Arthroscopy of the Sternoclavicular Joint

Abstract

Abstract:Traditionally, an open approach has been required to undertake any surgical intervention for intra-articular sternoclavicular joint pathology. This in itself carries a certain operative morbidity, including damage to the underlying mediastinal structures and damage to the sternoclavicular and costoclavicular ligaments, with subsequent joint instability and unsightly scarring. This technical note describes an arthroscopic approach to the sternoclavicular joint that reduces this morbidity. The evolution of the technique including the rationale for portal placement and the angle of instrument insertion is explained. Experience of over 50 arthroscopic procedures including diagnostic arthroscopy, discectomy, excision of loose bodies, and washout and debridement after infection and excision of the medial end of the clavicle for osteoarthritis is detailed.P athologic disorders around the sternoclavicular joint (SCJ) are rare, but symptoms can be debilitating, with limited treatment options. Traditionally, surgical intervention for SCJ disorders has required an open approach, which itself carries the risks of damage to the underlying mediastinal structures, instability, and scarring. 1,2 This in part has led to a high threshold for surgery. An arthroscopic approach for certain SCJ intraarticular pathologies could potentially decrease these risks. 3,4 This article describes an SCJ arthroscopic technique that has evolved over the past 5 years. The first procedures undertaken were diagnostic in 2 patients with an inflammatory monoarthropathy of the SCJ and a large effusion. In these patients we took an aspirate and synovial biopsy specimen. Subsequently, we have performed over 50 therapeutic procedures for intra-articular conditions including meniscectomy/discectomy for acute and chronic disk tears, excision of loose bodies, excision of the medial end of the clavicle for degenerative arthritis, and washout and debridement after infection. Surgical Technique Positioning and EquipmentThe procedure is performed with the patient under general anesthesia positioned supine. The patient's head is placed in a head ring, and a small sandbag is placed between the scapulae to open up the SCJs anteriorly. The operating surgeon stands on the operative side of the patient facing toward the head end of the table where the arthroscopic stack is positioned. A 2.7-mm arthroscope with a 3-mm cannula and trocar is used for visualization with the fluid pressure pump at 30 mm Hg. A mini-probe and punch with a mini-shaver using a 3.5-mm incisor blade and bur (Dyonics Smith & Nephew, Andover, MA) are used for instrumentation. A micro-bipolar VAPR radiofrequency probe (DePuy Mitek, Raynham, MA) is used for hemostasis and tissue ablation.Portal Placement Anatomic Considerations. The greatest perceived concerns surrounding SCJ surgery are the close proximity of the posteriorly lying mediastinal structures and damage to the anterior stabilizing structures. The potential advantage of an arthroscopic procedure is that once the arthroscope and ...

Arthroscopic Sternoclavicular Joint Resection Arthroplasty: A Technical Note and Illustrated Case Report

“…Diagnostic arthroscopy Always first identify the posterior capsule to ensure that the arthroscope is situated within the joint. 22 Lack of a systematic approach may result in missed diagnoses. SC joint decompression Bone should not be resected from the sternal facet.…”

“…SC joint decompression Bone should not be resected from the sternal facet. 19,22 Removing >10 mm of the medial clavicle increases the risk of postoperative SC joint instability. 17 Postoperative rehabilitation Passive motion should be encouraged immediately after surgery.…”

“…The left upper extremity was of caudal angulation from the horizontal plane to maximize visualization while also minimizing damage to the anterior SC ligament. 19,22 A distinct "pop" was heard as the arthroscope penetrated the joint capsule and therefore entered the SC joint. (D) Under direct visualization through the inferior viewing portal, a spinal needle was inserted into the joint through the previously marked site for superior portal placement with approximately 30 of caudal angulation from the vertical plane (outside-in technique).…”

Arthroscopic Intra-articular Disk Excision of the Sternoclavicular Joint

“…The anterior sternoclavicular ligament, the small area of bony congruence, and the inclination of the sternal side of the SCJ are taken into consideration. 9,17 The bony contours of the joint are palpated and an initial inferior portal is positioned approximately 1 cm directly inferior to the joint line. An 18-gauge spinal needle is inserted and angled at 30 cephalad to the horizontal plane and 30 lateral to the midline to take into the inclination of the sternal side of the joint.…”

“…3,[5][6][7] However, advances in routine computed tomographic (CT) and MRI imaging and the advent of arthroscopic sternoclavicular surgery may allow for easier diagnosis and treatment of symptomatic disk tears. [8][9][10] This Technical Note describes the diagnosis and arthroscopic surgical technique for the management of symptomatic SCJ intra-articular disk tears.…”