Abstract
Bipolar “floating” clavicle injuries are infrequent upper-extremity injuries that occur secondary to a high-energy trauma, which can cause dislocation at the sternoclavicular (SC) and acromioclavicular joints. Given the rarity of this injury, there is not a consensus regarding clinical management. Although anterior dislocations can be managed nonoperatively, posterior dislocations may pose a threat to chest-wall structures and typically are managed surgically. Here, we present our preferred technique for concomitant management of a locked posterior SC joint dislocation with associated grade 3 acromioclavicular joint dislocation. Reconstruction of both ends of the clavicle was performed in this case, using a figure-of-8 gracilis allograft and nonabsorbable suture reconstruction for the SC joint, and an anatomic acromioclavicular joint and coracoclavicular ligament reconstruction with semitendinosus allograft and nonabsorbable suture.
Technique Video
Here, we demonstrate our technique for anatomic combined SC and AC joint reconstruction. The SC joint is addressed first and reconstructed with a gracilis allograft and nonabsorbable suture in a figure-of-8 configuration. Anatomic reconstruction of the AC joint and coracoclavicular ligaments is then performed with a semitendinosus allograft, nonabsorbable suture, and cerclage suture construct using bone tunnels and interference screw fixation of the graft. (AC, acromioclavicular; SC, sternoclavicular.)
Ipsilateral acromioclavicular (AC) and sternoclavicular (SC) joint dislocations are a rare injury indicative of high-energy trauma. This unique pattern of injury was first described by Porral in 1831.1 Since the initial description of this injury, multiple terms have been used to characterize this injury, including bifocal clavicular dislocation, bipolar dislocation, panclavicular dislocation, and floating clavicle.2, 3, 4 AC-joint injuries are well described, as classified by Rockwood's modification on the works of Allman and Tossy.5 These injuries result in horizontal and/or vertical instability of the distal clavicle dependent upon the pattern of injury. SC-joint dislocations typically are classified as either anterior or posterior in nature. A variant of this exists in skeletally immature patients in whom the dislocation occurs in the form of a fracture though the medial physis of the clavicle.6,7 Although rare, the most common combined injury pattern in bipolar clavicle injuries involves an anteriorly dislocated SC joint with a type III or IV AC-joint dislocation. According to a recent review of the orthopaedic literature, there are only 3 described cases of bipolar clavicle dislocation involving a posterior SC joint dislocation.8
Given the paucity of literature, the ideal management of the panclavicular dislocation is undefined, with reports of treatments ranging from complete claviculectomy to conservative management.2,3 Even less defined is the management of a bipolar clavicle dislocation involving a posteriorly dislocated SC joint. In isolation, SC joint dislocations account for 3% of all dislocations around the shoulder, with 90% of those being anterior SC joint dislocations.9 Surgery is often indicated for patients with persistent anterior instability or for patients with posterior dislocations, given the proximity to mediastinal structures. Due to the unstable nature of a combined injury, as well as the large number of forces placed on both the SC and AC joints, the senior author advocates for fixation of both ends of the clavicle, if surgery is to be performed, to better stabilize both ends of the clavicle.
Surgical Technique (With Video Illustration)
Patient Evaluation
Ipsilateral dislocations at the SC and AC joints are rare injuries that are most commonly seen following high-energy trauma. Patients may present with associated chest-wall injuries (Fig 1A). Patients should be evaluated in standard Advanced Trauma Life Support fashion per institutional protocol. Some patients may complain of fullness or prominence of the anterior aspect of the chest, whereas other patients may present with a feeling of instability around the clavicle. These complaints may present in a delayed fashion if the patient has distracting injuries associated with the high-energy mechanism of injury.
Fig 1.
Initial presentation imaging demonstrating a left acromioclavicular joint dislocation (A) and subluxation of the left sternoclavicular joint (B) that was initially not noted.
Imaging
A computed tomography (CT) scan of the chest, which is commonly performed as part of the trauma workup for blunt chest trauma, provides for an assessment of the SC and AC joints. However, in some instances, the initial evaluation may demonstrate reduced left SC joint (Fig 1B). A dynamic CT scan can be performed to evaluate the position of the SC joint with the patient’s arms abducted away from the body and at their side. In this instance, a repeat CT scan of the chest revealed a fixed posteroinferior SC joint dislocation (Fig 2).
Fig 2.
A preoperative computed tomography scan of the chest, axial cut, demonstrating a fixed posterior left sternoclavicular joint dislocation (white arrow). This was obtained at follow-up.
Indications
Surgical intervention should be considered in patients with persistent anterior instability or those with posterior dislocations. Currently, there is not a consensus regarding the optimal treatment of this condition. For this type of injury, the senior author’s preference is to proceed with open reduction internal fixation of the SC joint with gracilis allograft tendon reconstruction and AC and coracoclavicular joint reconstruction with semitendinosus allograft in conjunction with our cardiothoracic surgery team.
Patient Positioning
Following induction of general anesthesia, the patient is positioned in a relaxed beach-chair position on the operative table. Wide draping is performed to access to the entire midline and shoulder joint (Fig 3). The SC joint is approached first with the patient sat up approximately 30°.
Fig 3.
Intraoperative image demonstrating patient positioning with wide draping of the chest in a lazy beach-chair position.
SC Joint Reconstruction
The surgical technique is shown in Video 1. An L-shaped incision is made over the medial aspect of the clavicle heading inferiorly down the sternum. Sharp dissection is carried out, and the sternal insertions of the sternocleidomastoid muscle are detached from the manubrium and the pectoral muscle is dissected off the manubrium and the medial clavicle. Any fibrinous scar tissue and callus present is debrided, and the posterior displaced clavicular head is identified. The distal 3 cm of the medial clavicle is dissected to allow mobilization of the clavicle and sternum and a trial reduction is performed with a penetrating towel clamp. The gracilis allograft is opened on the back table, and both ends are whipstitched and sized for a 4-mm hole with suture of the surgeon’s choice.
Two 4-mm holes are drilled from anterior to posterior through the clavicle using the malleable retractor for protection. The drill holes are approximately 1-1/2 cm away from the end of the medial clavicle and are evenly spaced apart superiorly and inferiorly. Passing sutures are placed through the drill holes. Two 4-mm drill holes are also drilled from anterior to posterior on the sternum and passing stitches are placed. The graft and a nonabsorbable suture (#2 FiberTape; Arthrex, Naples, FL) are shuttled together first through the superior drill hole in the sternum from anterior to posterior and through the superior clavicle drill hole from posterior to anterior. The leading limb is then passed in the inferior sternal hole from anterior to posterior and lastly through the inferior end of the clavicle from posterior to anterior creating a figure-of-8 configuration, which can then be crossed back to the initial superior hole on the sternum (Fig 4). The joint is held reduced, and the nonabsorbable suture is tied, effectively reducing the joint. The allograft is then crossed with its to free limbs and held tight while a running nonabsorbable suture is applied to hold the graft in place. The FiberTape is then brought over the graft and tied down once more to secure this in a pants-over-vest fashion (Fig 5). The arm is brought through full range of motion to assess stability of the SC joint. The wound is copiously irrigated and closed in a layered fashion.
Fig 4.
Intraoperative photograph demonstrating the final sternoclavicular joint reconstruction construct.
Fig 5.
Rendering of final figure-of-8 allograft and nonabsorbable suture construct.
AC Joint Reconstruction
The patient is then sat up in the beach chair to 60°. A strap incision is made centered over the coracoid and AC joint superiorly. Dissection is carried out medially over the clavicle and laterally over the AC joint, exposing the acromion. Full-thickness flaps are raised, elevating the deltoid anteriorly and trapezoid posteriorly. Anteriorly subperiosteal dissection occurs for identification and passage beneath the coracoid.
On the back table, a semitendinosus allograft is whipstitched at both ends and sized to pass through a 5-mm tunnel. Two drill tunnels are made in the lateral aspect of the acromion and passing sutures are placed within these holes for later reconstruction of the AC joint capsule. The distal 1 cm of distal clavicle is then resected with an oscillating saw and a trial reduction is performed. For anatomic reconstruction, 2 drill holes are created in the clavicle. A guide pin is placed 4.5 cm medial to the AC joint for the conoid ligament footprint and over-reamed with a 5.0-mm reamer. Approximately 1.5 cm lateral to this the trapezoid ligament footprint is drilled in a similar fashion. Passing stitches are placed through both drill holes.
The graft, a self-tensioning cerclage stitch (Arthrex), and a #2 FiberTape (Arthrex) are shuttled beneath the coracoid. The surgeons’ preference is to use a medium Satinsky vascular clamp for passage beneath the coracoid. The cerclage stitch is then passed anterior and posterior to the clavicle between the 2 drill tunnels for the coracoclavicular ligament reconstruction. The cerclage suture is loaded upon itself and provisionally tensioned to confer a provisional reduction of the AC joint. The limbs of the semitendinosus graft are then crossed and the medial conoid component is passed through the drill hole with a limb of FiberTape. This is fixated with a 5.5 × 8-mm Bio-Tenodesis screw (Arthrex). The limb of tape is loaded and passed through the tenodesis screw, and the screw fixates the graft. Counter tension is held on the graft and tape while the assistant pushes up on the elbow. The trapezoid component of the graft and tape are then passed. Once more, the FiberTape is passed through the 5.5 × 8-mm Bio-Tenodesis screw and counter tension is held on the graft and is fixed in place. The 2 limbs of the FiberTape are then tied for additional fixation. The 2 residual limbs of the semitendinosus graft are also then tied to each other to reinforce the coracoclavicular ligament reconstruction over the top of the clavicle. There should be excess graft of approximately 2 cm, which is whipstitched and then shuttled through the previously drilled holes in the acromion and tied over a bony bridge to complete the AC-joint reconstruction component of the procedure (Figs 6 and 7). The arm is taken through a full range of motion and fluoroscopy should confirm the reduction. The wound is copiously irrigated and closed in a layered fashion. The pearls and pitfalls of the described technique are summarized in Table 1, whereas the advantages and limitations are summarized in Table 2.
Fig 6.
Intraoperative photograph demonstrating the final acromioclavicular joint reconstruction repair construct.
Fig 7.
Rendering of final construct for combined coracoclavicular ligament and acromioclavicular-joint reconstruction.
Table 1.
Pearls and Pitfalls of Surgical Management of the Floating Clavicle
| Pearls | Pitfalls |
|---|---|
| Consider recruiting cardiothoracic surgery for assistance with the SC joint portion of the case, given the proximity of the associated neurovascular structures. | Failure to adequately protect the mediastinal structures while drilling for the SC joint reconstruction. |
| Wide draping of the extremity provides for the ability to perform both reconstructions without the need for tearing down the operative field. | Inadequate spacing of the drill holes for the SC-joint reconstruction may lead to iatrogenic fracture. |
| Ligamentous biologic reconstruction using a figure-of-8 configuration demonstrates robust time zero biomechanical strength. | Fixation techniques using orthopaedic hardware are associated with complications such as implant migration, prominence, and secondary reoperation. |
SC, sternoclavicular.
Table 2.
Advantages and Disadvantages of the Described Techniques
| Advantages | Disadvantages |
|---|---|
| Reconstruction of both the SC and AC joints serves to add further protection to each repair construct. | Possible foreign body reaction to the soft-tissue graft. |
| Avoidance of orthopaedic implants associated with complications. | Surgical management of the SC joint requires cardiothoracic surgery support, which is not available in some centers. |
| Soft-tissue figure-of-8 technique offers good early biomechanical strength. | Concerns related to cost and availability of soft tissue grafts. |
| Suture tape reinforcement of the repairs convey additional strength. | |
| The AC-joint reconstruction produces an anatomic repair construct. |
AC, acromioclavicular; SC, sternoclavicular.
Rehabilitation
Following the surgical procedure, the patient is seen postoperatively at the following intervals: 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The patient is initially immobilized in a sling with abduction pillow and is to remain non–weight-bearing for 6 weeks postoperatively. Physical therapy is initiated after the 6-week visit, with a focus on passive and active range of motion exercises. At the 3-month follow-up visit, the patient will be allowed to start strengthening exercises, with the goal of return to activities by the 6-month follow-up visit.
Discussion
Ipsilateral concomitant SC-joint and AC-joint dislocations are extremely rare injuries that occur secondary to high-energy trauma. In isolation, SC-joint dislocations account for 3% of all dislocations around the shoulder, with 90% of those being anterior SC-joint dislocations.9 Surgery often is indicated for patients with persistent anterior instability or for patients with posterior dislocations, given the proximity to mediastinal structures. AC-joint dislocations occur more frequently, accounting for 10% of all shoulder injuries.10 Operative indications include Rockwood type 3-5 injuries. There are a multitude of techniques that have been described for isolated AC- or SC-joint dislocations. However, when evaluating these injuries in concert, there are a limited number of case reports describing this injury pattern and there are even fewer descriptions of surgical techniques to manage this injury.
Operative intervention on the SC joint typically is reserved for symptomatic posterior dislocations with a failed closed reduction or those subacute in presentation.11 Surgical techniques include medial clavicle resection, open reduction and internal fixation with plates and screws, or ligamentous repair and reconstruction using various soft-tissue grafts.12, 13, 14, 15, 16 Techniques using orthopaedic hardware are associated with complications like implant loosening and the need for a secondary hardware procedure.17,18 Ligamentous reconstruction using a figure-of-8 configuration demonstrates robust biomechanical strength without the aforementioned concerns.19 As a result, the senior author opted to proceed with a SC-joint reconstruction using a soft-tissue graft in a figure-of-8 arrangement with suture tape augmentation.
Numerous techniques have been described for reconstruction of the AC joint. Early techniques used cerclage wires, hook plates, or lag screws, and they were associated with complications including hardware migration, fracture, loss of reduction, and hardware failure.20 In this patient, we opted for an open anatomic AC-joint reconstruction with cerclage reinforcement. Using this technique provided the opportunity to obtain fixation of the AC joint under a specified amount of tension and replicate the coracoclavicular ligaments while minimizing the risk of coracoid fracture associated with some other techniques that involve drilling through the coracoid.
Although ipsilateral concomitant AC and SC injuries are rare, there are various techniques that have been described for the management of this tandem injury, with no recognized gold standard.21,22 Early surgical treatment is recommended for this injury pattern, given the high degree of instability associated with it, especially in the setting of shortness of breath or other cardiopulmonary symptoms. Biologic soft-tissue reconstruction techniques, such as those described in the present chronicle, offer robust time zero strength and a diminished complication profile.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: S.D. reports grants from Arthrex and payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events from DJ Orthopaedics. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Here, we demonstrate our technique for anatomic combined SC and AC joint reconstruction. The SC joint is addressed first and reconstructed with a gracilis allograft and nonabsorbable suture in a figure-of-8 configuration. Anatomic reconstruction of the AC joint and coracoclavicular ligaments is then performed with a semitendinosus allograft, nonabsorbable suture, and cerclage suture construct using bone tunnels and interference screw fixation of the graft. (AC, acromioclavicular; SC, sternoclavicular.)
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Associated Data
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Supplementary Materials
Here, we demonstrate our technique for anatomic combined SC and AC joint reconstruction. The SC joint is addressed first and reconstructed with a gracilis allograft and nonabsorbable suture in a figure-of-8 configuration. Anatomic reconstruction of the AC joint and coracoclavicular ligaments is then performed with a semitendinosus allograft, nonabsorbable suture, and cerclage suture construct using bone tunnels and interference screw fixation of the graft. (AC, acromioclavicular; SC, sternoclavicular.)
Here, we demonstrate our technique for anatomic combined SC and AC joint reconstruction. The SC joint is addressed first and reconstructed with a gracilis allograft and nonabsorbable suture in a figure-of-8 configuration. Anatomic reconstruction of the AC joint and coracoclavicular ligaments is then performed with a semitendinosus allograft, nonabsorbable suture, and cerclage suture construct using bone tunnels and interference screw fixation of the graft. (AC, acromioclavicular; SC, sternoclavicular.)