Is reconstructing anterior sternoclavicular joint dislocation by a high-strength tape suture a good choice?

INTRODUCTION

Dislocations and fractures of the sternoclavicular joint (SCJ) are infrequent but potentially harmful. In fact, many reports have indicated that about 1% of all severe shoulder injuries are SCJ injuries.^[1]

The SCJ is a genuine diarthrodial joint between the medial clavicle and the clavicular notch of the sternum. A flat and circular fibrocartilaginous structure called the intra-articular disc is connected inferiorly to the first rib costocartilaginous junction and superiorly to the superoposterior part of the clavicular articular surface. The intra-articular disc is fully developed in most people, unlike its counterpart in the acromioclavicular joint. Large SCJ ligaments support the thicker anterior and posterior SCJ capsules on either side.^[2-4]

The SCJ’s proximity to mediastinal organs such as the esophagus, trachea, brachial plexus, aorta, common carotid arteries, and brachiocephalic veins is more crucial. Having reservations about these structures can affect orthopedic decision-making.^[5]

Often, a patient with SCJ dislocation presents with high-energy trauma (Falls from heights, road traffic accidents, and sports injuries). Trauma to the ipsilateral shoulder, either direct or indirect, may result in SCJ injuries.^[6]

Patients with anterior SCJ displacement typically experience pain restricted to the affected joint, as well as soreness, ecchymosis, and a prominent bony protrusion of the clavicular head. Shoulder motion results in pain and/or an unstable feeling. There is typically no corresponding neurovascular impairment.^[6]

Treatment options can often be categorized based on acuity and displacement direction. The ideal course of treatment for acute anterior SCJ fracture dislocations is hotly debated.^[1]

Particularly in the case of workers or overhead sports, the patient’s demands are a significant factor in the treatment and decision-making process. The most recent research on the pathoanatomy, natural history, and potential outcomes of SCJ injuries revealed that surgery could restore normal shoulder girdle morphology and mechanics and enhance functional results even though many of these injuries were treated nonoperatively.^[1]

The surgical management of anterior SCJ dislocation has been documented using several approaches.^[7-10] The figure-of-eight design is the most effective method for reconstructing an anterior or posterior SCJ dislocation.^[11]

This study aimed to evaluate patients clinically and radiographically to assess the safety, effectiveness and patient satisfaction following the restoration of the SCJ dislocation by using a high-strength non-absorbable tape suture.

MATERIALS AND METHODS

From May 2020 to May 2022, a prospective case series study was conducted at the hospitals affiliated with Al-Azhar University (Al-Hussein, Bab El Shaerrya and Al-Azhar Damietta Hospitals) in Egypt, on ten patients (nine males and one female). Their average age was 40.1 years (18–52 years). They all had a symptomatic anterior SCJ dislocation confirmed by the clinical and radiographic investigations, four on the left and six on the right side [Figure 1]. They were treated with open reduction and reconstruction by high-strength non-absorbable tape sutures. This addressed the injury pattern and evaluated pain, range of motion, complications, functional outcomes, and patient satisfaction by simple shoulder testing using the American shoulder and elbow score (ASES) and the disabilities of the arm, shoulder, and hand (DASH) score.^[12,13]

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Figure 1:

Deformity and swelling of the left sternoclavicular joint.

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Inclusion and exclusion criteria

All patients included in this study were symptomatic and had acute anterior SCJ dislocation within 3 weeks of the injury. Those with dislocation more than 3 weeks from injury were excluded from the study.

All patients were evaluated clinically for deformity, skin condition, range of motion, neurovascular status, and associated injuries. Four patients had isolated anterior SCJ dislocation, three had fractured ribs, one had hemothorax, one had pneumothorax, and the last had a distal radius fracture. Furthermore, routine anterior-posterior chest radiography, serendipity view and CT 3D were done for all patients [Figure 2].

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Figure 2:

Plain radiography and CT 3D show dislocation of the left sternoclavicular joint.

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The injury’s mechanism was as follows: Five motor car accidents, three pedestrian collisions and the remaining two patients fell on their ipsilateral shoulder while playing football.

All patients were evaluated with the routine investigation (laboratory, chest radiograph, ECG, and echocardiography) cardiac, chest, and anesthesia consultation before surgery to check fitness for surgery and consent for the operation was taken.

Surgical technique

The same operative technique was used in all patients included in the current study using a high-strength nonabsorbable tape suture [Figure 3].

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Figure 3:

Tape suture used in reconstruction.

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All patients were operated on under general anesthesia and were given prophylactic antibiotics with induction of anesthesia. All patients were positioned supine with the ipsilateral shoulder and arm free draped to be easy to move and manipulate during surgery to help in the reduction.

First, the identification of SCJ and marking-our planned incision was made (about 2 cm at each side of the joint to make about 4–6 cm incision). Next, skin, subcutaneous tissue, and platysma muscle were opened in line with the incision to be directly on the joint capsule. Then, we opened the capsule and started subperiosteal elevation of the tissue attached to the medial end of the clavicle, debriding it and removing the intra-articular disc [Figure 4]. Then, we made two holes with a drill about 1cm away from the end, allowing the needle to pass through with the tape [Figure 5].^[14]

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Figure 4:

Excision of the articular disc.

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Figure 5:

Sternoclavicular Joint Reconstruction. The tape suture is passing through holes in a figure-of-eight style and tied with suture knot.^[14]

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We elevated the periosteum and tissue attached to the sternum to allow a good view of the articular notch. We also made two holes in the sternum to allow passage of a sharp cutting needle of the tape suture. We carefully took a good grip from the sternal side to avoid cutting through bone with the threads.

We started a trial of reduction without passing sutures. Then, after confirmation that it was acceptable, we passed heavy non-absorbable tape sutures starting from the hole on the clavicular end toward the sternum in a figure-of-eight configuration [Figure 6a-d] and secured it with a suture knot. Finally, we closed the capsule, approximated the periosteum, and closed the muscle and skin.

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Figure 6:

(a) Elevation of clavicular end and passage of tape, (b) Passage of the tape through the sternal end using the sharp tipped needle attached to the tape, (c) Tying tape and suturing using non absorbable threads, and (d) Suture knot.

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RESULTS

This prospective study included ten patients with a mean age of 40.1 years who presented with acute symptomatic anterior SCJ dislocation and were treated with reconstruction by high-strength non-absorbable tape sutures [Table 1].

The mean operative time was 78.5 min. Eight patients had reconstruction in the 1^st week after injury, and the remaining two patients had reconstruction 2 weeks after stabilization of pulmonary function, as one had a pneumothorax and the other had hemothorax. There was no intraoperative complication. The average follow-up time was 12 months (9–18 months).

The ASES^[12] showed an average improvement of physical function of 24.59, which is extremely significant as the pre-operative mean was 68.11 ± 3.72 while the post-operative mean was 92.70 ± 3.54. Furthermore, the DASH questionnaire measured arm, shoulder, and hand impairments^[13] and showed extremely significant improvement as it decreased from 68.92 ± 4.38 preoperatively to 5.16 ± 2.91 postoperatively [Table 2].

Immediate post-operative radiographs [Figure 7] for all patients showed that all dislocated joints were effectively reduced.

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Figure 7:

Postoperative plain radiograph show reduction of the left sternoclavicular joint.

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On outpatient clinic follow-up no redislocation had occurred. Only one patient had slight subluxation after 3 months, but it did not affect the shoulder function.

All patients had satisfactory results due to the disappearance of deformity, swelling, pain, and regaining of function and pre-injury activity level with no serious complication or injury to the near structures of the joint [Figure 8].

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Figure 8:

Functional result 6 months following the left anterior sternoclavicular joint repair.

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DISCUSSION

The SCJ, which is created by the clavicle, perching over the top of the sternum, and the medial end of the first rib, is a unique joint that is crucial in the transmission of force and smooth scapulothoracic motion during shoulder elevation. Strong extrinsic ligaments and a dynamic muscular envelope serve as primary stabilizers. Due to a lack of thorough literature on the issue, challenges in diagnosis, limitations of conventional radiography, unfamiliar anatomy, and complex biomechanics, it is a frequently neglected joint.^[15]

Since the posterior joint capsule is stronger and requires a 50% stronger power to dislocate the clavicle posteriorly, the SCJ joint is most frequently displaced anteriorly.^[16,17]

When an anterior SCJ dislocation reduces on its own, the arm is immobilized for 6 weeks while still in the sling in case the joint settles and stabilizes. A closed reduction under general anesthesia may be tried if the dislocation persists and is discovered within 7–10 days. If closed reduction was unsuccessful, the surgeon should proceed with surgical reduction.^[7]

Various surgical methods are described for the reconstruction of anterior SCJ dislocation documented in the literature, including biologic reconstruction using tendon autografts (sternocleidomastoid, palmaris longus, semitendinosus, and gracillis) and fascial loops^[7] or non-biologic ligaments made of synthetic materials such as carbon fiber and dacron.^[18,19] Acromioclavicular joint hook plates, fiber wire, two screws, a T-plate, a locking plate, and a strong suture were also mentioned in the literature, along with using Kirschner (K) wires.^[7,20] Moreover, it was documented that resection of the sternal head of the clavicle without repair of the ligamentous tissues appears to be a poor option for treating SCJ instability. Last but not least, tenodesis of the subclavius tendon, sternal head of the sternocleidomastoid muscle, and myoplasty were also reported for treating SCJ dislocations.^[11]

The trachea, esophagus, brachiocephalic vein, brachiocephalic artery, and brachial plexus are significant thoracic structures behind the SCJ. They are safeguarded against unintentional injury caused by surgical intervention on the manubrium sterni, regardless of the surgical techniques used.^[3,21-23]

A systematic review reported that although 18 articles recommended having a cardiothoracic surgeon on standby during the operation, they found no instances, they were needed in the 35 cases of open reduction, leading them to the conclusion that the recommendation to have one on standby during an open reduction of an SCJ dislocation is, at best, weak.^[24]

Our surgeries were done in collaboration with the cardiothoracic surgeon, who was present in all cases guarding against major complications. Therefore, it was a good option to work in a multidisciplinary team.

Full anterior dislocations necessitate better-fixing methods since they have a higher propensity to redislocate. The SCJ provides stability to the thoracic cage and the shoulder girdle’s range of motion through clavicle rotation around its longitudinal axis and elevation at the SCJ of up to 40°. Due to its inflexible nature and these qualities, plating is not a good option for reconstructing the SCJ. Besides that, the disturbance of soft tissue during the implantation and removal of plates and the increased risk of metal fatigue and failure must be contemplated.^[9,25,26]

On the contrary, tendon grafts provide an alternate and more physiologic choice. Hence, most surgeons favor figure-of-eight restoration with a tendon graft (sternocleidomastoid, palmaris longus, gracillis, fascia lata, or semitendinosus tendon).^[26] The main disadvantages of tendon grafting include comorbidity, as well as the notion that tendon grafts are vulnerable to early failure due to disintegration, rupture, and stretching, which could also lead to repeated SCJ instability.^[11]

We have similar results compared to Adamcik et al.^[27] which used a similar technique. However, with fiber wire in five cases presented with anterior and posterior SCJ dislocations, all patients showed improvement in terms of physical activity and return to the pre-injury activity level in the last follow-up. They also used the DASH score for evaluation of the activity of the patient post-operative, as we did in our patients.

In another study by Qu et al.^[20] they reconstructed anterior SCJ dislocation in ten patients by hook plates. They improved their average ASES score by 21.71 points, which was 68.11 preoperatively and 89.82 postoperatively. Moreover, it was similar to our result as the ASES in our patients had an average improvement of 24.59 points and changed from 68.11 preoperatively to 92.70 postoperatively.

Finally, our method for repair of anterior SCJ dislocation by a high-strength non-absorbable tape suture has many advantages compared to the other methods or techniques used for the reconstruction described in the literature (1) The suture is available, cheap, and easy to use. (2) Avoids donor site morbidity compared to biological reconstruction by tendon grafts. (3) Avoids injury to the vital structures behind the SCJ by screws or K-wires penetration used in other fixation methods. (4) Furthermore, the shoulder girdle may benefit from our method’s provision of micromotion within a specific range between the clavicle and manubrium sterni. (5) Avoids hardware-related complications (skin irritation, infection, loosening, osteolysis, and infection). (6) The patient does not need a second operation to remove the hardware.

CONCLUSION

Reconstruction of SCJ with high-strength non-absorbable tape suture (polyester) is simple, safe, and efficient, with good functional outcomes and high patient satisfaction. Furthermore, it avoids other side comorbidities like autogenous grafts with few complications.

AUTHORS’ CONTRIBUTIONS

MAAI, EA, GA, SA, conceived, designed the study and provided research materials. Also, they collected, organized data, analyzed, interpreted data and wrote the initial and final draft of the article. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

ETHICAL APPROVAL

The Al-Azhar Ethics Council of Al-Azhar University Hospitals authorized this research project. The registration number: Pat.3Med.Research.0000003 issued on 01/04/2020.