Shoulder and Elbow
Sternoclavicular Joint Arthritis
Indications for Surgery
- Surgical Technique
Pearls and Pitfalls of Technique
- Potential Complications
Outcomes/Evidence in the Literature
Osteoarthritis of the sternoclavicular (SC) joint is a prevalent, but mostly asymptomatic disorder. It is the most common condition to affect the SC joint. Cadaveric examinations of the SC joint report degenerative changes present in all patients over the age of fifty. Radiographically, SC arthritis was seen in over half of specimens over sixty years of age. Symptomatic patients usually respond to conservative treatment with improvement in their pain and swelling within a few weeks.
Patients refractory to conservative measures may be indicated for surgical intervention. Traditionally, surgery involves open excision of the medial end of the clavicle, though newer arthroscopic techniques have also been described.
The clavicle is the first bone to ossify in the womb at 5 weeks. However, its medial physis does not appear until approximately 17 years of age, and does not close until age 25 or later. The SC joint is a saddle-shaped, diarthrodial joint. It is the only true articulation between the upper extremity and the axial skeleton. The larger medial clavicle articulates with the superomedial manubrium and superior aspect of the first rib. This articulation is highly incongruous, and relies upon its capsular and ligamentous structures to provide stability. The anterior and posterior SC ligaments reinforce the joint capsule. The anterior ligaments are stronger than their posterior counterparts. The interclavicular ligament attaches to the upper border of the sternum and connects the medial ends of both clavicles. The SC joint also contains an intra-articular disk. This disk is a dense, fibrous structure that arises from the chondral junction of the first rib, and passes through the joint to create two separate joint spaces. The costoclavicular (rhomboid ligament) is the strongest of the SC ligaments. It is composed of anterior and posterior fasiculii that extend from the first rib and costal cartilage to the inferomedial margin of the clavicle.
Osteoarthritis of the SC joint is most commonly encountered in postmenopausal women. Manual laborers, those with a history of a radical neck dissection, and patients with chronic SC joint instability are also at risk for degenerative arthritis of the SC joint. Patients may complain of pain about the medial aspect of the clavicle that may radiate into the shoulder. Patients report pain with activity, particularly overhead. Pain at rest and at night are often described. Patients may notice swelling and asymmetry of their SC joints.
Other conditions that may affect the SC joint, such as rheumatoid arthritis, septic arthritis, atraumatic subluxation, seronegative spondyloarthropathies, gout, pseudogout, SC hyperostosis, condensing osteitis, and Friedrich’s disease/avascular necrosis must also be considered in the differential diagnosis. In younger patients with a history of trauma one must have a strong suspicion of a physeal injury, even in the setting of negative radiographs, given the delay in the appearance of the epiphysis.
Many systemic conditions may affect the SC joint. For this reason, a thorough history, including personal/family history of inflammatory arthritis, recent trauma, and parenteral drug use should be obtained. Physical examination may reveal warmth, erythema, swelling, crepitus, or fluctuance about the SC joint. Resisted arm abduction, the cross-shoulder sign, or a downward force on the medial clavicle (push-down test) may reproduce pain in this area.
Plain radiographs are routinely obtained as part of the initial evaluation. The initial evaluation should include anteroposterior (AP) radiographs of the chest or SC joint. These images may demonstrate sclerosis of the SC joint. Special projected views, such as the Serendipity view, may also prove helpful. To obtain the Serendipity view the patient is positioned supine on the X-ray table. The X-ray cassette is positioned flat on the X-ray table, under the patient’s upper torso and neck. The X-ray tube is angled 40 degrees cephalad off the vertical, and centered on the sternum. The purpose of this view is to identify anterior or posterior displacement of the medial clavicle in relation to the sternum.
X-rays often prove difficult to interpret and further imaging is usually required. A CT scan is the imaging modality of choice to identify arthritis, joint incongruity, fractures of the medial clavicle, and joint subluxations/dislocation.
Though bony detail is readily identified on CT, MRI imaging may provide additional information when ruling out soft tissue masses, osteonecrosis of the medial clavicle, or inflammatory/infectious processes. Bone scan may also be utilized to detect an inflammatory process when MRI is not possible.
Ultrasound, though user dependent, can readily detect an effusion at the SC joint. Additionally it may assist in an aspiration/injection of the joint if clinically warranted. Lab work including WBC, ESR, CRP, and joint aspirate fluid cell count and culture may help identify a potential infectious process.
Conservative measures for SC osteoarthritis are the mainstay of treatment. Most symptoms are self-limiting and may resolve after 1 or 2 months without much intervention. Non-operative management may include rest, activity modification, local cryotherapy, non-steroidal anti-inflammatory medications, and possibly an intra-articular injection of lidocaine and corticosteroid. As the pain eases, a physical therapy program is initiated, including range of motion exercises, a scapular stabilization program, and strengthening exercises for the shoulder. Initially range of motion exercises are maintained below the shoulder level, and gradually increased as pain allows. Only in patients that fail a prolonged non-operative course should surgery be considered.
Indications for Surgery
Given the risks of vascular injury while operating in the area of the mediastinum, surgery should only be considered in cases in which the patient complains of significant disability and fails at least 6 months of conservative measures. Traditional treatment for recalcitrant SC joint arthritis is an open resection of the medial end of the clavicle. Newer arthroscopic techniques have also been described.
Prior to planning a resection arthroplasty of the SC joint, the surgeon must be completely familiar with the anatomy cephalad and posterior to the SC joint. We recommend utilizing a thoracic surgeon or having one immediately available to assist if vascular complications arise.
Open Medial Clavicle Resection
Surgery is performed under general anesthesia with the patient in the supine position. Four folded towels are placed between the scapulae. The ipsilateral arm is draped free. A “hockey stick” incision is carried out along the superior border of the clavicle and curved inferiorly along the sternum, medial to the SC joint. The fascia and periosteum of the medial clavicle are incised in line with the skin incision. Care is taken to preserve the periosteal sleeve for later repair. The clavicular head of the sternocleidomastoid and the medial clavicular origin of the pectoralis major are reflected to expose the SC joint.
The anterior capsule is incised and the SC joint is inspected. The intra-articular disk ligament is identified and debrided to further examine the SC joint.
When determining the amount of distal clavicle to excise, it is of utmost importance to ensure that the costoclavicular ligament (rhomboid ligament) is preserved. Injury to this ligament can destabilize the SC joint and lead to postoperative instability. Therefore, resection should never be carried lateral to the costoclavicular ligament or anterior joint capsule origin. Normally we plan on a resection of 1 cm of medial clavicle.
To prevent serious vascular complications, a malleable retractor is placed posterior to the SC joint to protect the structures in the mediastinum that lie just posterior to it. The planned level of osteotomy is marked on the clavicle. It is useful to drill multiple, bicortical drill holes along the path of the resection. A side cutting burr or an osteotome is then used to complete the osteotomy. The anterior and superior aspects of the osteotomy site are smoothed. The ipsilateral shoulder is then ranged and stability of the SC joint is confirmed. The preserved periosteal sleeve and anterior joint capsule are closed meticulously over the medial clavicle for additional support.
When the costoclavicular ligament is not preserved, stabilization of the remaining clavicle to the first rib is necessary. Heavy non-absorbable suture passed around the remaining medial end of the clavicle and the remnant of the rhomboid ligament can be utilized. Additionally, if the intra-articular disk ligament is preserved, it may also be utilized to stabilize the joint.
Arthroscopic Medial Clavicle Excision
Arthroscopic techniques have the benefit of causing less disruption to the SC joint ligaments, making the technique theoretically less susceptible to instability. Additionally, less soft tissue disruption may allow for a quicker rehabilitation. If during any portion of the arthroscopic procedure, visualization proves difficult, conversion to an open procedure can readily be performed.
Surgery is performed under general anesthesia with the patient in the supine. Four folded towels are placed between the scapulae to open the SC joints anteriorly. The ipsilateral arm is draped free. The bony landmarks of the SC joint are marked on the skin. A two portal technique is utilized. An 18 gauge needle is used to enter the joint at the inferior soft spot, below the anterior SC ligament. The needle is directed 30 degrees cephalad off the vertical. Through this needle the joint is insufflated with normal saline. With the inferior portal localized, a 2.7 mm 30 degree arthroscope is bluntly inserted into the joint. A portal superior to the anterior SC ligament is created under direct visualization. Marked synovitis may be encountered. Using an arthroscopic shaver, a thorough synovectomy can be performed. Additionally the intra-articular disk may be excised. An arthroscopic burr is utilized to resect the medial 1 cm of the clavicle. Care is taken to preserve the capsule of the SC joint and the attachment of the sternocleidomastoid muscle. Portals should be switched to ensure adequate resection. At the end of the procedure, the SC joint can be visualized arthroscopically for dynamic stability and to ensure no persistent bony impingement.
Pearls and Pitfalls of Technique
If there is a history of trauma, a high index of suspicion for SC joint dislocation should be kept. Additionally, in younger patients, a physeal injury should be suspected even with negative plain radiographs.
A thoracic surgeon as an assistant or being immediately available is recommended in order to address any vascular injury that may occur during surgery.
When performing an open medial clavicle resection, utmost care is taken to preserve the costoclavicular ligament to avoid postoperative instability.
In the setting of an unstable SC joint, never transfix the joint with Kirschner wires or Steinmann pins. Tremendous amounts of stress are placed on these wires, which lead to breakage and migration. Reports of death associated with these pins migrating to the heart, aorta and other great vessels have been reported.
Because of the proximity of the SC joint to major neurovascular structures, the risk for vascular injury is significant and potentially life threatening. Directly posterior to the SC joint lies the great vessels of the brachiocephalic trunk, the internal jugular vein, and common carotid artery. Additionally, the trachea and the vagus nerve are close to the surgical field. Before performing this procedure, the surgeon must be knowledgeable regarding the relation of these structures to the SC joint.
Over-resection of the medial clavicle that extends lateral to the joint capsule and disrupts the costoclavicular ligament will lead to cephalad displacement of the remaining clavicle. This instability has been noted to result in poor post-operative outcomes. Stability of the SC joint after resection arthroplasty should be tested intra-operatively by ranging the ipsilateral shoulder. If instability is noted, repair or reconstruction of the costoclavicular ligament will be necessary.
Patients are immobilized in a sling for 6 weeks postoperatively. Pendulum exercises are initiated on the second post-operative day. Additionally active-assisted range of motion exercises are allowed below 90 degrees of forward flexion and abduction for 6 weeks. Range of motion is then gradually increased and a strengthening program is initiated at 8-12 weeks. Heavy lifting and return to activity is permitted after 3 months.
Outcomes/Evidence in the Literature
Bearn, JG. "Direct observations on the function of the capsule of the sternoclavicular joint in clavicular support". J Anat. vol. 101. 1967. pp. 159-70.(A cadaveric examination of the strength and role of each of the ligaments at the SC joint. The sternum was mounted to a vise and the lateral clavicle loaded with weights. Subsequently,each of the ligaments was sectioned individually, and in various combinations. The author concluded that the capsular ligaments are the most important to maintain stability of the SC joint.)
Bisson, LJ, Dauphin, N. "A safe zone for resection of the medial end of the clavicle". J Shoulder Elbow Surg. vol. 12. 2003. pp. 592-4.(Cadaveric study of 86 specimens which were dissected to determine the distance, or “safe resection length,” from the inferior articular surface of the medial end of the clavicle to the most medial insertion of the costoclavicular ligament. This distance was found to be approximately 1 cm in male and 0.9 cm in female specimens.)
Higginbotham, TO, Kuhn, JE. "Atraumatic disorders of the sternoclavicular joint". J Am Acad Orthop Surg. vol. 13. 2005. pp. 138-45.(Review of many conditions that affect the SC joint. The differential diagnosis and patient evaluation is thoroughly discussed.)
Lyons, FA, Rockwood, CA. "Migration of pins used in operations on the shoulder". J Bone Joint Surg Am. vol. 72. 1990. pp. 1262-7.(Authors describe the complications of pins used in surgeries about the shoulder. Of the cases 37 reported, 24 of them involved pins about the SC joint. All eight of the patients who died had pins placed for fixation of the SC joint. All 8 patients died within 3 months of the operation.)
Pingsman, A, Patsalis, T. "Resection arthroplasty of the sternoclavicular joint for the treatment of primary degenerative sternoclavicular arthritis". J Bone Joint Surg Br. vol. 84-B. 2002. pp. 513-7.(Case series of 8 patients treated with open resection arthroplasty of the SC joint. Midterm results, with mean follow-up of 31 months show 7 out of 8 good to excellent results.)
Rockwood, CA, Groh, GI. "Resection arthroplasty of the sternoclavicular joint". J Bone Joint Surg Am. vol. 79-A. 1997. pp. 387-93.(Study comparing 8 patients who had a primary resection arthroplasty with the costoclavicular ligament left intact (Group 1), and 7 patients who underwent revision surgery with reconstruction of the costoclavicular ligament (Group 2). All patients in Group 1 had excellent outcomes, compared to three patients in Group 2. This illustrates the importance of preservation of the costoclavicular ligament during the primary surgery. The article has excellent illustrations of the surgery, including reconstruction of the costoclavicular ligament.)
Silberberg, M, Frank, EL. "Aging and osteoarthritis of the human sternoclavicular joint". Am J Pathol. vol. 35. 1959. pp. 851-65.(A cadaveric examination of 100 male and 100 female SC joints. Specimens were grouped according at age. Gross and histologic descriptions were compared between the different groups. The authors noted that osteoarthritis of the SC joint first appeared in the third and fourth decades of life. Within the fifth and sixth decades, osteoarthritis was noted in over 70% of specimens.)
Spencer, EE, Wirth, MA, Iannotti, JP, Williams, GR. "Disorders of the sternoclavicular joint: pathophysiology, diagnosis, and management". Disorders of the shoulder: diagnosis and management. Lippincott Williams and Wilkins. 2007. pp. 1007-54.(Excellent textbook chapter reviewing the entire spectrum of SC joint conditions. The illustrations of the applied surgical anatomy of the SC joint are quite useful to review in preparation for surgery.)
Tavakkolizadeh, A, Hales, PF. "Arthroscopic excision of the sternoclavicular joint". Knee Surg Sports Traumatol Arthrosc. vol. 17. 2009. pp. 405-8.(First published case report of an arthroscopic excision of the medial end of the clavicle. The patient was a 55 year-old female who suffered from monoarticular SC rheumatoid arthritis who did not respond to conservative measures. At 12 months follow-up, the patient was pain free with full range of motion in all planes.)
Tytherleigh-Strong, GM, Getgood, AJ. "Arthroscopic intra-articular disk excision of the sternoclavicular joint". Am J Sports Med. vol. 40. 2012. pp. 1172-5.(The authors describe an arthroscopic technique to excise the intra-articular disk and case series of two patients. The illustration of portal placement and trajectory is helpful if one is considering performing SC joint arthroscopy.)
Sternoclavicular osteoarthritis, when symptomatic, is usually self limited and responds well to conservative measures. The diagnostic study of choice to clearly evaluate osteoarthritis of the SC joint is a CT scan, though other imaging modalities also provide important diagnostic information. In the rare instance where non-operative measures fail to provide relief after several months, resection of the medial end of the clavicle may be indicated. Both open and arthroscopic techniques have been described. During surgery, care is taken to preserve the ligamentous stabilizers of the SC joint, in particular the costochondral (rhomboid) ligament. Potential complications of surgery include postoperative instability, and vascular injury. The latter of which may be life threatening.
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