Open sternoclavicular osteophyte debridement in the surgical management of sternoclavicular osteoarthritis: clinical outcome of a new procedure

Abstract

Introduction

Symptomatic sternoclavicular osteoarthritis is uncommon but remains the most frequent non-traumatic condition affecting the sternoclavicular joint and tends to have a predilection for middle-aged women. It responds well to conservative management. Surgery is indicated when conservative management fails. We present the clinical outcome of open symptomatic sternoclavicular osteophyte debridement, a new operation for treating recalcitrant symptomatic sternoclavicular osteoarthritis.

Methods

Five patients (five symptomatic sternoclavicular joints) with symptomatic sternoclavicular osteoarthritis underwent open sternoclavicular debridement following failure of conservative treatment. There were three females and two males. Mean age was 46.6 years (range 37.17–66). Four cases were primary osteoarthritis and one case was secondary to trauma. They were reviewed at mean follow-up at 35.4 months with minimum follow-up of 29 months. Assessment included Quick Disabilities of Arm Shoulder and Hand (DASH) and subjective patient satisfaction score.

Results

There was no post-operative complication. Mean Quick DASH score 10.9 (range 0–29.5) at mean 35.4-month follow-up (range 29–43 months). Three patients reported excellent and two reported good outcome as per subjective satisfaction score.

Conclusions

Open sternoclavicular debridement has proved to be a simple, safe and highly effective new surgical treatment for patients with symptomatic sternoclavicular osteoarthritis unresponsive to non-operative management.

Introduction

Symptomatic sternoclavicular (SC) osteoarthritis is uncommon^1,2 but remains the most frequent non-traumatic condition affecting the sternoclavicular joint. ³ It tends to affect middle-aged women^4,5 and has been documented to respond well to conservative management with rest, nonsteroidal anti-inflammatory drugs, physiotherapy and steroid injection.^6–9 Surgery is indicated in a minority of cases that fail to respond to conservative management.

Literature on surgical management of sternoclavicular osteoarthritis is sparse with most studies consisting of case reports and small case series describing open excision of the medial end of the clavicle of variable length and with or without soft tissue interposition.^4,5,10–13 Results are inconsistent, with some series describing suboptimal outcomes^4,11 and others reporting satisfactory results.^5,10,12,13

The main concerns regarding open excision of the medial end of the clavicle include the instability that can result particularly when stabilizing ligaments are compromised, ¹³ the exposure of the osteotomized soft clavicular bone end to weightbearing load, excision of the articular disc which may have a dual load bearing and joint stabilizing function.^14,15 Finally, the proximity of great vessels to the posterior sternoclavicular joint, with the potential for catastrophic bleeding^16,17 if damaged has likely discouraged surgeons from more frequent surgical intervention when indicated.

Recently, arthroscopic sternoclavicular excision has been described^18–20 that appears to hold some promise due to the minimal access it offers. However, it is a potentially difficult procedure in the tight space of a narrow undulating saddle shaped bicompartmental joint separated by a tough articular disc.^14,15 The disc therefore has to be sacrificed in order to obtain adequate visualization. Furthermore, SC arthroscopy does not necessarily preclude the risk of neurovascular injury or joint instability. A cadaveric study by van Tongel et al. ¹⁶ showed that breach of the posterior capsule by instruments in the trajectory of arthroscopic portals will invariably result in injury to the great mediastinal vessels 88–100% of the time. Only three papers are available^18–20 with outcome data on this arthroscopic technique with two of them being case reports^18,19 and one a small case series. ²⁰ The authors of the case series recommend that due to the low numbers of cases requiring SC surgery for arthritis and the potential risk of significant complications, arthroscopic SC joint excision should only be undertaken by surgeons experienced in this procedure. ²⁰

We present a new procedure involving open sternoclavicular osteophyte debridement in five consecutive cases with sternoclavicular osteoarthritis, including a technical note on the new operation and present the clinical result of our cohort of patients at a mean of 35.4 months follow-up.

Method

The senior author (SF) introduced a new operative procedure involving the open debridement of sternoclavicular periarticular osteophytes in the management of cases of SC osteoarthritis unresponsive to conservative treatment. The premise of this procedure was that the periarticular osteophytes were likely to be significant contributors to the pain due to the stretching and impingement on the unyielding periarticular capsule and soft tissues. Furthermore, the medial end of the clavicle is covered only in its anteroinferior third/half by articular cartilage, ¹⁵ with this area being the commonest location for periarticular osteophytes. ²¹ It is therefore only this area that needs to be addressed with no need to sacrifice the whole segment of medial clavicular bone with the adverse consequences for joint stability inherent in such excision. ¹³ In addition, excision of the medial end of the clavicle may result in the exposure of osteotomized soft clavicle bone end to weight bearing load which may contribute to post-operative failure. There is evidence that regrowth of the medial clavicle can occur following medial clavicle excision and was responsible for poor results in some series.^11,21 The articular disc is carefully inspected but not excised in this procedure unless it was noted to be torn, as we believe that its retention potentially preserves its weightbearing and joint stabilizing function.^14,15 The posterior capsule is not disturbed during this procedure with no risk of injury to the great vessels^16,17 Thus, this removes a major concern that may have hindered surgeons from performing surgery on this joint for symptomatic osteoarthritis in the past.

We reviewed the clinical result of five sternoclavicular joints in five consecutive patients who underwent open osteophyte debridement for SC joint osteoarthritis.

The study was approved by the Research and Ethics committee, Royal Liverpool and Broadgreen University Hospitals, UK (Study number: TA2278).

From 2015 to date, we performed open osteophyte debridement in five SC joints in five patients with SC joint osteoarthritis. All patients were included in the study. The indication for surgery in every case was persistent pain following adequate (6–12 months) non-operative management. Each patient underwent full clinical assessment.

A full informed written consent was obtained in every patient and in the two patients whose anonymized computed tomography (CT) and magnetic resonance imaging (MRI) scans were used for illustration their verbal consent was obtained. There was no history of trauma in four patients with one case following trauma. There was no history of head/neck surgery for malignancy, none had inflammatory or infective arthritis. In one patient, psoriatic arthritis was suspected as he also suffered with polyarthralgia but this was ruled out following rheumatology consult. Radiography, CT scan and biopsy did not confirm inflammatory arthritis. In another patient, osteitis condensans was initially considered but repeat CT scan ruled it out because of involvement of both sides of the joint in arthritis and the sclerotic medial clavicle and large anteroinferior osteophyte were more consistent with osteoarthritis.

Clinically, there was pain with use of the arm particularly with high elevation or cross body movement or lifting and carrying in all cases. There was visible and palpable bony swelling of the SC joint in all cases. There was no clinical instability noted in any of the patients. Preoperative planning included routine blood checks including test for inflammatory markers, plain radiographs and CT scan. In all cases, there were features on CT scan consistent with osteoarthritis of the sternoclavicular joint with joint enlargement, subchondral sclerosis, cysts and frequently large anteroinferior periarticular osteophytes and preserved joint space (Figure 1). Joint space was preserved in four cases with only one case demonstrating reduction in joint space. Two patients demonstrated additional small superior osteophytes. MRI scan was also undertaken in one case in order to exclude septic arthritis. Inflammatory markers were normal. The MRI scan showed large anteroinferior osteophyte and preserved joint space consistent with osteoarthritis but no evidence of joint sepsis (Figure 2).

Figure 1.

CT scan showing osteoarthritic involvement of the left sternoclavicular joint with large anteroinferior osteophyte with preserved joint space.

Figure 2.

T₂-weighted MRI scan showing osteoarthritis of the left sternoclavicular joint with enlarged medial end of clavicle, large anteroinferior osteophyte and preserved joint space. No evidence of articular disc tear.

Surgical technique

A full informed consent was obtained in every case with potential risks, benefits, rehabilitation and likely outcome explained to the patient. The regional cardiothoracic service is within the same hospital and was always notified and available if needed. All procedures were undertaken as day case surgery with all patients discharged home the same day. Under general anaesthetic, patients were placed in a beach chair position with a rolled towel in the interscapular space to retract the clavicle and open up the anterior sternoclavicular joint. Double skin preparation and draping was carried out to expose the sternoclavicular joint, root of the neck, ipsilateral chest wall, sternum and contralateral medial chest wall. A 5–7 cm transverse skin incision was made over the anterior sternoclavicular joint and carried down through subcutaneous tissues and platysma, down to the anterior capsule. The anterior capsule was incised transversely and a subperiosteal dissection was carried out medially and laterally over the manubrium and medial clavicle respectively. Care was taken to protect the adjacent stabilizing ligaments. Dissection was next carried superiorly and inferiorly to expose the medial clavicle and manubrium.

There was no posterior dissection in any case. Periarticular osteophytes were carefully removed using small osteotomes and rongeur to ensure complete debridement of the osteophytes. These were often large anteroinferior osteophytes with two cases having additional small superior osteophytes. No medial clavicle bone was excised/removed. The articular disc was carefully inspected but not disturbed if not torn. No articular disc was excised in any of the patients. Copious saline irrigation of the joint was carried out. Stability of the joint was assessed by manual stressing of the joint and movement of the arm. No instability was noted in any of the cases post debridement. The anterior capsule was securely repaired with strong vicryl or fibrewire suture. Layered closure was carried out with subcuticular monocryl skin closure. The arm was rested in a polysling postoperatively. The patients were reviewed before discharge by a physiotherapist with follow-up rehabilitation continued on an out-patient basis.

Outcome assessment

Patients were reviewed at 2 weeks post-operation for wound inspection and clinical review, followed by review at 6 weeks, 3 months and 6 monthly assessments until recovered or discharged. Clinical assessment was undertaken at each visit. At the most recent follow-up, functional assessment was undertaken using the Quick Disabilities of Arm Shoulder and Hand (DASH) functional scale. ²² There was also subjective assessment of patient satisfaction with the treatment. Three patients attended for follow-up review and the remaining three patients underwent telephone assessment as they could not attend.

Results

There were three women and two men. Mean age at surgery was 46.6 years (range 37.17–66) (Table 1). In four patients, the diagnosis was primary osteoarthritis while in one patient the osteoarthritis was secondary to trauma. In three patients, the dominant arm was affected. Two patients had radiation of pain outwards into the neck, anterior chest wall and shoulder. There was clinical swelling and tenderness on palpation of the sternoclavicular joint but no instability on stressing the joint in all cases. All the operations were either undertaken by the senior author (SF) or done under his supervision. There were no surgical complications. All patients could be discharged on the same day of surgery.

Table 1.

Patient characteristics and outcome data.

Age (years)	Sex	Side	Diagnosis	CT findings	F/U (months)	Quick DASH	Satisfaction	PERS
50	M	R	Primary OA	Large AIO.PJS	43	20.5	Good	PA
37.25	F	L	Primary OA	Large AIO.PJS	38	29.5	Good	HML
42.5	M	L	Post-traumatic	Small AIO.NJS	36	0	Excellent
66	F	R	Primary OA	Large AIO.PJS	31	4.5	Excellent
37.17	F	L	Primary OA	Large AIO.PJS	29	0	Excellent

CT, computed tomography; M, male; F, female; OA, osteoarthritis; HML, heavy manual labour; AIO, inferior osteophyte; PJS, preserved joint space; NJS, narrow joint space; PERS, potential explanation for residual symptoms; PA, polyarthralgia.

Mean time to latest follow-up was 35.4 months (range 29–43 months). There was no instability symptom in any of the patients at any time during follow-up. At latest follow-up the mean Quick DASH score was 10.9 (range 0–29.5). Using a subjective outcome assessment (excellent, good, fair and poor), three patients described being very satisfied with their result and rate their result as excellent. The other two patients had mild discomfort with heavy or repetitive use of the arm and rated their result as good. All patients were satisfied with the cosmetic result.

Discussion

Results of sternoclavicular surgery for osteoarthritis have been inconsistent with good outcome in some series^5,10,12,13 while others have recorded unsatisfactory results.^4,11 Furthermore, the location of the sternoclavicular joint in proximity to important mediastinal structures has led to a reluctance by surgeons in undertaking surgery on this joint. In a survey of shoulder surgeons undertaken by Van Tongel ²³ across national and international societies, only 20% of surgeons stated that they would proceed to open medial clavicle excision if conservative management of sternoclavicular osteoarthritis fails with the others stating that it was too risky or not worth the risk.

In one of the earliest series by Bremner ⁴ in 1959, 12 female patients, mean age 56 years, presented with sternoclavicular pain and swelling involving solely the dominant arm. Six patients had synovectomy and excision of medial 2.5 cm of the clavicle. Results were described as good although the assessment criteria were not stated. They further stated that no functional disability resulted from the loss of the medial end of the clavicle but admitted that some patients did complain that the remaining clavicle was prominent, a likely result of loss of stabilizing soft tissues. It is therefore likely that these would have represented failures had they been objectively assessed. Acus et al. ¹¹ report on 15 patients at mean follow-up of 4.6 years following open excision of medial end of clavicle. Initial good result was followed by worsening symptoms over time in many of their patients. They attributed this failure to regrowth of the medial end of clavicle that was noted in 7 (58%) of 12 patients in whom X-rays were taken. Katthagen et al. ¹² reported their series of 17 patients most of who were the result of post-traumatic arthritis. There were three failures, one patient refused to participate but they made no comments on two cases. They reported on 11 joints. They concluded that excision of the medial end of clavicle resulted in significant improvement in function and high rate of return to sport. They however had a 17% failure rate. Meis et al. ¹⁰ reported on 17 SC joints in 16 patients at mean 46-month follow-up. Surgery consisted of open excision and soft tissue interposition using the sternal head of the sternocleidomastoid tendon. Results were excellent in four, good in six, fair in three and poor in one patient. Their explanation for the fair and poor results was that these were workers compensation patients. Pingsmann et al. ⁵ reported their clinical outcome in eight female patients with primary osteoarthritis who underwent open excision of the medial end of clavicle. Mean age at surgery was 54 years. At mean 31-month follow-up, four patients had excellent result, three had good result and one had poor result. They concluded that open excision of the SC joint for osteoarthritis is a safe and effective treatment with a high degree of patient satisfaction.

The paper by Rockwood et al. ¹³ emphasized the importance of preserving the soft tissue stabilizers of the sternoclavicular joint during excision of the medial end of the clavicle. They reported on the outcome of eight revision cases referred to them from other centres. These patients were referred due to failures resulting from loss of soft tissue stabilizers following the primary surgery and despite attempts at salvage surgery outcome was poor. This was in sharp contrast to the excellent outcome obtained in all eight primary open sternoclavicular joints excisions that they carried out where the soft tissue restraints were preserved.

There is a lack of consistency in the length of the medial clavicle to be excised when undertaking an open SC joint excision, with this varying from 6 mm to 4 cm. In Rockwoods series ¹³ of eight primary cases, the amount of medial clavicle bone excised was about 1.5 cm. In Bremner’s series, ⁴ 2.5 cm of medial clavicle was excised while Pingsmann et al. ⁵ excised about 1 cm of medial clavicle in all their cases. Despite the large variation in length of medial clavicle excised in these series, all claimed good to excellent results. Anatomic and biomechanical studies have suggested that no more than 1 cm of bone should be excised from the end of the medial clavicle as encroachment on the attachment of the important costoclavicular ligament can occur beyond this length, potentially compromising joint stability.^24,25 There is also evidence that the sternoclavicular capsule and its anterior and posterior thickenings are most important for anteroposterior stability of the sternoclavicular joint. ²⁶ Secure repair of the capsule is therefore important in restoring stability to the SC joint following open surgery.

Our result with open sternoclavicular osteophyte debridement demonstrated excellent satisfaction in three patients, good satisfaction in two patients at mean 35.4 months follow-up which is identical to other reports in literature. One patient with good satisfaction suffers with pre-existing polyarthralgia that was investigated by a consultant rheumatologist and inflammatory arthritis was ruled out. The polyarthralgia might explain the lower score. The other patient with a good score does heavy manual work and also fell onto the same side about 6 months post-operation with recurrent symptoms. This improved with conservative treatment but did not fully settle down.

We did not encounter posterior osteophytes in any case but are aware that these may be present and can cause significant symptoms. We feel that the predominance of osteophytes in the anteroinferior aspect of the joint is consistent with the anatomic findings that show that the medial surface of the medial clavicle is covered by articular cartilage in only its anteroinferior half with the posterior-superior portion serving as attachment site for the broad posterior sternoclavicular ligament and the fibrous disc. We are however aware that posterior osteophytes can be present in SC osteoarthritis and can cause severe symptoms.^27,28 In this situation, open or arthroscopic medial clavicle excision may be more appropriate.^27,28

When periarticular osteophytes are localized to the anterior, superior or anteroinferior aspects of the joint (which is where they are most often found), open sternoclavicular osteophyte debridement appears to yield excellent result. Our clinical result is as good as any of the best outcomes available for either open or arthroscopic medial end of clavicle excision for the same indication. In addition, our result revealed a low risk profile compared to the other surgical modalities. The advantages of open sternoclavicular osteophyte debridement are its simplicity and safety. Periarticular osteophytes are mostly anteroinferior and easily accessible. Also, superior and anterior osteophytes can be easily reached through this exposure. There is no need to disturb the posterior capsule and risk significant injury to vital mediastinal structures if impinging posterior osteophytes are not present. Second, there is no requirement to remove the medial end of clavicle, thus minimizing the risk of instability that can result from detaching the costoclavicular ligament. The anterior capsule is securely repaired with fibrewire. The articular disc is carefully inspected and left in situ if it is not torn, as we believe that it subserves an important weight bearing function and contributes to the congruence and stability of the joint. We however recognize that others remove the disc because they believe it is a source of pain^29,30 but we do not believe that it must be excised in every case. The good/excellent outcome at mid-term follow-up in this study supports this decision although the number of patients in the study is small.

A limitation of this technique is the difficulty with reaching the posterior aspect of the joint and when this is necessary, other techniques such as open (with medial clavicle excision) or arthroscopic approaches should be considered. If there is associated instability then other approaches for addressing this should be considered.

Limitations of this study include its retrospective nature and the lack of a comparative arm. The homogeneity of the included sternoclavicular pathology (primary osteoarthritis) increases its internal validity but reduces generalizability. The small study number is another limitation but reflects the small number of cases in published literature on this subject. There is a need for higher quality, preferably prospective randomized controlled studies adequately powered and blinded and with longer term follow-up to determine relative efficacy of these techniques.

Conclusion

We believe that open sternoclavicular osteophyte debridement is a simple, safe and highly effective addition to the surgical options available for treatment of patients with symptomatic SC osteoarthritis unresponsive to adequate conservative management. It is most appropriate for the majority of SC osteoarthritis with superior, anterior and anteroinferior osteophytes which are easily accessible with this approach.

Ethical Review and Patient Consent

The study was approved by the Research and Ethics committee, Royal Liverpool and Broadgreen University Hospitals, UK (Study number: TA2278). Level IV study. Both verbal and written consent was obtained from every participant including consent for the use of anonymized images used in the study.

ORCID iDs

Charles I Ayekoloye https://orcid.org/0000-0002-0953-3896

Amanda Wood https://orcid.org/0000-0001-5757-0731