Sternoclavicular Joint Reconstruction Using a Hamstring and Cadaveric Fibular Cortical Allograft

Abstract

Case:

A 49-year-old woman with sternoclavicular insufficiency following medial clavicle resection underwent sternoclavicular joint reconstruction using a hamstring allograft and a cadaveric fibular cortical allograft. After 4 months of follow-up, the patient was pain-free, with radiographic evidence of graft incorporation by 8 months.

Conclusion:

Medial clavicle resection is a rare procedure with broad indications. The necessity and optimal technique for subsequent sternoclavicular reconstruction remain debated. We demonstrate a figure-of-eight reconstructive technique that may provide acceptable clinical results when addressing large medial clavicle defects.

Level of Evidence:

IV.

Medial clavicle resection is a rare procedure with a wide range of indications including instability of the sternoclavicular joint (SCJ), arthritis, osteomyelitis, tumors, nonunion fractures, thoracic outlet syndrome (TOS), and for emergency access to the aorta^1-4. Given the rarity of this procedure, few studies have explored postoperative outcomes.

The benefits of reconstruction following medial clavicle resection are debated, as well as the preferred technique to do so^3,5-7. Some argue that reconstruction is imperative to prevent shoulder instability, abnormal scapular motion, weakness, pain, and damage to the great vessels beneath. Others argue that the technical demands of reconstruction, slower recovery process, and potentially higher rate of postoperative complications, such as infection, prosthesis loosening, and pain, are contraindicating^2,8,9. Various reconstruction techniques have been described including graft figure-of-eight reconstruction, intramedullary graft reconstruction, synthetic reconstruction using suture, and tenodesis using the sternocleidomastoid or subclavius.^3,5,6

In this report, we present a case of a large medial clavicle resection following symptomatic SCJ insufficiency and outline the figure-of-eight surgical technique used to reconstruct the SCJ with a hamstring allograft and a cadaveric fibular cortical allograft.

The patient was informed that data concerning the case would be submitted for publication, and she provided consent.

Case Report

History and Physical Examination

An active 49-year-old, right-hand–dominant woman with a medical history of Graves disease and migraine headaches presented with right upper extremity pain and dysfunction. Four months ago, the patient underwent a 4-cm resection of her right medial clavicle due to an enlarging benign growth with no abnormal pathology results at an outside institution. The postoperative course was complicated by an infected hematoma requiring irrigation and debridement.

Following these procedures, the patient experienced lifestyle-limiting pain radiating from her medial chest wall to her right axilla and down her arm on lifting and reaching, as well as associated numbness, tingling, and extreme tenderness to palpation over the soft tissue defect. The patient recorded an American Shoulder and Elbow Surgeons score of 21.7/100.0 and a VAS of 10/10. In addition, the patient denied difficulties before her index medial clavicle resection.

On physical examination, the right clavicle was hypermobile with painful instability of the medial clavicle stump. An equivocal Roos test was demonstrated. There was medial winging of the scapula and scapular dyskinesis bilaterally. With active range of motion, lateral winging of the scapula was demonstrated on the patient’s affected side. Despite pain and dysfunction, the patient exhibited 5/5 strength with resisted adducted external and internal rotation. On radiograph, a medial clavicle resection with no apparent acute fracture, dislocation, or degenerative joint disease of the shoulder was evident (Fig. 1).

Fig. 1.

Preoperative anterior-posterior (Fig. 1-A) and modified anterior-posterior (Fig. 1-B) views demonstrating a partial right medial clavicle resection with no apparent acute fracture, dislocation, or degenerative joint disease.

Owing to the constellation of symptoms, the patient was referred to vascular surgery for concern of TOS. A computed tomography angiography of the chest demonstrated no static TOS compression. However, vascular surgery had a high clinical suspicion that SCJ insufficiency was a source of dynamic thoracic outlet compression causing neurogenic TOS-like symptoms. Consequently, SCJ reconstruction was recommended in combination with a revision thoracic outlet procedure performed by vascular surgery.

Surgical Technique

The patient was positioned supine on a radiolucent table. General anesthesia was induced, IV antibiotics were administered, and compression devices were applied to the lower extremities. An incision was made centered over the defect, anterior to the anterior border of the clavicle, to generate skin flaps down to the muscular fascia in a full-thickness manner. Next, the periosteum was elevated off the residual end of the native clavicle. Then, the medial clavicle defect was measured. A cortical fibular allograft that was 12 mm longer than the defect was selected to allow for the addition of a 2-cm step-cut notch and 8 mm of space between the graft and the manubrium to avoid overstuffing the joint. Next, the 2-cm step cuts were made along the superior half of the native clavicle and the inferior half of the cortical allograft (Fig. 2) using a posteriorly positioned malleable retractor to protect the great vessels, and a 2.7-mm plate (Depuy-Synthes) was applied for fixation of the native and allograft bone ends under fluoroscopic guidance to confirm the position (Fig. 3-A).

Fig. 2.

Step-cut technique used to fashion the NC and the CA together. CA = cortical allograft, and NC = native clavicle.

Fig. 3.

Intraoperative images. Structural fibular cortical graft fashioned to the native clavicle using a 2.7-mm contoured combination plate with 9 holes (Depuy-Synthes) (Fig. 3-A). Fluoroscopic images demonstrating a well-fixed construct with good overall alignment (Figs. 3-B and C).

We then proceeded with the SCJ reconstruction. Two 4-mm holes were drilled into the distal end of the cortical allograft and the native manubrium. The hamstring graft was augmented using #2 FiberWire (Arthrex) and prepared with a FiberLoop (Arthrex) at both ends in a whipstitch fashion. Then, the graft was passed through the drill holes in a figure-of-eight fashion and tied down over the top. Intraoperative fluoroscopic images demonstrated the ideal alignment, reconstruction, and reduction of the SCJ (Figs. 3-B and 3-C). The SCJ was stable on intraoperative stressing.

Following the SCJ reconstruction, vascular surgery performed a right anterior scalenectomy and brachial plexus neurolysis. The SCJ reconstruction and revision TOS surgery were well tolerated by the patient with no immediate postoperative complications.

Postoperative Protocol

Postoperatively, the patient was immobilized in a sling and non–weight-bearing for 6 weeks (Table I). Pendulum exercises, as well as hand, wrist, and elbow range of motion (ROM) exercises were initiated to prevent the stiffness. Weight-bearing was progressed to a 3-lb to 5-lb lifting restriction at 6 weeks, followed by ROM as tolerated by 4 months while avoiding high impact activities. At 8 months, all restrictions were lifted.

Table I.

Postoperative Protocol

Timing	Protocol
Postoperatively	Sling, non–weight-bearing. pendulums, and ROM exercises
6 weeks	3-lb to 5-lb lifting restriction
4 months	Avoid high impact activities; ROM as tolerated
8 months	Weight-bearing and lifting restrictions waived

ROM = range of motion.

Postoperative Course

At 6 weeks postoperative follow-up, radiograph demonstrated no interval displacement with any hardware loosening, breakage, or subsidence (Fig. 4-A). By 4 months, the patient reported being pain-free and off all narcotics. Range of motion was 160 degrees of active forward flexion, 50 degrees of adducted external rotation, internal rotation to the thoracolumbar junction, and strength was 5/5 with resisted adducted external rotation, internal rotation, and in Jobe position. No crepitus was observed at the medial clavicle or SCJ, and all anatomy moved as a unit. Radiographs had not yet shown definitive incorporation of the lateral graft interface (Fig. 4-B). By 8 months, the patient had resumed pain-free labor intensive outdoor leisure activities. Radiographs showed evidence of incorporation of the graft despite faint radiolucent lines between the patient’s native bone and the graft (Fig. 4-C). At 14 months, the patient had resumed all activities of daily living. Imaging revealed the absence of significant graft resorption with only slight radiolucency at the inferior part of the graft (Fig. 4-D). At 4 years postoperative follow-up, the patient maintained a pain-free, active outdoor lifestyle with an American Shoulder and Elbow Surgeons score of 93.3/100.0 and a VAS of 1/10.

Fig. 4.

Postoperative AP views of the right clavicle. At 6-week postoperative follow-up, no interval displacement with no hardware loosening, breakage, or subsidence (Fig. 4-A); at 4 months, no definitive incorporation of the lateral graft interface (Fig. 4-B); at 8 months, evidence of graft incorporation with a faint radiolucent line between the patient's native bone and the graft (Fig. 4-C); at 14 months, continued graft incorporation (Fig. 4-D). AP = anterior-posterior.

Discussion

Medial clavicle resection is a rare procedure with a wide range of indications including SCJ instability, arthritis, infection, tumors, nonunion fractures, and TOS^1-3. To achieve a favorable outcome, preserving the costoclavicular ligament (CCL) is imperative and requires an understanding of the anatomical positioning of the clavicle in relation to the first rib^3,6. To avoid compromising the CCL, limiting medial clavicle resection to less than 10 mm has been recommended in studies for SCJ osteoarthritis without instability^10-12. Importantly, in cases of joint instability, as in this case report, medial clavicle resection alone has been cautioned against due to more favorable clinical outcomes observed with subsequent SCJ reconstruction, as demonstrated in a case series by Eskola et al.¹³

Many SCJ reconstruction techniques have been presented in the literature such as graft figure-of-eight reconstruction, intramedullary graft reconstruction, synthetic reconstruction using suture, and tenodesis using the sternocleidomastoid or subclavius^3,5,6. While small sample sizes limit the external validity of many of these studies, the figure-of-eight reconstructive technique has gained recent popularity after Spencer and Kuhn demonstrated its superiority over intramedullary ligament reconstruction and subclavius tendon reconstruction in a biomechanical study^5-7. Similar to our reconstruction, Stahel et al. used a figure-of-eight technique with a semitendinosus allograft to treat post-traumatic SCJ arthritis related to chronic ligamentous instability, and Kawaguchi et al. used the technique with a gracilis tendon autograft to manage symptomatic SCJ instability, both with acceptable outcomes.^14,15

In this report, we used an allograft hamstring tendon fashioned in a figure-of-eight technique to reconstruct the SCJ with a fibular cortical allograft to fill a large medial clavicle defect for chronic pain, dysfunction, and instability. During the procedure, important steps to be cognizant of includes protecting the great vessels with a posteriorly positioned malleable retractor during the manubrium dissection, using a protective guide pin when drilling the manubrium to protect the retrosternal structures, and leaving space between the graft and manubrium. Areas that could potentially negatively affect outcomes include overstuffing the SCJ with an oversized graft and failed incorporation of the cortical graft. A detailed overview of the pearls and pitfalls with the figure-of-eight reconstruction technique is presented in Table II. The patient overall had excellent functional and pain outcomes at the latest follow-up of 4 years. This may be a viable, long-term reconstructive option when dealing with large medial clavicle defects with SCJ instability, pain, and dysfunction.

Table II.

Pearls and Pitfalls of the Figure-of-Eight SCJ Reconstruction Technique for a Large Medial Clavicle Defect

Pearls
Vascular surgery on call to perform a revision thoracic outlet procedure or repair damaged retrosternal structures
Careful dissection around the manubrium using a malleable retractor positioned posteriorly to protect the great vessels
Use of a protective guide pin when drilling holes in the manubrium to protect the retrosternal structures
Step-notch cut technique to interlock the graft with the native clavicle
Leave space between the graft and the manubrium to avoid overstuffing the SCJ
Augmentation of the hamstring graft to prevent loosening over time
Figure-of-eight technique to adequately secure the graft to the manubrium

Pitfalls
Failure to include vascular surgery in case of damaged retrosternal structures
Failure to protect the retrosternal space when drilling holes in the manubrium
Overstuffing the SCJ with an oversized graft
Potential resorption or failed incorporation of the graft

SCJ = sternoclavicular joint.