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Arthroscopic excision of sternoclavicular joint

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We report an unusual case of chronic inflammatory arthropathy involving the sternoclavicular joint. Arthroscopic debridement of the sternoclavicular joint cavity was accompanied with the arthroscopic excision of the medial end of clavicle. Twelve months post-surgery the patient is asymptomatic with no signs of recurrence and a full pain free range of movement.
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KNEE
Arthroscopic excision of sternoclavicular joint
Adel Tavakkolizadeh ÆP. F. Hales Æ
G. C. Janes
Received: 17 June 2008 / Accepted: 13 November 2008 / Published online: 17 December 2008
ÓSpringer-Verlag 2008
Abstract We report an unusual case of chronic inflam-
matory arthropathy involving the sternoclavicular joint.
Arthroscopic debridement of the sternoclavicular joint
cavity was accompanied with the arthroscopic excision of
the medial end of clavicle. Twelve months post-surgery the
patient is asymptomatic with no signs of recurrence and a
full pain free range of movement.
Keywords Sternoclavicular joint Arthroscopy
Medial end clavicle Debridement Excision
Introduction
Symptomatic sternoclavicular joint pathology unresponsive
to conservative treatment is not common [6]. Degenerative
joint disease, instability and infection are the more com-
mon reasons for need for surgical intervention [7].
Traditionally surgical treatment involves open debridement
and excision of the medial end of clavicle with varying
degrees of success [4]. We report the first arthroscopic
debridement of the sternoclavicular joint accompanied with
the arthroscopic excision of the medial end of clavicle.
This technique causes less disruption to the sternoclavic-
ular joint ligaments avoiding instability and allows a rapid
functional recovery.
Case report
A 55-year-old lady was referred with pain and swelling in
her left sternoclavicular joint. She had suffered an injury
about 6 years earlier when she was carrying a box in her
left arm and struck a door frame with her left shoulder. She
subsequently developed pain and aching throughout the left
shoulder girdle. The symptoms however became more
localised to the left sternoclavicular joint with significant
pain and swelling which deteriorated over the years with
marked functional limitations.
Imaging showed evidence of erosion and destruction of
the sternoclavicular joint. She denied any other joint
symptoms and there was no history of psoriasis, pustular
lesions or inflammatory disease affecting the skin, eye or
bowel.
Examination revealed normal skin. Neck and thoraco-
lumbar spine examinations were both normal. Passive and
active elevation of the left shoulder was restricted to 110°
due to pain whilst there was full preservation of rotation.
There was swelling and marked tenderness over the left
sternoclavicular joint but not on the right. CT scans were
performed which demonstrated a destructive process of
unknown origin in the left sternoclavicular joint with
periosteal reaction along distal end of clavicle and thick-
ening of left costal cartilage (Fig. 1). It was considered
suggestive of an inflammatory condition.
A MRI was also performed which confirmed an
inflammatory, possibly post-traumatic process with florid
synovitis, oedema and degenerative changes in the joint.
Blood tests were positive for rheumatoid factor with a level
of 64 (Normal \14) which in absence of other joint
involvement, suggested a diagnosis of monoarticular
rheumatoid arthritis rather than infection. Inflammatory
markers were raised with ESR 57 (mm/h) and CRP 11.
A. Tavakkolizadeh P. F. Hales G. C. Janes
Perth Orthopaedic and Sports Medicine Centre,
Perth, WA 6008, Australia
A. Tavakkolizadeh (&)
Locum Consultant Orthopaedic Surgeon,
King’s College Hospital, London SE3 9EJ, UK
e-mail: adeltav@hotmail.com
123
Knee Surg Sports Traumatol Arthrosc (2009) 17:405–408
DOI 10.1007/s00167-008-0692-x
Medical treatment using anti-inflammatory drugs was
unsuccessful.
On imaging, a large cavity around the joint was noted
which raised the possible option of an arthroscopic pro-
cedure in view of increased joint space allowing for
potential use of arthroscopic instrumentation.
The options of performing the procedure openly or
arthroscopically were considered with the patient as well as
with a cardiothoracic surgeon. The patient was fully
informed of the risk to the vascular structures with poten-
tial fatal consequences. However it was also pointed out
that this risk also exists with the open procedure. It was felt
an arthroscopic procedure will give better access, will
reduce the damage to the overlying sternoclavicular liga-
ments and will allow for quicker functional recovery.
Procedure was performed in a unit with cardiothoracic
facilities.
Two portals at the levels of the superior and inferior
borders of the sternoclavicular joint were used (Fig. 2).
A 2.7-mm scope with 30°-angle was used.
Inspection of the joint was followed by removal of the
significant synovitis mass with the use of a soft tissue
shaver. This was followed by use of a bony burr to resect
the medial end of the clavicle by approximately 10 mm.
There was marked synovial proliferation and specimens
were taken for histological and microbiological analysis.
Post-operatively early mobilisation was allowed.
At 2 weeks post-operatively the patient experienced no
pain and her range of movement in cross adduction and
elevation was better than before the index procedure.
Microbiology and cultures were negative including for acid
fast bacilli. Histology excluded neoplasia or presence of
crystals. Chronic, non-specific inflammatory changes were
noted in the synovium.
At follow 12 months post-operatively the patient was
completely pain free with a full range of movement in all
directions. The constant score had improved from 30 pre-
operatively to 100 post-operatively.
The inflammatory markers were down to normal by
three months and rheumatoid factor was down to 40.
A post-operative CT scan confirmed the extent of the
excised medial end of clavicle as well as the decreased
inflammatory mass at the sternoclavicular joint (Fig. 3).
Discussion
Sternoclavicular joint is subject to the same disease
processes that occur in other synovial joints, including
degenerative arthritis, rheumatoid arthritis, infection, sub-
luxation, osteitis condensans, and joint infection [6,7].
Most of these conditions present with swelling of the joint,
which may be associated with pain and tenderness.
Plain radiographs can demonstrate changes on both
sides of the joint [6] but computed tomography and mag-
netic resonance imaging are often necessary. With the
exception of acute infection, most conditions can be
managed non-surgically, with joint resection reserved for
patients with persistent symptoms [6].
In non-infective cases the response to conservative
treatment is good but occasionally surgery is required in
the form of extensive debridement and excision of medial
end of clavicle [4,5].
Resection arthroplasty is an effective and safe treatment
for chronic, symptomatic degenerative arthritis of the
sternoclavicular joint with a high degree of patient satis-
faction. In the study of Pingsmann et al. [8] 7 out of 8
patients had good or excellent results. Resection and
Fig. 1 Axial CT image at the level of the sternoclavicular joint
showing the marked destruction of the joint with the associated peri-
articular cavity pre-operatively
Fig. 2 Picture demonstrating the position of the arthroscopy portal
sites as well as the proposed extent of bony resection from medial
clavicle
406 Knee Surg Sports Traumatol Arthrosc (2009) 17:405–408
123
interposition Arthroplasty have also been shown to have
reasonable results with good or better outcome in 10 out of
14 patients as reported by Meis et al. [7]. In a previously
reported series by Acts et al. [1] an average of 2.9 cm of
the medial clavicle was excised (range 1–4 cm) and 9 out
of 15 patients had an excellent or good outcome.
The medial claviculectomy sometimes needs to be carried
out in conjunction with ligamentous stabilization. This is
particularly important to avoid risk of instability post-exci-
sion arthroplasty. For this reason ideally the costoclavicular
ligament should be left intact but if this can not be achieved
then the costoclavicular ligament should be reconstructed.
Rockwood et al. [9] in their retrospective series of 15 patients
concluded that preservation of the costoclavicular ligaments
does lead to a better outcome as compared to cases with
secondary reconstruction performed as a second stage pro-
cedure. This is where an arthroscopic technique is likely to
cause less damage to the ligament complexes around the
joint with the potential benefit.
In this case the differential diagnosis included post-
traumatic arthritis, infection, inflammatory arthropathy or
SAPHO (synovitis, acne, pustulosis, hyperostosis and
osteitis) syndrome. However microscopy and culturing of
the specimens excluded an infective process.
Our patient suffered from monoarticular sternoclavicu-
lar rheumatoid arthritis unresponsive to conservative
treatment. As part of pre-operative planning all surgical
options were considered which included resection arthro-
plasty openly or arthroscopically. The risks of performing
the procedure arthroscopically were considered carefully
and were also discussed with an experienced cardiothoracic
surgeon.
In our case the arthroscopic approach meant that whilst
a reasonable amount of the medial clavicle was excised
which was estimated to be approximately 1 cm; there were
no concerns with regard to the stability of the sterno-
clavicular joint post-operatively as the majority of the
costoclavicular ligament as well as the anterior sternocla-
vicular ligament were undamaged during the procedure.
The post-operative morbidity of the procedure is signifi-
cantly reduced with less pain and faster functional recovery
and so far our patient has remained completely symptom
free with full range of movement. The technique is limited
by the size of the joint cavity and the local structures at
risk. If there is any difficulty with visualisation, then a
conversion to an open procedure is recommended. Any
damage to the major vessels can be life threatening.
The consequences of secondary instability post-opera-
tively can be significant. Treatment can be difficult and both
conservative and surgical options have been used to stabilise
the sternoclavicular joint with limited success [2,3].
We feel arthroscopic treatment of sternoclavicular
arthropathy may be appropriate in selected cases with
adequate joint cavity as assessed by pre-operative imaging
in order to improve functional recovery and reduce the risk
of secondary instability post-excision arthroplasty.
References
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Fig. 3 Coronal and axial CT images at the level of the sternoclavic-
ular joint showing the sternoclavicular joint post-operatively. The
extent of the resection arthroplasty can be noted and the decrease in
the inflammatory mass
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... Arthroscopic surgery of the SCJ is described in a few series [4][5][6]20] . Resection of the medial clavicular end is the procedure that has been reported in most of the cases [4,5,20] , and in open [10] as well as arthroscopic [4,5,20] series it resulted in marked pain reduction. ...
... Arthroscopic surgery of the SCJ is described in a few series [4][5][6]20] . Resection of the medial clavicular end is the procedure that has been reported in most of the cases [4,5,20] , and in open [10] as well as arthroscopic [4,5,20] series it resulted in marked pain reduction. The indication for this operation is degenerative changes that can be demonstrated by X-rays, MRI or CT-scan. ...
... Arthroscopic surgery of the SCJ is described in a few series [4][5][6]20] . Resection of the medial clavicular end is the procedure that has been reported in most of the cases [4,5,20] , and in open [10] as well as arthroscopic [4,5,20] series it resulted in marked pain reduction. The indication for this operation is degenerative changes that can be demonstrated by X-rays, MRI or CT-scan. ...
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AIM To investigate if there are typical degenerative changes in the ageing sternoclavicular joint (SCJ), potentially accessible for arthroscopic intervention. METHODS Both SCJs were obtained from 39 human cadavers (mean age: 79 years, range: 59-96, 13 F/26 M). Each frozen specimen was divided frontally with a band saw, so that both SCJs were opened in the same section through the center of the discs. After thawing of the specimens, the condition of the discs was evaluated by probing and visual inspection. The articular cartilages were graded according to Outerbridge, and disc attachments were probed. Cranio-caudal heights of the joint cartilages were measured. Superior motion of the clavicle with inferior movement of the lateral clavicle was measured. RESULTS Degenerative changes of the discs were common. Only 22 discs (28%) were fully attached and the discs were thickest superiorly. We found a typical pattern: Detachment of the disc inferiorly in connection with thinning, fraying and fragmentation of the inferior part of the disc, and detachment from the anterior and/or posterior capsule. Severe joint cartilage degeneration ≥ grade 3 was more common on the clavicular side (73%) than on the sternal side (54%) of the joint. In cadavers < 70 years 75% had ≤ grade 2 changes while this was the case for only 19% aged 90 years or more. There was no difference in cartilage changes when right and left sides were compared, and no difference between sexes. Only one cadaver - a woman aged 60 years - had normal cartilages. CONCLUSION Changes in the disc and cartilages can be treated by resection of disc, cartilage, intraarticular osteophytes or medial clavicle end. Reattachment of a degenerated disc is not possible.
... Ten patients had returned to their previous level of sporting activity. Preoperatively, the mean VAS score was 6.1 (range, [3][4][5][6][7][8]; at most recent follow-up, this had improved to 1.2 (range, 0-4) (P ¼ .001). The mean Rockwood score had increased from 7 (range, 5-9; standard deviation [SD], 1.4) preoperatively to 13.6 (range, 9-15; SD, 1.9) (P ¼ .001) ...
... Sternoclavicular arthroscopic surgery has previously been reported as a safe and reproducible procedure for intra-articular pathology. 4,[7][8][9][10]14 Our indications for SCJ arthroscopy include diagnostic, joint debridement, removal of loose fragments, excision of the disk, and resection of the medial end of the clavicle. In this reported series of arthroscopic disk excision cases, the anterior portals were positioned superior and inferior to the anterior sternoclavicular ligament and above the costoclavicular ligament. ...
... [54][55][56][57][58] Resection of the medial clavicle has also been explored in the setting of a chronically unstable and painful SCJ, with both open and arthroscopic techniques being described. 56,[59][60][61][62][63][64] In a biomechanical study by Spencer and Kuhn, 51 three different graft techniques of SCJ repair were examined. The study compared subclavius tendon stabilization, 65 intramedullary tendon stabilization, 62 sternoclavicular joints for open resection arthroplasty. ...
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Chronic anterior sternoclavicular joint (SCJ) instability may cause pain and persistent functional limitation in active patients. Although SCJ reconstruction and medial clavicular resection have been advocated in these situations, the results of surgical treatment are not well characterized. The purpose of this investigation was to determine the functional outcome of surgical treatment in adolescent and young adult patients with chronic recurrent anterior SCJ instability. Fifteen patients with chronic recurrent anterior SCJ instability refractory to nonoperative therapy who underwent joint reconstruction or medial clavicular resection were evaluated for pain and function using the American Shoulder and Elbow Surgeons (ASES) Standard Shoulder Assessment Form and the Simple Shoulder Test (SST). At average follow-up of 55 months, the mean ASES score was 85 and the mean SST score was 10.9. Sixty percent of patients reported stable, pain-free joints, although 87% (n = 13) reported some limitations of athletic or recreational activity. There were no surgical complications, and no patient underwent subsequent revision procedures. Although subsequent activity modification is often required, surgical treatment of chronic anterior SCJ instability in adolescents and young adults can provide near-complete pain relief and return of shoulder and upper extremity function.
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Bacterial arthritis of the sternoclavicular joint is an uncommon disorder caused by a variety of microorganisms. Both Gram-positive and Gram-negative bacteria have been identified as etiologies of an acute suppurative arthritis, whereas a few other bacteria such as mycobacteria and treponemes have been incriminated in chronic disease of the sternoclavicular joint. We recently treated a patient with staphylococcal synovitis of the sternoclavicular joint, which is the 24th recorded in the literature. His illness was complicated by a retrosternal abscess, soft tissue abscess of the chest, septic bursitis, and lumbosacral discitis. He recovered after 6 weeks of nafcillin therapy without any residual infection. Six previous patients with extension into the substernal space and mediastinum have been described. Staphylococcal infection of the sternoclavicular joint, although usually confined to the joint, can be associated with sepsis and metastatic abscess formation as well as substernal extension even in immunocompetent individuals.