A safe technique for sternoclavicular stabilization

Sternoclavicular stabilization using metal implants is associated with an unacceptably high complication rate. A simple and safe technique of sternoclavicular stabilization utilizing sutures and the clinical results thereof are described in this case of an 11-year-old boy with an unstable anterior sternoclavicular dislocation.     

Suture anchors for treatment of sternoclavicular joint instability

Instability of the sternoclavicular joint is a difficult problem to treat and can present with gross limitation in activities. Eight sternoclavicular joint stabilization procedures were performed over an 8-year period. The patients' ages ranged from 16 to 48 years (mean, 23.5 years). The indication for stabilization was pain associated with instability of the sternoclavicular joint. The joint was stabilized by use of suture anchors on the manubrium and capsular plication. The functional outcome was evaluated by use of the Constant score and patient-based Oxford Shoulder Questionnaire. At a mean follow-up of 4.5 years (range, 1-7.6 years), none of the patients had instability at the sternoclavicular joint, and all except one had returned to their previous employment. The Oxford score was 16 (range, 12-38). The mean Constant score was 74.88 (range, 33-87). We had only 1 poor result (Constant score of 33). Stabilization of the sternoclavicular joint can safely be performed by use of suture anchors. The technique is recommended for symptomatic sternoclavicular joint instability.     

Biomechanical analysis of reconstructions for sternoclavicular joint instability

BACKGROUND: A variety of reconstructive methods have been described for the treatment of sternoclavicular joint instability, yet none have been analyzed in the laboratory, to our knowledge. The purpose of the present study was to evaluate three different reconstruction techniques with use of a cadaveric model: (1) intramedullary ligament reconstruction, (2) subclavius tendon reconstruction, and (3) reconstruction with use of a semitendinosus graft placed in a figure-of-eight fashion through drill-holes in the clavicle and manubrium. METHODS: Thirty-six fresh cadaveric specimens were mounted supine on a materials testing machine in a custom testing fixture and were subjected to anterior and posterior subfailure translation to determine stiffness in the intact state after preloading. One of the three reconstruction methods was performed, and the specimens were subjected to anterior or posterior translation to failure. Changes in stiffness compared with the intact state were analyzed statistically. RESULTS: In the anterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than that of the intramedullary ligament reconstruction but was not significantly different from that of the subclavius tendon reconstruction. The peak load to failure (as defined by translation equal to the anteroposterior diameter of the medial head of the clavicle) was 230.3 +/- 146.1 N for the semitendinosus figure-of-eight reconstruction, 84.6 +/- 45.7 N for the intramedullary ligament reconstruction, and 75.6 +/- 19.0 N for the subclavius tendon reconstruction. In the posterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than those of both of the other reconstructions. The peak load to failure was 241.4 +/- 49.7 N for the semitendinosus figure-of-eight reconstruction, 85.0 +/- 22.8 N for the intramedullary ligament reconstruction, and 51.5 +/- 28.9 N for the subclavius tendon reconstruction. CONCLUSIONS: The figure-of-eight semitendinosus reconstruction for sternoclavicular joint instability has initial biomechanical properties that are superior to those of the intramedullary ligament reconstruction and subclavius tendon reconstruction techniques. Clinical Relevance: While it is difficult to extrapolate in vitro data to the clinical situation, the figure-of-eight semitendinosus technique has superior initial biomechanical properties and may produce improved clinical outcomes in the surgical treatment of sternoclavicular joint instability.     

胸锁钩钢板治疗胸锁关节脱位的临床观察

目的:观察应用胸锁钩钢板治疗胸锁关节脱位患者的临床治疗效果。方法:2010年6月至2012年6月对7例胸锁关节脱位患者行胸锁钩钢板复位固定术治疗,其中男5例,女2例;年龄38～54岁,平均42.3岁;病程1～4周。术前患者均有外伤史,患侧胸锁关节肿胀、疼痛明显,患侧肩关节活动明显受限。术前X线片及CT证实为胸锁关节脱位,根据Rockwood评分法对术后疗效进行评价。结果:本组7例胸锁关节脱位患者按Rockwood评分法进行评价,优6例,良1例。术后未出现内固定松动、断裂,未出现再次脱位,肩关节功能良好,胸锁关节无疼痛,外观无畸形,患肢活动自如无疼痛。结论:胸锁钩钢板治疗胸锁关节脱位,手术操作简单,固定可靠,疗效肯定,值得临床推广。     

新型胸锁钩钢板治疗胸锁关节周围不稳定性骨折脱位的疗效观察

目的:探讨新型胸锁钩钢板治疗胸锁关节周围不稳定性骨折脱位的临床疗效。方法 :自2011年6月至2013年12月,应用胸锁钩钢板对32例成年胸锁关节骨折脱位患者进行手术治疗。其中男24例,女8例;年龄25~76岁,平均42岁;胸锁关节前脱位12例,胸锁关节后脱位5例,锁骨内侧端骨折10例,骨折合并脱位5例。胸锁关节前骨折脱位采用标准胸锁钩钢板,后脱位则在钢板钩的远端,即胸骨柄前方加用螺母和垫片,预防术后再脱位。根据Rockwood评分法评定疗效。结果 :患者手术过程中无并发症发生。术后复查X线片及CT显示胸锁关节解剖位置正常,内固定位置良好。32例均获得随访,时间6~24个月,平均10个月。术后3~6个月骨折达Ⅰ期愈合,胸锁关节无再脱位,锁骨内侧端解剖结构均恢复,功能满意,其中9例患者胸锁关节周围存在肿胀,但无疼痛等症状。Rockwood评分结果12.78±1.43;疗效优24例,良8例。结论:使用该新型胸锁钩钢板治疗胸锁关节周围不稳定性骨折,内植物固定确实可靠,安全性高,操作简便,为治疗此类创伤提供了一种可靠的方法。     

Use of demineralized bone matrix and plate for sternal stabilization after traumatic dislocation

Traumatic sternal segments dislocation is a rare pathology that is on the increase because of road accidents. Ideal treatment is controversial as it is a benign non-life-threatening lesion. The few cases reported in the literature do not shed light on any preferred procedure. In the present study, three patients were treated by surgical steel monofilament and eight by titanium screws and plates and demineralized bone matrix. The reduced hospitalization, rapid functional recovery, and excellent aesthetic results of the titanium patients make use of the surgical approach inevitable.     

A simple surgical treatment for acute traumatic sternoclavicular dislocation

Sternoclavicular lesions may sometimes require surgery. Many techniques have been described and they appear to be very demanding. We describe a simple technique using two screws and a strong suture (Arthrex Inc. Naples. FL 34108 USA). Level of evidence; Level IV, Case Series, Treatment Study.     

胸锁钩钢板内固定治疗创伤性胸锁关节前脱位的疗效观察

目的 探讨胸锁钩钢板内固定治疗创伤性胸锁关节前脱位的作用及临床疗效.方法 2002年5月至2009年10月,采用自行设计制造的胸锁钩钢板内固定治疗创伤性胸锁关节前脱位患者66例,男47例,女19例;年龄21～68岁,平均32.6岁;左侧25例,右侧41例.受伤原因:交通伤40例,压砸伤21例,摔伤5例.根据Allman分型:Ⅲ型31例,Ⅱ型35例;其中胸锁关节前脱位合并锁骨胸骨端骨折41例.受伤至手术时间3～62 d,平均7.5 d.Rockwood等胸锁关节评分标准对患者术后功能进行评价.结果 手术时间20～48 min,平均33 min;术中出血20～90ml,平均60 ml;术后无一例发生神经、血管损伤;切口均一期愈合.术后X线片及CT扫描示胸锁关节复位满意.66例患者均得到随访,随访时间12～37个月,平均17个月.末次随访时无一例患者发生胸锁关节再脱位和内固定失效.胸锁钩钢板均于术后12个月取出.Rockwood等胸锁关节评分为8～15分,平均为13.2分,其中优50例、良15例、可1例,优良率为98.5%.结论 胸锁钩钢板治疗创伤性胸锁关节前脱位手术安全,固定可靠,术后能允许肩胛带早期进行功能锻炼.

Abstract：

Objective To investigate the clinical outcomes of sternoclavicular hook plate in treatment of the anterior sternoclavicular joint dislocation. Methods A new device named sternoclavicular hook plate was devised by our team. Between May 2002 and Octorber 2009, 66 patients with sternoclavicular joint anterior dislocation were treated with the new device, among whom there were 47 males and 19 females,aged 21-68 years old (average, 32.6 years old). Twenty-one cases were caused by crush injury, 5 cases by falling and 40 cases by traffic accident. Anterior fracture-dislocation was found in 41 cases. According to the Allman system, there were 35 cases of type Ⅱ and 31 cases of type Ⅲ. Patients were evaluated with serial clinical and radiographic examinations. Rockwood score were used after the operation to assess the curative effect. Results The average operative time was 33 min (range, 20-48 min). The mean blood loss was 60 ml (range, 20-90 ml). There were no vascular or peripheral nerve injuries in the patients. All incisions healed smoothly. The X-ray and CT showed that the reduction of sternoclavicular joint and the location of internal fixation were satisfactory. All the 66 patients were followed up for 12-37 months (average, 17 months). There was no internal fixation failure, redislocation or other complications. The sternoclavicular hook plate was removed 12 months after operation. The mean Rockwood's score was 13.2 (8 to 15). There were excellent in 50cases, good in 15 cases, and fair in 1 case. Conclusion The sternoclavicular hook plate is a new, safe and liable technique for sternoclavicular fracture-dislocation. This new technique is helpful for early functional exercises.     

Right sternoclavicular dislocation after traumatic delivery: a case report

Sternoclavicular (SC) dislocation is an injury that is very rare in the newborn. Thus far there have been no reports describing this in neonates after a traumatic birth injury. This condition can be difficult to differentiate from epiphyseal separation, which occurs more often in older children. For successful treatment, early diagnosis is essential. Timely surgical reposition and fixation with following immobilization is recommended in instances of complete (SC) dislocation. We report a trauma-induced case of SC dislocation in a neonate successfully managed by polydioxanon cord fixation.     

Chronic recurrent anterior sternoclavicular joint instability: results of surgical management

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.     

Patients undergoing stabilization surgery for recurrent, traumatic anterior shoulder instability commonly have restricted passive external rotation

An important component in the surgical treatment of recurrent anterior shoulder dislocations is the Bankart repair. This is often supplemented with ligament plication for perceived laxity. The glenohumeral ligaments define translational laxity and restrict glenohumeral range of motion. The purpose of this study was to measure the external rotation (ER) range of motion of patients under anesthesia for glenohumeral stabilization surgery. A blinded observer measured bilateral shoulder ER in 15 patients by use of a standardized torque and goniometry. ER in the unstable shoulder with the arm abducted 90 degrees averaged 14 degrees less than that in the uninjured shoulder, and this was statistically significant. There was a significant loss of 11 degrees ER in the unstable shoulder with the arm at the side. The findings indicate that the glenohumeral joint in patients with a Bankart lesion is commonly rotationally stiff.     

Proximal interphalangeal joint instability: a dynamic technique for stabilization

Chronic, disabling, proximal interphalangeal joint instability is difficult to treat. We describe a method of stabilizing an unstable proximal interphalangeal joint using an adaptation of the oblique retinacular ligament reconstruction.     

Open posterior stabilization for recurrent posterior glenohumeral instability

Open posterior capsular shift is used for posterior glenohumeral instability that has failed nonoperative treatment. Few series have fully evaluated the outcome after open posterior stabilization. The purpose of this series was to evaluate the clinical and radiographic outcome after open posterior stabilization of the shoulder. Preoperative and intraoperative factors were analyzed with regard to their impact on results. Forty-eight consecutive shoulders were identified that had undergone primary open shoulder stabilization by use of open posterior capsular shift. Of the shoulders, 4 were lost to follow-up, resulting in a study group of 44 shoulders in 41 patients. Shoulders were evaluated at a range of 1.8 to 22.5 years after surgery by use of the L'Insalata shoulder form, Short Form-36 (SF-36), and a subjective shoulder rating in 44 shoulders. Thirty-nine shoulders were evaluated by physical examination, and thirty-seven underwent radiographic examination. A recurrence of posterior instability occurred in 8 shoulders (19%). Of the patients, 84% were satisfied with the current status of their shoulder. The mean L'Insalata score was 81.25+/-17.8 points, the mean SF-36 physical component score was 50.81+/-7.87, and the mean mental component score was 53.82+/-7.55. Significantly poorer satisfaction and outcome scores were seen in shoulders found to have a chondral defect at the time of stabilization and in patients aged greater than 37 years at the time of surgery. No progressive radiographic signs of glenohumeral arthritis were seen up to 22 years after surgery. Open posterior shoulder stabilization is a reliable procedure for treating significant posterior instability without causing arthritic changes. Patients found to have chondral damage within the shoulder and older patients were found to have less success after stabilization.     

Transpedicular reduction and stabilization for postlaminectomy lumbar instability

Summary This study retrospectively reviewed the outcomes of 17 patients with postlaminectomy lumbar instability treated by transpedicular reduction and stabilization. The criteria of instability were defined strictly by both the clinical symptom of instability catch and the radiological findings that fulfilled Nachemson's criteria. Low back pain and/or sciatica that interfered largely with the patients' work or quality of life were the indications for this treatrment. All the operations were performed by one surgeon with the same spinal instrumentation system — AO internal fixator. The follow-up period was between 16 and 36 months (mean 24 months).Face to face questionnaire revealed that this treatment modality is encouraging. Fourteen patients (82%) had complete or nearly complete relief from all the pre-operative symptoms. Two (12%) had partial relief of the symptoms that required a subsequent discectomy or wider laminectomy. Only one case (6%) with osteoporosis remained unchanged after the operation. On the follow-up radiographs, sixteen patients (94%) showed good alignment and solid arthrodesis of the treated motion segment. These radiological findings correlated quite well with the absence of the clinical symptom of instability catch.A common, but acceptable, complication found in this series was a variable degree of low back stiffness secondary to the instrumentation. Fracture of the screw was found in one patient and pull out of the screw was found in another patient. However, they did not elicit detectable symptoms.Osteoporosis, concomitant disc herniation and persistent spinal stenosis at/or adjacent to the operated level were the three main factors that may contribute to unsatisfactory results secondary to this treatment. These problems remain to be resolved in thp future.     

Bulge of the scapholunate ligament: an arthro-CT sign of traumatic scapholunate instability

Tears of the scapholunate ligament are usually diagnosed during an arthro-CT or arthro-MRI examination. Typically, the contrast agent passes from one joint to the other. In certain cases, fibrous scar tissue devoid of any mechanical effect may block the passage and lead to an erroneous interpretation of the images. We reviewed retrospectively patients who underwent arthroscopic treatment for scapholunate tears and who had normal arthro-CT images. We searched for specific aspects suggestive of ligament injury. Analysis of the arthro-CT images demonstrated that a bulge of the scapholunate ligament could be noted in patients whose diagnosis of scapholunate ligament injury was established arthroscopically. We propose that appropriate lecture of wrist images can identify scapholunate ligament injury in patients wrongly considered to be free of wrist injury, but who actually have an occult injury to the scapholunate ligament.