- Email: [email protected]
Arthroscopy of the Sternoclavicular Joint
Arthroscopy of the Sternoclavicular Joint Graham Tytherleigh-Strong, F.R.C.S.(Orth), DSportMed, F.F.S.E.M.
Abstract: Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.
P
athologic disorders around the sternoclavicular joint (SCJ) are rare, but symptoms can be debilitating, with limited treatment options. Traditionally, surgical intervention for SCJ disorders has required an open approach, which itself carries the risks of damage to the underlying mediastinal structures, instability, and scarring.1,2 This in part has led to a high threshold for surgery. An arthroscopic approach for certain SCJ intraarticular pathologies could potentially decrease these risks.3,4 This article describes an SCJ arthroscopic technique that has evolved over the past 5 years. The first procedures undertaken were diagnostic in 2 patients with an inflammatory monoarthropathy of the SCJ and a large effusion. In these patients we took an aspirate and synovial biopsy specimen. Subsequently, we have performed over 50 therapeutic procedures for intra-articular conditions including meniscectomy/discectomy for acute and chronic disk tears, excision of loose bodies, excision of the medial end of the clavicle for degenerative arthritis, and washout and debridement after infection.
From the Division of Orthopaedics, Addenbooke’s Hospital, Cambridge University Teaching Hospital Trust, Cambridge, England. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received October 2, 2012; accepted January 9, 2013. Address correspondence to Graham Tytherleigh-Strong, F.R.C.S.(Orth), DSportMed, F.F.S.E.M., Cambridge University Hospital Trust, Orthopaedics & Trauma, Addenbrooke’s Hospital, Hills Road, Cambridge, Cambs CB2 2QQ, England. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12647/$36.00 http://dx.doi.org/10.1016/j.eats.2013.01.005
Surgical Technique Positioning and Equipment The procedure is performed with the patient under general anesthesia positioned supine. The patient’s head is placed in a head ring, and a small sandbag is placed between the scapulae to open up the SCJs anteriorly. The operating surgeon stands on the operative side of the patient facing toward the head end of the table where the arthroscopic stack is positioned. A 2.7-mm arthroscope with a 3-mm cannula and trocar is used for visualization with the fluid pressure pump at 30 mm Hg. A mini-probe and punch with a mini-shaver using a 3.5-mm incisor blade and bur (Dyonics Smith & Nephew, Andover, MA) are used for instrumentation. A micro-bipolar VAPR radiofrequency probe (DePuy Mitek, Raynham, MA) is used for hemostasis and tissue ablation. Portal Placement Anatomic Considerations. The greatest perceived concerns surrounding SCJ surgery are the close proximity of the posteriorly lying mediastinal structures and damage to the anterior stabilizing structures. The potential advantage of an arthroscopic procedure is that once the arthroscope and instruments have been introduced into the joint space, any intra-articular procedure can then be undertaken with the knowledge that the mediastinal structures lie safely behind the posterior capsule. A cardiothoracic surgeon was present for the first 3 cases that we undertook; since then, reassured by the previously mentioned factors and our experience, we have not required the presence of a cardiothoracic surgeon.
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e141-e145
e141
e142
G. TYTHERLEIGH-STRONG
Fig 1. Coronal computed tomography scan of the SCJs with superimposed inferior and superior portal positions (yellow X) on either side of the anterior SC ligament (red diamonds). One should note the relatively small area of bony congruence at the inferior part of the joint, making it the most suitable position to establish the initial portal.
The main factors taken into consideration when determining the most appropriate and safest position for portal placement are the anterior sternoclavicular (SC) ligament, the area of bony congruence in the coronal plane, and the angle of joint inclination in the axial plane. Two portals are required to undertake any therapeutic procedure. Placing 1 portal at the inferior point of the SCJ and the other at the level of the superior point of the medial end of the clavicle minimizes damage to the anterior SC ligament (Fig 1). The plane of the SCJ does not actually lie perpendicular to the mediastinum. We undertook a study of the computed tomography scans of 80 patients (160 SCJs) undergoing computed tomography scans of their chests and looked at the angle of inclination of the SCJ in 3 orthogonal planes. In the axial plane, we found that the medial end of the clavicle showed great variation but that the angle of inclination of the
Fig 2. Axial computed tomography scan of the SCJ showing the 30 angulation of the sternal articular surface in relation to the vertical axis. This indicates the angle at which the arthroscopic camera and instruments need to be inserted to run parallel to the medial side of the joint.
manubrium was consistent, at 60 to the transverse plane and 30 to the vertical plane (Fig 2).5 Technique. The sternal articular surface is shallow, and as a result, there is only a relatively small area of bony congruence with the inferior part of the medial clavicle when the shoulder girdle is in the lowered position (Fig 1). We choose to use an 18-gauge spinal needle inserted into the inferior part of the SCJ at an inclination of 30 , injecting normal saline solution to initially distend the joint. This serves to open up the joint inferiorly and to ascertain the correct position and angle at which to insert the trocar while also distending the superior part of the joint capsule (Fig 3). By use of a small skin stab incision over the inferior part of the SCJ, the cannula and trocar are carefully inserted at a 30 inclination. A definite “pop” can be felt as the anterior joint capsule is penetrated with a flashback of saline solution, confirming entry into the joint. Fig 3. (A) An 18-gauge spinal needle is inserted at the inferior part of the SCJ at an angle of 30 to the vertical plane. Normal saline solution is then infiltrated into the joint space with minimal resistance to confirm correct placement. (B) The arthroscopic cannula with a blunt trocar is inserted into the inferior joint space at an angle of 30 . The cannula often passes more than 20 mm before it penetrates the anterior capsule with a definite “pop.”
e143
ARTHROSCOPY OF STERNOCLAVICULAR JOINT Table 1. Tips and Pitfalls Preoperative imaging
Patient positioning Portal placement
Tips
Pitfalls
Magnetic resonance imaging scan: diagnostic arthroscopy Discectomy Postinfection debridement Computed tomography scan: SCJ excision Excision of loose bodies Supine with sandbag between scapulae Arthroscopic stack at head-end of table Inferior and superior anterior portals: establish inferior portal first 18-gauge spinal needle at 30 to vertical with normal saline solution infiltration Establishment of superior portal by inside-out technique
Head not sufficiently extended and anterior joint not opened up Spinal needle/instruments inserted too perpendicular Insufficient space between inferior and superior portals
Surprisingly, the cannula often needs to be inserted more than 30 mm. Having established an inferior viewing portal, we create a superior portal above the anterior SC ligament. The 18-gauge spinal needle is used in an outside-in technique to achieve this. A mini-probe and instruments can then be introduced. Table 1 lists some of the tips and pitfalls associated with arthroscopy of the SCJ. Diagnostic Arthroscopy The intra-articular disk in the normal SCJ is complete and divides the joint into a sternal and a clavicular side. However, the disk is commonly torn after trauma, after infection, and in the presence of degenerative joint disease. Of the 53 arthroscopies that we have undertaken, the disk has been complete in only 2 cases. When the disk is complete, the sternal and clavicular sides of the joint have to undergo arthroscopy separately. The most important structures to initially identify are the fibers of the posterior SC ligament within the posterior joint capsule. This confirms that the arthroscope is safely positioned within the joint. In the vast majority of joints, the disk has undergone a degenerative tear and has usually torn off of the superior and anterior capsule.
The superior edge of the torn disk is usually seen lying in the inferior part of the joint and can be probed (Fig 4). The articular surfaces are then visualized and assessed. As a general rule, the sternal articular surface is usually relatively well preserved in comparison with the medial end of the clavicle. Therapeutic Arthroscopy The first 2 arthroscopies that we undertook were simple diagnostic procedures in which we took small synovial biopsy samples with no complications. After this, we have gradually undertaken and refined a number of therapeutic procedures (Table 2). In the vast majority of patients, these have been undertaken as day-surgery procedures. Arthroscopic Discectomy. The SCJ disk is commonly damaged after trauma, and degenerative tears are often associated with SCJ arthritis. The SCJ disk has often been likened to the meniscus in the knee, in that tears may present with mechanical symptoms and be of a degenerative nature. After magnetic resonance imaging diagnosis, we have undertaken 9 arthroscopic SCJ discectomies (Figs 5 and 6, Video 1). Three were for acute tears in young patients in whom mechanical clicking and pain developed after an acute injury, and 6 were for degenerative tears with predominantly mechanical symptoms. At surgery, there is an obvious difference in disk tissue quality between the acute and chronic tears, akin to that found in acute and chronic meniscal tears at arthroscopy of the knee. In addition, degenerative changes at the medial end of the clavicle are present with degenerative tears. Table 2. SCJ Arthroscopic Procedures Undertaken to Date
Fig 4. Arthroscopic image of right SCJ. The mini-probe is on the superior edge of the torn disk and the relatively wellpreserved sternal articular cartilage is on the right, with the more degenerated clavicular cartilage on the left.
Procedure
No.
Diagnostic arthroscopy Arthroscopic meniscectomy Arthroscopic excision of loose bodies Arthroscopic joint debridement Arthroscopic SCJ excision
3 9 (3 acute and 6 degenerative) 2 9 30
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G. TYTHERLEIGH-STRONG
Fig 5. Magnetic resonance imaging scans (T2 short tau inversion recovery coronal views) of both SCJs showing a superior tear of the disk on the left side compared with the normal right side. The truncated appearance with edema outlining the disk is characteristic of a disk tear.
Postoperatively, the mechanical symptoms and pain had resolved in all of the patients with an acute disk tear and 4 with a degenerative tear at 6 months. Of the 2 patients with ongoing symptoms, 1 underwent an arthroscopic excision of the medial end of the clavicle with resolution of symptoms whereas the other chose to have no further treatment. Arthroscopic Excision of Loose Bodies. We have undertaken an arthroscopic excision of bony loose bodies from the SCJ in 2 patients (Fig 7). Both of the patients had presented with pain and an intermittent clicking after trauma. In 1 case the intra-articular disk was complete and the loose fragment was excised from the clavicular compartment. In the other case, the disk was damaged and we undertook an additional discectomy and removed the loose fragments. Postoperatively, the pain and clicking resolved in both cases. Arthroscopic Joint Debridement (After Infection). After septic arthritis of the SCJ, patients are often left with ongoing swelling, pain, and stiffness on movement. We have undertaken an arthroscopic debridement and excision of the disk remnant in 9 patients. In all of the cases, samples were sent for microbiologic testing but there was no organism in any. We did not resect any
bone or articular cartilage. Postoperatively, 5 patients noticed a significant improvement in pain and stiffness. The other 3 patients did not notice a significant benefit, but they believed that they were no worse off than before surgery. Arthroscopic Excision of SCJ. In the majority of patients with symptomatic degenerative arthritis of the SCJ, the symptoms usually settle with nonoperative management and time. However, in a few patients, significant symptoms can continue despite rest, antiinflammatory medication, and steroid injection. We have undertaken an arthroscopic excision of the SCJ in 30 patients who continued to have significant symptoms, predominantly pain, despite optimal nonoperative management. Our surgical technique evolved over the first 7 cases. In all of the procedures we excised the remnants of the intra-articular disk. In the earlier cases, we excised bone from both the sternal and clavicular sides of the joint. We then began to only resect varying amounts of the clavicle. From case 7 onward, we have aimed to remove sufficient bone to uniformly expose cancellous bone at the medial end of the clavicle. This has required between 5 and 10 mm of resection (Video 2). The postoperative results of the first 5 SCJ excisions were initially good, but in 2 of the patients a recurrence
Fig 6. Arthroscopic image of left SCJ. (A) Micro-punch resecting torn disk. (B) The disk has been resected, and the probe touching the posterior capsule can be seen. One should note the relative preservation of the sternal articular cartilage on the left side.
e145
ARTHROSCOPY OF STERNOCLAVICULAR JOINT
Fig 7. Computed tomography scan of a 19-year-old man with a loose fragment present on the right side.
of pain developed after 6 months, particularly over the sternal side of the joint. Since our establishment of a standard technique of excising the medial end of the clavicle, all of the patients have reported good symptomatic relief, which so far seems to have been sustained. We have undertaken a prospective study of 10 of the patients with a mean of 2.4 years of follow-up. At final follow-up, 7 reported an excellent result, 2 reported a good result, and 1 reported a fair result according to Rockwood’s SCJ scoring system.6 Postoperative Protocol At the end of each procedure, we close the wounds with No. 3-0 Prolene subcuticular sutures (Ethicon, Somerville, NJ). We usually infiltrate the area with 10 mL of 0.25% bupivacaine, and more recently, we have been trying to perform a selective cervical plexus block. We do not immobilize the patients’ arms, and we encourage free movement. SCJ arthroscopy is usually a day-case procedure. So far, we have had no complications after arthroscopy of the SCJ and particularly no evidence of joint instability. The portal incision scars are relatively small, and patients seem to be happy with the cosmetic outcome.
Discussion Open surgery for intra-articular SCJ pathology is relatively rare. Only a few series have been reported on
SCJ excision and fewer on intra-articular disk excision. In all of these, the patients have had a relatively protracted recovery and have often required sling immobilization. Problems with instability and cosmesis have been reported. As a result, despite improved imaging modalities (magnetic resonance imaging and computed tomography) leading to a better understanding and diagnosis of SCJ disorders, there remains a reluctance to proceed with surgery. Arthroscopy of the SCJ and the early results described in this initial series are encouraging, and arthroscopy appears to be a safe and reproducible procedure. As a result, it may lead to a decrease in the threshold to undertake SCJ surgery. Although this is not a technique for the occasional arthroscopist, it should be well within the realms of the experienced shoulder and elbow arthroscopic surgeon. However, it is understandably quite disconcerting to insert the trocar into the SCJ for the first time for both the surgeon and the anesthetist, and it may be wise, if not just for peace of mind, to initially have cardiothoracic support available. There is a learning curve to placing the arthroscope into the joint, obtaining adequate visualization, and then undertaking a therapeutic procedure. As a result of this and because of the relative rarity of SCJ intra-articular pathology, it is probable that, in reality, only surgeons in larger referral units with a sufficient volume of cases are likely to perform the described procedure.
References 1. Lunseth PA, Chapman KW, Frankel VH. Surgical treatment of chronic dislocation of the sterno-clavicular joint. J Bone Joint Surg Br 1975;57:193-196. 2. Pierce R. Internal derangement of the sternoclavicular joint. Clin Orthop Relat Res 1979:247-250. 3. Tavakkolizadeh A, Hales PF. Arthroscopic excision of sternoclavicular joint. Knee Surg Sports Traumatol Arthrosc 2009;17:405-408. 4. Tytherleigh-Strong GM, Getgood AM, Griffiths DE. Arthroscopic intra-articular disk excision of the sternoclavicular joint. Am J Sports Med 2012;40:1172-1175. 5. Wijeratna MD, Turmezei TD, Tytherleigh-Strong G. The relevant anatomy of the sternoclavicular joint in relation to arthroscopic surgical approaches. Skeletal Radiol 2013;42: 473-478. 6. Rockwood CA, Groh GI, Worth MA, Grassi FA. Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg Am 1997;79:387-393.
Abstract: Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.
P
athologic disorders around the sternoclavicular joint (SCJ) are rare, but symptoms can be debilitating, with limited treatment options. Traditionally, surgical intervention for SCJ disorders has required an open approach, which itself carries the risks of damage to the underlying mediastinal structures, instability, and scarring.1,2 This in part has led to a high threshold for surgery. An arthroscopic approach for certain SCJ intraarticular pathologies could potentially decrease these risks.3,4 This article describes an SCJ arthroscopic technique that has evolved over the past 5 years. The first procedures undertaken were diagnostic in 2 patients with an inflammatory monoarthropathy of the SCJ and a large effusion. In these patients we took an aspirate and synovial biopsy specimen. Subsequently, we have performed over 50 therapeutic procedures for intra-articular conditions including meniscectomy/discectomy for acute and chronic disk tears, excision of loose bodies, excision of the medial end of the clavicle for degenerative arthritis, and washout and debridement after infection.
From the Division of Orthopaedics, Addenbooke’s Hospital, Cambridge University Teaching Hospital Trust, Cambridge, England. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received October 2, 2012; accepted January 9, 2013. Address correspondence to Graham Tytherleigh-Strong, F.R.C.S.(Orth), DSportMed, F.F.S.E.M., Cambridge University Hospital Trust, Orthopaedics & Trauma, Addenbrooke’s Hospital, Hills Road, Cambridge, Cambs CB2 2QQ, England. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/12647/$36.00 http://dx.doi.org/10.1016/j.eats.2013.01.005
Surgical Technique Positioning and Equipment The procedure is performed with the patient under general anesthesia positioned supine. The patient’s head is placed in a head ring, and a small sandbag is placed between the scapulae to open up the SCJs anteriorly. The operating surgeon stands on the operative side of the patient facing toward the head end of the table where the arthroscopic stack is positioned. A 2.7-mm arthroscope with a 3-mm cannula and trocar is used for visualization with the fluid pressure pump at 30 mm Hg. A mini-probe and punch with a mini-shaver using a 3.5-mm incisor blade and bur (Dyonics Smith & Nephew, Andover, MA) are used for instrumentation. A micro-bipolar VAPR radiofrequency probe (DePuy Mitek, Raynham, MA) is used for hemostasis and tissue ablation. Portal Placement Anatomic Considerations. The greatest perceived concerns surrounding SCJ surgery are the close proximity of the posteriorly lying mediastinal structures and damage to the anterior stabilizing structures. The potential advantage of an arthroscopic procedure is that once the arthroscope and instruments have been introduced into the joint space, any intra-articular procedure can then be undertaken with the knowledge that the mediastinal structures lie safely behind the posterior capsule. A cardiothoracic surgeon was present for the first 3 cases that we undertook; since then, reassured by the previously mentioned factors and our experience, we have not required the presence of a cardiothoracic surgeon.
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e141-e145
e141
e142
G. TYTHERLEIGH-STRONG
Fig 1. Coronal computed tomography scan of the SCJs with superimposed inferior and superior portal positions (yellow X) on either side of the anterior SC ligament (red diamonds). One should note the relatively small area of bony congruence at the inferior part of the joint, making it the most suitable position to establish the initial portal.
The main factors taken into consideration when determining the most appropriate and safest position for portal placement are the anterior sternoclavicular (SC) ligament, the area of bony congruence in the coronal plane, and the angle of joint inclination in the axial plane. Two portals are required to undertake any therapeutic procedure. Placing 1 portal at the inferior point of the SCJ and the other at the level of the superior point of the medial end of the clavicle minimizes damage to the anterior SC ligament (Fig 1). The plane of the SCJ does not actually lie perpendicular to the mediastinum. We undertook a study of the computed tomography scans of 80 patients (160 SCJs) undergoing computed tomography scans of their chests and looked at the angle of inclination of the SCJ in 3 orthogonal planes. In the axial plane, we found that the medial end of the clavicle showed great variation but that the angle of inclination of the
Fig 2. Axial computed tomography scan of the SCJ showing the 30 angulation of the sternal articular surface in relation to the vertical axis. This indicates the angle at which the arthroscopic camera and instruments need to be inserted to run parallel to the medial side of the joint.
manubrium was consistent, at 60 to the transverse plane and 30 to the vertical plane (Fig 2).5 Technique. The sternal articular surface is shallow, and as a result, there is only a relatively small area of bony congruence with the inferior part of the medial clavicle when the shoulder girdle is in the lowered position (Fig 1). We choose to use an 18-gauge spinal needle inserted into the inferior part of the SCJ at an inclination of 30 , injecting normal saline solution to initially distend the joint. This serves to open up the joint inferiorly and to ascertain the correct position and angle at which to insert the trocar while also distending the superior part of the joint capsule (Fig 3). By use of a small skin stab incision over the inferior part of the SCJ, the cannula and trocar are carefully inserted at a 30 inclination. A definite “pop” can be felt as the anterior joint capsule is penetrated with a flashback of saline solution, confirming entry into the joint. Fig 3. (A) An 18-gauge spinal needle is inserted at the inferior part of the SCJ at an angle of 30 to the vertical plane. Normal saline solution is then infiltrated into the joint space with minimal resistance to confirm correct placement. (B) The arthroscopic cannula with a blunt trocar is inserted into the inferior joint space at an angle of 30 . The cannula often passes more than 20 mm before it penetrates the anterior capsule with a definite “pop.”
e143
ARTHROSCOPY OF STERNOCLAVICULAR JOINT Table 1. Tips and Pitfalls Preoperative imaging
Patient positioning Portal placement
Tips
Pitfalls
Magnetic resonance imaging scan: diagnostic arthroscopy Discectomy Postinfection debridement Computed tomography scan: SCJ excision Excision of loose bodies Supine with sandbag between scapulae Arthroscopic stack at head-end of table Inferior and superior anterior portals: establish inferior portal first 18-gauge spinal needle at 30 to vertical with normal saline solution infiltration Establishment of superior portal by inside-out technique
Head not sufficiently extended and anterior joint not opened up Spinal needle/instruments inserted too perpendicular Insufficient space between inferior and superior portals
Surprisingly, the cannula often needs to be inserted more than 30 mm. Having established an inferior viewing portal, we create a superior portal above the anterior SC ligament. The 18-gauge spinal needle is used in an outside-in technique to achieve this. A mini-probe and instruments can then be introduced. Table 1 lists some of the tips and pitfalls associated with arthroscopy of the SCJ. Diagnostic Arthroscopy The intra-articular disk in the normal SCJ is complete and divides the joint into a sternal and a clavicular side. However, the disk is commonly torn after trauma, after infection, and in the presence of degenerative joint disease. Of the 53 arthroscopies that we have undertaken, the disk has been complete in only 2 cases. When the disk is complete, the sternal and clavicular sides of the joint have to undergo arthroscopy separately. The most important structures to initially identify are the fibers of the posterior SC ligament within the posterior joint capsule. This confirms that the arthroscope is safely positioned within the joint. In the vast majority of joints, the disk has undergone a degenerative tear and has usually torn off of the superior and anterior capsule.
The superior edge of the torn disk is usually seen lying in the inferior part of the joint and can be probed (Fig 4). The articular surfaces are then visualized and assessed. As a general rule, the sternal articular surface is usually relatively well preserved in comparison with the medial end of the clavicle. Therapeutic Arthroscopy The first 2 arthroscopies that we undertook were simple diagnostic procedures in which we took small synovial biopsy samples with no complications. After this, we have gradually undertaken and refined a number of therapeutic procedures (Table 2). In the vast majority of patients, these have been undertaken as day-surgery procedures. Arthroscopic Discectomy. The SCJ disk is commonly damaged after trauma, and degenerative tears are often associated with SCJ arthritis. The SCJ disk has often been likened to the meniscus in the knee, in that tears may present with mechanical symptoms and be of a degenerative nature. After magnetic resonance imaging diagnosis, we have undertaken 9 arthroscopic SCJ discectomies (Figs 5 and 6, Video 1). Three were for acute tears in young patients in whom mechanical clicking and pain developed after an acute injury, and 6 were for degenerative tears with predominantly mechanical symptoms. At surgery, there is an obvious difference in disk tissue quality between the acute and chronic tears, akin to that found in acute and chronic meniscal tears at arthroscopy of the knee. In addition, degenerative changes at the medial end of the clavicle are present with degenerative tears. Table 2. SCJ Arthroscopic Procedures Undertaken to Date
Fig 4. Arthroscopic image of right SCJ. The mini-probe is on the superior edge of the torn disk and the relatively wellpreserved sternal articular cartilage is on the right, with the more degenerated clavicular cartilage on the left.
Procedure
No.
Diagnostic arthroscopy Arthroscopic meniscectomy Arthroscopic excision of loose bodies Arthroscopic joint debridement Arthroscopic SCJ excision
3 9 (3 acute and 6 degenerative) 2 9 30
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G. TYTHERLEIGH-STRONG
Fig 5. Magnetic resonance imaging scans (T2 short tau inversion recovery coronal views) of both SCJs showing a superior tear of the disk on the left side compared with the normal right side. The truncated appearance with edema outlining the disk is characteristic of a disk tear.
Postoperatively, the mechanical symptoms and pain had resolved in all of the patients with an acute disk tear and 4 with a degenerative tear at 6 months. Of the 2 patients with ongoing symptoms, 1 underwent an arthroscopic excision of the medial end of the clavicle with resolution of symptoms whereas the other chose to have no further treatment. Arthroscopic Excision of Loose Bodies. We have undertaken an arthroscopic excision of bony loose bodies from the SCJ in 2 patients (Fig 7). Both of the patients had presented with pain and an intermittent clicking after trauma. In 1 case the intra-articular disk was complete and the loose fragment was excised from the clavicular compartment. In the other case, the disk was damaged and we undertook an additional discectomy and removed the loose fragments. Postoperatively, the pain and clicking resolved in both cases. Arthroscopic Joint Debridement (After Infection). After septic arthritis of the SCJ, patients are often left with ongoing swelling, pain, and stiffness on movement. We have undertaken an arthroscopic debridement and excision of the disk remnant in 9 patients. In all of the cases, samples were sent for microbiologic testing but there was no organism in any. We did not resect any
bone or articular cartilage. Postoperatively, 5 patients noticed a significant improvement in pain and stiffness. The other 3 patients did not notice a significant benefit, but they believed that they were no worse off than before surgery. Arthroscopic Excision of SCJ. In the majority of patients with symptomatic degenerative arthritis of the SCJ, the symptoms usually settle with nonoperative management and time. However, in a few patients, significant symptoms can continue despite rest, antiinflammatory medication, and steroid injection. We have undertaken an arthroscopic excision of the SCJ in 30 patients who continued to have significant symptoms, predominantly pain, despite optimal nonoperative management. Our surgical technique evolved over the first 7 cases. In all of the procedures we excised the remnants of the intra-articular disk. In the earlier cases, we excised bone from both the sternal and clavicular sides of the joint. We then began to only resect varying amounts of the clavicle. From case 7 onward, we have aimed to remove sufficient bone to uniformly expose cancellous bone at the medial end of the clavicle. This has required between 5 and 10 mm of resection (Video 2). The postoperative results of the first 5 SCJ excisions were initially good, but in 2 of the patients a recurrence
Fig 6. Arthroscopic image of left SCJ. (A) Micro-punch resecting torn disk. (B) The disk has been resected, and the probe touching the posterior capsule can be seen. One should note the relative preservation of the sternal articular cartilage on the left side.
e145
ARTHROSCOPY OF STERNOCLAVICULAR JOINT
Fig 7. Computed tomography scan of a 19-year-old man with a loose fragment present on the right side.
of pain developed after 6 months, particularly over the sternal side of the joint. Since our establishment of a standard technique of excising the medial end of the clavicle, all of the patients have reported good symptomatic relief, which so far seems to have been sustained. We have undertaken a prospective study of 10 of the patients with a mean of 2.4 years of follow-up. At final follow-up, 7 reported an excellent result, 2 reported a good result, and 1 reported a fair result according to Rockwood’s SCJ scoring system.6 Postoperative Protocol At the end of each procedure, we close the wounds with No. 3-0 Prolene subcuticular sutures (Ethicon, Somerville, NJ). We usually infiltrate the area with 10 mL of 0.25% bupivacaine, and more recently, we have been trying to perform a selective cervical plexus block. We do not immobilize the patients’ arms, and we encourage free movement. SCJ arthroscopy is usually a day-case procedure. So far, we have had no complications after arthroscopy of the SCJ and particularly no evidence of joint instability. The portal incision scars are relatively small, and patients seem to be happy with the cosmetic outcome.
Discussion Open surgery for intra-articular SCJ pathology is relatively rare. Only a few series have been reported on
SCJ excision and fewer on intra-articular disk excision. In all of these, the patients have had a relatively protracted recovery and have often required sling immobilization. Problems with instability and cosmesis have been reported. As a result, despite improved imaging modalities (magnetic resonance imaging and computed tomography) leading to a better understanding and diagnosis of SCJ disorders, there remains a reluctance to proceed with surgery. Arthroscopy of the SCJ and the early results described in this initial series are encouraging, and arthroscopy appears to be a safe and reproducible procedure. As a result, it may lead to a decrease in the threshold to undertake SCJ surgery. Although this is not a technique for the occasional arthroscopist, it should be well within the realms of the experienced shoulder and elbow arthroscopic surgeon. However, it is understandably quite disconcerting to insert the trocar into the SCJ for the first time for both the surgeon and the anesthetist, and it may be wise, if not just for peace of mind, to initially have cardiothoracic support available. There is a learning curve to placing the arthroscope into the joint, obtaining adequate visualization, and then undertaking a therapeutic procedure. As a result of this and because of the relative rarity of SCJ intra-articular pathology, it is probable that, in reality, only surgeons in larger referral units with a sufficient volume of cases are likely to perform the described procedure.
References 1. Lunseth PA, Chapman KW, Frankel VH. Surgical treatment of chronic dislocation of the sterno-clavicular joint. J Bone Joint Surg Br 1975;57:193-196. 2. Pierce R. Internal derangement of the sternoclavicular joint. Clin Orthop Relat Res 1979:247-250. 3. Tavakkolizadeh A, Hales PF. Arthroscopic excision of sternoclavicular joint. Knee Surg Sports Traumatol Arthrosc 2009;17:405-408. 4. Tytherleigh-Strong GM, Getgood AM, Griffiths DE. Arthroscopic intra-articular disk excision of the sternoclavicular joint. Am J Sports Med 2012;40:1172-1175. 5. Wijeratna MD, Turmezei TD, Tytherleigh-Strong G. The relevant anatomy of the sternoclavicular joint in relation to arthroscopic surgical approaches. Skeletal Radiol 2013;42: 473-478. 6. Rockwood CA, Groh GI, Worth MA, Grassi FA. Resection arthroplasty of the sternoclavicular joint. J Bone Joint Surg Am 1997;79:387-393.