicle at the intended site of the osteotomy.
An air-powered drill with a side-cutting bit is used
to make the holes and to complete the osteotomy (Fig.
5). The anterior and superior corners of the clavicle are
beveled with an air burr. The periosteal tube is care-
fully repaired around the residual portion of the clavicle
(Fig. 6).
If the sternal attachment of the intra-articular disc
ligament is intact, a non-absorbable number-one cot-
Illustration demonstrating the skin incision, which should be made tony Dacron suture (Deknatel, Fall River, Massachu-
along the superior border of the medial aspect of the clavicle to the setts) can be woven through the ligament so that the
notch of the manubrium and then continued caudad on the manu-
brium for three to four centimeters.
ends of the suture exit through the free end of the
ligament. The medullary canal of the medial end of the
clavicle is drilled and curetted to receive the transferred
capsular ligament as well as the intra-articular disc liga-
ment, if available. Two small drill-holes are then placed
in the superior cortex of the remaining medial portion
of the clavicle, approximately one centimeter lateral
to the site of the resection. The free ends of the suture
are passed into the medullary canal of the clavicle and
out the two small drill-holes in the superior cortex of
the clavicle. While the clavicle is held in a reduced
anteroposterior position in relation to the first rib and
the sternum, the sutures are used to pull the ligament
tightly into the medullary canal of the clavicle. The com-
bination of fixing the intra-articular disc ligament into
FIG. 3
the clavicle and of tying the non-absorbable sutures
Illustration demonstrating the deep incision that is made along the
medial four to five centimeters of the clavicle across the capsular
ligament and onto the manubrium.

(Fig. 4). While the sternal head of the sternocleido-

mastoid muscle can be preserved, the clavicular head
is reflected free. The capsular ligament is opened care-
fully to expose the joint. The capsular ligament and the
intra-articular disc ligament may need to be debrided to
expose the sternoclavicular joint. However, if the intra-
articular disc ligament is intact, it is preserved for stabi-
lization of the joint at the time of closure.

Procedure When the Costoclavicular

Ligament Is Intact
After exposure of the medial portion of the clav-
icle, a curved one or two-centimeter-wide retractor is
passed posterior to the clavicle to isolate it and to pro-
tect the vital posterior vascular structures during resec-
tion of the medial portion of the clavicle. An oblique
incision is made through the periosteum of the medial Illustration demonstrating how the periosteum is carefully dis-
sected off the medial portion of the clavicle. Care is taken to preserve
portion of the clavicle from lateral superior to medial the periosteal tube for later closure and to protect and preserve the
inferior so that the prominent superior prominence can costoclavicular ligament.

T H E J O U R N A L OF BONE A N D JOINT SURGERY

 RESECTION ARTHROPLASTY OF T H E STERNOCLAVICULAR JOINT 391

or through holes in the first rib for stability. However,

care must be taken not to tighten the sutures so much
that the medial end of the clavicle is compressed onto
the first rib. If the intra-articular disc ligament can be
preserved, it should be used, as described, to help to
stabilize the reconstruction.
Postoperative Management
All of the shoulders were immobilized in a sling
for six weeks. On the second day, the patient was al-
lowed to perform gentle pendulum exercises but was
cautioned against active flexion or abduction of the
shoulder above 90 degrees. Forceful pushing, pulling,
FIG. 5
and lifting were avoided for three months. Beginning at
Illustration demonstrating how the drill-holes are made through eight to twelve weeks, the patient began strengthening
both of the cortices of the clavicle at the intended site of the osteot-
omy. An air-powered side-cutting drill is then used to complete the exercises. If the costoclavicular ligament was intact,
osteotomy. the patient was permitted to return to his or her usual
activities and job, including manual labor, at eight to
twelve weeks. However, if the costoclavicular ligament
had been reconstructed, the patient was restricted from
returning to strenuous manual labor.
Results
Group 1
The average duration of follow-up was 5.7 years
(range, 2.0 to 14.5 years). Each of the eight patients had
an excellent result and was completely satisfied (Table
I). The pain had resolved completely in all but two pa-
tients, who reported slight discomfort during manual
labor. Three patients had slight limitation in the perfor-
FIG. 6 mance of strenuous activities or sports requiring over-
Illustration demonstrating how closure of the periosteal tube se- head motion.
cures a stabilized medial end of the clavicle when the costoclavicular
ligament is intact. If the sternal attachment of the intra-articular disc Group II
ligament is intact, as it occasionally is with a traumatic dislocation,
this ligament can be passed into the medullary canal for additional The average duration of follow-up was 10.1 years
support. (range, 3.3 to 18.3 years). Only three patients had an
excellent result (Table I). The primary procedure in two
through the costoclavicular ligament and around the (Cases 9 and 15) of these three had consisted of open
periosteal tube stabilizes the remaining medial end of reduction and internal fixation of the sternoclavicular
the clavicle.
Procedure When the Costoclavicular
Ligament Is Absent
When the costoclavicular ligament is absent, as is
usually the case in chronic dislocation of the sterno-
clavicular joint, it is necessary to re-establish the conti-
nuity of the remaining portion of the clavicle to the
first rib. After any prominences on the remaining me-
dial portion of the clavicle have been resected, two or
three pieces of non-absorbable suture (one-millimeter
Dacron tape) are passed around the remaining medial
end of the clavicle and its periosteal tube and then
through the residual scar of the old costoclavicular liga-
ment on the dorsal surface of the first rib (Fig. 7). Illustration demonstrating how closure of the periosteal tube in-
Closure of the periosteal tube stabilizes the medial por- cludes sutures that pass through the stump of the old costoclavicular
ligament on the first rib when the costoclavicular ligament is not
tion of the clavicle to the first rib. In some patients, intact. It may be necessary to pass sutures through drill-holes or
it may be necessary to pass additional sutures around around the first rib for stability.

VOL. 79-A, NO. 3, MARCH 1997

392 C. A. R O C K W O O D , JR., G. I. G R O H , M. A. WIRTH, A N D F. A. GRASST

joint with pinning for anterior dislocation following a trous results, in patients who were managed operatively
fracture-dislocation and for a traumatic anterior dis- for these conditions.
location, respectively. The severe discomfort and limi- The course of a traumatic anterior dislocation is
tation caused by subsequent chronic instability and less predictable. Unlike posterior dislocation, closed
degenerative spurring of the joint were reduced dra- reduction of an acute anterior dislocation is usually un-
matically after resection of the medial portion of the stable25. We do not agree with authors who recommend
clavicle and reconstruction of the costoclavicular liga- an operative procedure if a closed reduction is not
ment. The third patient who had an excellent result achieved1420,23'36. Persistent anterior displacement of the
(Case 12) had had residual fragments of bone pos- medial end of the clavicle usually does not cause serious
teriorly displaced after two previous resections of the problems2728. Operative treatment of an unstable an-
medial end of the clavicle. The fragments posterior to terior dislocation is justified only for patients who
the sternum were removed, one centimeter of the me- continue to have severe pain and marked functional
dial portion of the clavicle was resected, and the costo- impairment41521223". If an operation is performed, the
clavicular ligament was reconstructed. critical part of the procedure is the stabilization of the
Four patients had a fair or poor result; all had been medial portion of the clavicle to the first rib.
managed previously with resection of the medial por- In most patients, degenerative problems of the ster-
tion of the clavicle. noclavicular joint, such as osteitis condensans, sternocla-
The three patients (Cases 10,11, and 14) who had a vicular hyperostosis, and postmenopausal osteoarthrosis,
fair result had had a revision procedure to resect more can be controlled successfully with conservative treat-
of the medial portion of the clavicle and to restabilize ment, such as rest, moist heat, and anti-inflammatory
the medial portion of the clavicle to the first rib. In one medications724283435. Occasionally, because of an intra-
(Case 11), this procedure had been preceded by an un- articular fracture or persistent pain due to a degenera-
successful attempt at open reduction and internal fixa- tive problem, the medial end of the clavicle must be
tion with pinning of a traumatic anterior dislocation of resected. This situation is analogous to resection of the
the sternoclavicular joint. These three patients had a lateral end of the clavicle because of an intra-articular
decrease in the symptoms and were satisfied with the fracture or osteoarthrosis of the acromioclavicular joint.
result at an average of 7.9 years (3.3, 10.0, and 10.5 An operative procedure is indicated for persistent
years) postoperatively. subluxation or dislocation of the sternoclavicular joint
The patient who had a poor result (Case 13) had that does not respond to non-operative treatment or
been seen for a spontaneous atraumatic anterior dis- that constitutes a danger to the patient. The latter cir-
location of the sternoclavicular joint that was initially cumstance occurs with chronic unreduced posterior dis-
treated with resection of the medial portion of the clav- location because of the compression of and subsequent
icle without stabilization of the clavicle to the first rib. erosion into the great vessels, the trachea, or the esoph-
Before the index procedure, the patient reported per- agus by the medial aspect of the clavicle. However, acute
sistent instability and worsening pain. We performed a posterior dislocations can be treated effectively with
revision in which the medial portion of the clavicle was closed reduction, which is usually successful and sta-
stabilized to the first rib with one-millimeter Dacron UlgS.24,26,28.30

tape. Postoperatively, the patient did weir and, against The need for a ligamentous repair or reconstruction
our advice, returned to his job as a laborer. Four years has been recognized by authors who have reported on
postoperatively, the result for this patient was excellent. different types of procedures for the treatment of dislo-
However, five years postoperatively, he had sudden, se- cations of the sternoclavicular joint2-3-9-13-17w*-™»w-*-\
vere pain while lifting a heavy weight overhead. A pain- In order to keep the sternoclavicular joint in a re-
ful and unstable clavicle necessitated a second revision duced position, some surgeons have fixed it with pins or
to restore stability of the clavicle to the first rib. At the wires. Since tremendous force is applied on these pins
time of the latest follow-up examination, the pain and whenever the upper extremity is moved, fatigue break-
instability had decreased, but the patient was unable to age or migration of pins, or both, is common and can
return to strenuous manual labor. On the basis of our lead to fatal complications. Instances of death and near
experience with this patient, we recommend that a pa- death resulting from migration and penetration of the
tient not return to strenuous labor after reconstruction pins into the heart and great vessels were recently re-
of the costoclavicular ligament. ported by Lyons and one of us19.
We believe that if the medial end of the clavicle is
Discussion to be resected, the resection must be accompanied by
Spontaneous atraumatic anterior dislocations and removal of a sufficient amount of bone and either by
subluxations have a benign natural course and do not maintenance of an intact costoclavicular ligament when-
necessitate specific treatment other than education and ever possible or by reconstruction of the ligaments that
reassurance of the patient. Furthermore, one of us and stabilize the remaining portion of the clavicle to the
Odor29 reported increased symptoms, and even disas- first rib.

THE JOURNAL OF BONE AND JOINT SURGERY

 RESECTION ARTHROPLASTY OF THE STERNOCLAVICULAR JOINT 393
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