Sternoclavicular joint reconstruction: a systematic review.
Abstract: Background: Dislocation of the sternoclavicular joint is a rare injury that has a low incidence of significant long-term symptoms. Surgical reconstruction of the joint is indicated in patients with symptomatic, chronic anterior instability or with irreducible or recurrent posterior instability. There have been many reported techniques for stabilization of the joint, but few investigators have reported more than several cases. The ideal reconstruction has not been identified.

Purpose: The purpose of this investigation was to perform a systematic review of the available literature with the objective of identifying one technique of sternoclavicular reconstruction that could be recommended.

Methods: A systematic review of literature pertaining to treatment of sternoclavicular joint injuries was performed, focusing on clinical reports with at least six patients and 1 year of follow-up. We also reviewed biomechanical reports pertaining to sternoclavicular reconstruction.

Results: Six clinical reports and two biomechanical studies were identified that met our inclusion criteria. Treatments described in the clinical reports included conservative treatment with a sling, repair of the joint capsule with provisional stabilization, and joint reconstruction with local tissue or graft tissue. One biomechanical study compared the strength of three reconstruction techniques.

Conclusion: Reconstruction with tendon tissue woven in a figure-of-eight pattern through drill holes in the manubrium and clavicle is stronger than reconstructions with local tissue. The review of clinical reports suggests excellent outcomes with this technique, and it is recommended in cases of chronic instability. In cases of acute instability requiring open reduction or inability to maintain a reduction in a posterior dislocation, there is evidence that repair of the joint capsule is sufficient surgical treatment.
Article Type: Clinical report
Subject: Surgery, Plastic
Authors: Thut, David
Hergan, David
Dukas, Alex
Day, Michael
Phil., M.
Sherman, Orrin H.
Pub Date: 04/01/2011
Publication: Name: Bulletin of the NYU Hospital for Joint Diseases Publisher: J. Michael Ryan Publishing Co. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 J. Michael Ryan Publishing Co. ISSN: 1936-9719
Issue: Date: April, 2011 Source Volume: 69 Source Issue: 2
Product: Product Code: 8000418 Cosmetic Surgery NAICS Code: 62 Health Care and Social Assistance
Accession Number: 289120436
Full Text: Injuries to the sternoclavicular joint are rare. (1-3) While the bony architecture lends little inherent stability to the joint, the anterior and, particularly, the posterior ligaments make it one of the most stable joints in the body. (4-7) Allman (8) described sprain injuries to the sternoclavicular joint and assigned them a grade from I (no joint laxity) to III (complete rupture of sternoclavicular and costoclavicular ligaments with dislocation). Dislocation of the sternoclavicular joint occurs most commonly in the anterior direction. The mechanism of traumatic anterior dislocation typically involves an indirect force on the shoulder with the arm abducted. (9) Spontaneous anterior and, rarely, posterior dislocations have been reported as well. (10-15) Biomechanical studies have shown that the force required to dislocate the clavicle posteriorly is 50% greater than the force needed for an anterior dislocation, due to the strength of the posterior joint capsule. (5,16) Accordingly, clinicians see posterior dislocations less frequently. The mechanism can involve either a medially directed force on the shoulder, with the arm adducted and flexed, or a posterior force on the medial clavicle. (17-19) Posterior dislocations can be associated with injuries to the underlying mediastinal structures and require formal reduction. (20-24) Investigators have encouraged the presence of thoracic surgery personnel in the operating theater during reduction, due to the risk of significant vascular or visceral injury. (25)

While both spontaneous and traumatic anterior dislocations frequently remain chronically unstable, the incidence of debilitating symptoms is low. (26-28) Conversely, the sternoclavicular joint is commonly stable following reduction of a posterior dislocation. (23,29) Chronic instability, however, can lead to vascular and visceral injuries over time. (30) Indications for surgical stabilization of the sternoclavicular joint include 1. chronic symptomatic anterior instability and 2. recurrent or irreducible posterior dislocation. (31) Given the benign course of chronic anterior instability and the rarity of recurrent posterior instability, reconstruction of the sternoclavicular joint is a rare procedure. (32) The proximity of the mediastinal structures and the lack of familiarity of most orthopaedic surgeons with the local anatomy make stabilization a relatively risky procedure. Multiple techniques have been reported in the literature, though the published series are typically quite small. (33-37) The goal of this article is to review the literature systematically with the objective of finding a preponderance of support for one specific technique.

Materials and Methods

We searched the Medline[R] and PubMed[R] databases for English language articles relevant to sternoclavicular joint instability. The search terms "sternoclavicular" and "clavicle" were used independently as well as paired with "dislocation" and "reconstruction." Relevant articles, including review articles, were pulled for study. The bibliographies of each report were reviewed for relevant articles missed in our computerized literature search.

Two different groups of articles were included in our review according to criteria chosen prior to beginning the literature search. Any article directly addressing the biomechanics of sternoclavicular reconstructions in cadavers was included. Clinical articles were required to be primary case series of at least six patients, each receiving the same reconstruction and with at least 1 year of follow-up. Case control studies or randomized studies with six patients per group and 1 year follow-up would have been included as well. Articles were restricted to reconstructions after ongoing traumatic or spontaneous instability. Reconstructions required after clavicle or manubrial resection for infection or tumor were excluded, as those reconstructions included soft tissue reconstruction for chest wall defects. (38) Treatment of sternoclavicular arthritis without instability was also excluded. (39,40) Two of the authors reviewed articles and abstracts and agreed upon the final list of included articles. The same authors also assessed the level of evidence of each clinical report.

Results

Literature Search

The literature search identified six reports that met inclusion criteria for the clinical reports. While several of the included papers reported results of reconstructions in a heterogeneous group of patients, each had tables that allowed extraction of a group of at least six patients treated in a uniform fashion for instability. All reports represented level IV clinical evidence. The quality of the outcome measures was inconsistent among the reports, but any report with a follow-up of at least 1 year was included per our methodology. Two relevant biomechanical studies were identified that report upon the strength of specific sternoclavicular reconstruction techniques. The clinical reports are summarized in Table 1, and the biomechanical reports are summarized in Table 2.

Clinical Reports

In 1988, Ferrandez and colleagues (41) reported their experience with 17 acute sternoclavicular injuries. Patients were divided into two groups. One group represented a series of six patients with subluxations of the joint, which were treated conservatively with a Valpeau sling for 3 weeks. At follow-up, ranging from 1 to 4 years (average, 2.5 years), all conservatively treated patients had "excellent results in terms of pain, mobility, and resumption of work." The only exception was one patient unable to return to work due to an unrelated femur fracture. The remaining 10 patients had sternoclavicular dislocations and were treated surgically. All patients were treated with sternoclavicular Kirschner (K-) wires to temporarily stabilize the joint while a capsular repair healed. Four patients had the addition of surgical wire fixation from the medial clavicle to the manubrium. Those patients did not represent a large enough group to be independently included in this study, though it is relevant to note that one of these patients experienced mediastinal migration of a K-wire. The six patients who did not have sternoclavicular wiring, however, are included here. On an average of a 2.5 year follow-up, four patients were reported as having deformity at the sternoclavicular joint, one had no deformity and one had a "small prominence." Five of the six had what was described as normal motion, while one had moderate limitation. All were able to resume work though one had retired. Two patients had cheloid scarring, and one had mediastinal migration of K-wires.

In 2003, Franck and coworkers (42) reported their experience with sternoclavicular stabilization with a Balser plate. They operated on 10 patients diagnosed with acute instability of the sternoclavicular joint but in whom a stable reduction could not be achieved. Seven patients had anterior dislocations, and three had posterior dislocations. One of the posterior dislocations was associated with a medial clavicular physeal injury. The surgical technique consisted of placing a hooked plate on the medial clavicle to reduce the dislocation. In patients with anterior dislocations, the hooks were placed posterior to the manubrium. In the patients with posterior dislocations, the hooks were placed in an intraosseus position in the manubrium to prevent redisplacement posteriorly. Plates were removed at 3 months after injury, with the exception of one patient who had the plate removed at 2 months due to seroma formation. Nine patients were available for follow-up at greater than 1 year after surgery (average length of follow-up was not reported). DASH (disabilities of the arm, shoulder, and hand) score and Constant scores were reported. The investigators noted no redislocations. One patient had arthrosis noted on radiographic evaluation, and he had the lowest Constant score in the group. The average Constant score for the group was 90.2 [+ or -] 6.6. The seroma was the only complication.

In 1997, Rockwood and associates (14) reported on their results of reconstructing the stabilizing ligaments of the medial clavicle using the joint capsule and disc, while preserving the periosteal attachments of the proximal clavicle. All patients had chronic symptoms following sternoclavicular injuries. Their two groups were divided based upon presence of previous surgery. While they included patients with post traumatic arthritis and instability, we were able to extract data for those with instability. The procedure involved dissecting the periosteal sleeve off of the medial clavicle from the cranial to caudad surface, keeping a tube intact for later repair. The medial aspect (1.5 cm) of clavicle was resected. The capsule and disc were maintained and brought with a suture into the medial medullary canal of the clavicle and tied through drill holes. The periosteal sleeve was then repaired. If the costoclavicular ligaments were injured, several sutures were placed to hold reduction of the medial clavicle to the first rib. The investigators devised a rating scale based on pain, range of motion, strength, limitation, and subjective result in order to evaluate outcomes. Excellent, good, fair, and poor results were defined based on numerical scores. Of the six instability patients in group I, those without prior surgery, all achieved excellent results. Time of follow-up ranged from 2.0 to 14.5 years (average, 5.7 years). Of the 6 patients with instability in group II, the prior surgery group, two achieved excellent results, three fair and one poor results. Time of follow-up ranged from 3.3 to 18.3 years (average, 10.1 years). The study concluded that patients with atraumatic spontaneous anterior dislocation should be treated nonsurgically. Traumatic anterior dislocations are treated conservatively, unless there is ongoing painful instability. Acute posterior dislocations are typically stable after reduction and only require resection and reconstruction for ongoing pain.

In 2006, Bae and colleagues (43) reported the results of surgical stabilization of the sternoclavicular joint for chronic instability after anterior dislocations. All patients had been through and failed a course of conservative treatment. Twenty-four patients had undergone surgery and 15 were available for longer-term follow-up. Average age of patients was 15.9 years, with a range of 12 to 23 years. Average follow-up was 55 months, with a range of 7 to 164 months. The investigators utilized several surgical techniques. Five had medial clavicular resections, with removal of 2 to 2.5 cm of bone and closure of the medial periosteum "when possible." Nine patients had reconstruction of the medial sternoclavicular joint. In eight patients, semitendinosus tendon was used, and, in one case, sternocleidomastoid fascia graft was used. In each reconstruction case, the graft was woven in a figure-of-eight through drill holes in the medial clavicle and the manubrium. Postoperatively, the patients were immobilized in a sling and swathe for 2 to 4 weeks, followed by progressive mobilization in PT. Unfortunately, the only outcome measure that is divided out based upon surgical technique is the Simple Shoulder Test (SST). The maximum possible score is 12, and higher numbers reflect better shoulder function. In the reconstructed patients, the average score was 11.4, with a range from 8 to 12. No major complications were reported.

Abiddin and coworkers (44) published their experience with sternoclavicular stabilization using suture anchors in 2006. Their cases were somewhat heterogeneous. Of their eight shoulders, five had traumatic instability and three had spontaneous instability. All but one of the patients had anterior instability. The indications for surgery were described as "pain associated with instability of the sternoclavicular joint." Patient age ranged from 16 to 48 years, average 23.5 years. Follow-up ranged from 1 to 7.6 years with a mean of 4.5 years. The procedure was performed at a mean of 14 months after initial dislocation, but the range was from immediate to 4 years. Though not explicitly stated in the text, it appears that the one joint that was immediately stabilized was in a 16-year-old patient, who had undergone stabilization on the right side and then in falling from a horse sustained a redislocation of the operative side and a new dislocation of the left sternoclavicular joint. The right side was revised and the left side was repaired acutely. The reported technique involved placing two suture anchors in the manubrium and passing the sutures through drill holes on the anterior surface of the clavicle. The joint capsule was then repaired. Patients were immobilized in a sling for 2 weeks, followed by progressive mobilization. No strenuous activities were allowed for 4 months. At follow-up, there were no instances of infection or hardware migration. Two patients required reoperation. One was the patient who had fallen from a horse, and the other was a patient with initial injuries that included sternum and rib fractures. He required revision stabilization 1 year after initial surgery. He had satisfactory results after initial revision for 3 years, but then had a medial clavicle excision. Reported results included the subjective Oxford Shoulder Questionnaire and the objective Constant Score. On a range from 12 (best) to 60 (worst), the mean Oxford score was 15.75 (range, 12 to 38). The average Constant score was 74.88 (range, 33 to 87), with the maximum Constant score of 100 representing a best outcome. The only unsatisfactory result was for the patient with multiple surgeries (Constant score, 33). The investigators concluded that their technique was anatomic and easy to perform, with a low complication rate. They recommended the procedure for patients with persistent, painful recurrent instability of the sternoclavicular joint.

Armstrong and Dias (45) published their results of sternoclavicular reconstruction using sternocleidomastoid tendon in 2007. Their series included seven shoulders in six patients with chronic sternoclavicular instability. Their patients ranged in age from 18 to 24 years, with an average of 20.7 years. Four patients had a history of trauma, and the others had spontaneous instability. In six, shoulder symptoms were present from 2 to 8 years. One patient had 3 months of symptoms, and in one patient duration was not documented. Their surgical technique was as follows: the medial border of the sternocleidomastoid tendon was released proximally to obtain a 3 mm piece of tendon, with a strong manubrial attachment of at least 8 cm in length. The suture was passed from cranial to caudal through a 3.2 mm drill hole made in the medial clavicle. The tendon was then repaired to itself at the manubrial insertion. The capsule and disc were repaired. Patients were reviewed at a mean follow-up of 39.7 months (range, 15 to 63 months). Two patients reported scar sensitivity, one transient, but on resolving only after 1 year. They reported only on the stability of the joint. Two patients had a joint that was stable for all activities; four patients were stable except for transient subluxation but were not limited in activity; and one patient was stable most of the time but unable to participate in sports. The only patient with residual pain was the one with scar sensitivity, which resolved. They note that one of their patients was able to return to rugby.

Biomechanical Reports

Thomas and associates (46) reported on a "safe" technique to suture the medial clavicle to the manubrium. They described their "safe" repair as using two sutures passed through drill holes in the medial clavicle and manubrium anteriorly. Rather than passing the sutures out the posterior cortices, however, the sutures were brought through the cortex in the joint, so as not to enter the intrathoracic space. This approach was compared to a repair where the sutures were passed around the medial clavicle and first rib. Four joints were used. The "safe" repair was performed using No. 5 Ethibond and PDS (polydioxone) suture. The first rib repair was performed using the same two sutures. Each construct, therefore, was tested in only one joint. The two "safe" repairs were intact with 50 kg of anteriorly directed force applied to the medial clavicle; however, both had 50% anterior subluxation of the joint. The first rib repairs also held 50 kg of force but with 75% anterior subluxation. The investigators then reported on three cases where their "safe" technique was used for joint reconstruction, making no mention of capsular closure.

Spencer and Kuhn (47) compared the strength of three different reconstructions in cadavers. The first reconstruction used the subclavian tendon, left on its first rib attachment, and bringing it through a drill hole in the medial clavicle, as described by Burrows. (48) The second reconstruction, the intramedullary ligament reconstruction, was as described by Rockwood and colleagues. (14) The details are outlined above. The third reconstruction was using a semitendinosus tendon in a figure-of-eight through two drill holes in the medial clavicle and two drill holes in the manubrium. Each repair was tested in anterior and posterior directions. The reconstructions were compared to the stiffness of native ligaments. In the anterior direction, the intramedullary reconstruction showed a 70.1% decrease in stiffness, the subclavian reconstruction showed a 56.9% decrease in stiffness, and the figure-of-eight reconstruction showed a 36.9% reduction in stiffness. There was no significant difference between the figure-of-eight and the subclavian reconstructions (p = 0.078), but there was between the figure-of-eight and the intramedullary ligament reconstruction (p = 0.004). The peak load, defined as the load causing 100% displacement of the medial clavicle, was 230.3 [+ or -] 146.1 N for the figure-of-eight, 84.6 [+ or -] 45.7 N for the intramedullary, and 75.6 [+ or -] 19.0 N for the subclavian. In the posterior direction, the intramedullary reconstruction showed a 74.4% decrease in stiffness, the subclavian reconstruction showed an 82.3% decrease in stiffness, and the figure-of-eight reconstruction showed a 3.8% reduction in stiffness. The differences were significant between the figure-of-eight and the other two methods (p = 0.004). Peak load was 241.4 [+ or -] 49.7 N for the figure-of eight reconstruction, 85.0 [+ or -] 22.8 N for the intramedullary reconstruction, and 51.5 [+ or -] 28.9 N for the subclavian reconstruction. Four of the six subclavian reconstructions failed before reaching 100% anterior displacement, and all of them failed prior to reaching 100% posterior displacement.

Discussion

The goal of our systematic review was to determine the best method of reconstructing the unstable sternoclavicular joint. We were able to identify six clinical papers reporting on seven case series that met our inclusion criteria. No report had a level of evidence greater than level IV. Unfortunately, the reports' heterogenous outcome measures do not lend themselves easily to comparison. Additionally, the paucity of complications reported hinders stratification of the techniques based on that measure.

Two reports addressed the stabilization of acutely injured joints. Ferrandez and coworkers (41) treated six patients with acute capsular repair and stabilization with K-wires. One patient had a K-wire migrate into the mediastinum, only one of the six had no deformity, one had limitation of motion, but all returned to work. The second report by Franck and associates (42) reported the use of a hooked Balser plate to provisionally fix the joint, while awaiting healing of the repaired capsule. They had no redislocations and an average constant score of 90.2 [+ or -] 6.6. One patient developed arthritis in the joint. The positive results in these studies suggest that if surgery is required in the acute setting, capsular repair with provisional fixation may be satisfactory treatment. The risk of wire migration is significant and is reported in multiple other studies in the literature. (49-52)

The reports included in our review described five different reconstruction techniques for chronic instability. Rockwood and colleagues14 developed their own scoring system to evaluate sternoclavicular symptoms. They found that in patients with instability, excellent results were consistently obtained by simple resection of the medial clavicle and closure of the periosteal sleeve over the bone. Abbidin and coworkers (44) stabilized the medial clavicle with suture anchors in the manubrium. Two of eight shoulders required revision surgery, one due to recurrent trauma and one because of failure at 1 year.

Three of the reconstruction techniques utilized tissue grafts to reconstruct the joint. Rockwood and associates (14) used the joint capsule and intra-articular disc, pulled to into the osseous canal, to stabilize joints that had previous resections. Two patients achieved excellent results, three had fair results, and one had a poor result; there were no good results. Armstrong and Dias (45) used sternocleidomastoid tendon through a single drill hole in the medial clavicle to reconstruct the joint in seven shoulders. Two patients had a joint that was stable for all activities, four were stable except for transient subluxation, and one was unable to participate in sports.

Bae and colleagues (43) reported their results reconstructing the sternoclavicular ligaments, using tendon graft passed in a figure-of-eight through drill holes. They reported no complications and an average score on the SST of 11.4 (maximum, 12). The excellent results in their report are corroborated in two case reports in the literature as well. In addition, the strong clinical outcomes for this technique are supported by biomechanical studies. Spencer and Kuhn (47) showed that the initial strength of such a reconstruction was significantly stronger than either an intramedullary reconstruction, as recommended by Rockwood and coworkers (14) or a subclavian reconstruction as advocated by Burrows. (48)

In preparing our study, we performed a thorough review of the English literature on reconstruction for sternoclavicular instability. Strict, predetermined criteria were used to evaluate reports for inclusion in our review. We were able to include six clinical reports and examine the results of different treatments. Our clinical findings were strengthened by the results of a very good biomechanical report evaluating reconstruction strength.

A review of this literature is limited by the fact that most papers report single cases or small series of patients. There are several published techniques without sufficient numbers of patients or sufficient follow-up to be included in our review. (53) We identified no prospective studies, and the outcome measures in most reports were weak. The incidence of sternoclavicular instability requiring surgery is low enough that a randomized prospective study is unlikely to have sufficient numbers of patients unless a multicenter trial was developed. Our hope is that future reviews of clinical results will include prospectively collected data on joint stability, shoulder range of motion, return to activity, and validated shoulder-specific outcome measures. Because of the low numbers of patients, studies have not adequately separated shoulders with different types of instability. Anterior and posterior instability are typically reported together, with little effort to separate acute from chronic instability. A large multicenter study may demonstrate that different techniques are successful in different clinical scenarios.

The medial physis of the clavicle remains open into a person's mid-twenties, so dislocations of the sternoclavicular joint in children typically represent a fracture dislocation. We excluded articles that explicitly described treatment of fracture dislocations. (53-56) We note that in the Bae and associates (43) report, the average age of the patients was 15.9 years, though injuries were described as joint dislocations. Future studies should be clear about the difference between shoulder dislocation and fracture dislocation.

Conclusion

The literature supports conservative treatment for most patients with chronic anterior sternoclavicular instability, as these patients will tolerate their condition. Those patients with ongoing disability may be candidates for joint reconstruction. Patients with posterior dislocations are typically stable after reduction, but require surgery if they redislocate or if there is ongoing symptomatic instability. The clinical literature is replete with proposed procedures to stabilize the sternoclavicular joint. A systematic review of both clinical and biomechanical data led us to recommend a reconstruction technique for patients who have continued symptomatic instability. The approach is to use tendon graft in a figure-of-eight fashion through drill holes in the sternum and manubrium. Patients who are treated surgically in the acute setting may do well with provisional stabilization of the joint and repair of local joint capsule. Surgeons should be aware of the significant risk of pin migration at the sternoclavicular joint.

Disclosure Statement

None of the authors have further financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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(49.) Venissac N, Alifano M, Dahan M, et al. Intrathoracic migration of Kirschner pins. Ann Thorac Surg. 2000 Jun;69(6):1953-5.

(50.) Leppilahti J, Jalovaara P. Migration of Kirschner wires following fixation of the clavicle-a report of 2 cases. Acta Orthop Scand. 1999 Oct;70(5):517-9.

(51.) Chou NS, Wu MH, Chan CS, et al. Intrathoracic migration of Kirschner wires. J Formos Med Assoc. 1994 NovDec;93(11-12):974-6.

(52.) Liu HP, Chang CH, Lin PJ, et al. Pulmonary artery perforation after Kirschner wire migration: case report and review of the literature. J Trauma. 1993 Jan;34(1):154-6.

(53.) Battaglia TC, Pannunzio ME, Chhabra AB, et al. Interposition arthroplasty with bone-tendon allograft: a technique for treatment of the unstable sternoclavicular joint. J Orthop Trauma. 2005 Febr;19(2):124-9.

(54.) Franck WM, Siassi RM, Hennig FF. Treatment of posterior epiphyseal disruption of the medial clavicle with a modified Balser plate. J Trauma. 2003 Nov;55(5):966-8.

(55.) Waters PM, Bae DS, Kadiyala RK. Short-term outcomes after surgical treatment of traumatic posterior sternoclavicular fracture-dislocations in children and adolescents. J Pediatr Orthop. 2003 Jul;23(4):464-9.

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David Thut, M.D., David Hergan, M.D., Alex Dukas, M.A., Michael Day, M.Phil., and Orrin H. Sherman, M.D.

David Thut, M.D., and David Hergan, M.D., are Fellows in the Division of Sports Medicine, Department of Orthopaedic Surgery. Alex Dukas, M.A., and Michael Day, M.Phil., are from the Department of Orthopaedic Surgery. Orrin Sherman, M.D., is Associate Professor of Orthopaedic Surgery, NYU School of Medicine, and within the Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York.

Correspondence: Orrin H. Sherman, M.D., Suite 8U, Skirball Institute, 530 First Avenue, NYU Langone Medical Center, New York, New York 10016; orrin.sherman@nyumc.org.
Table 1 Overview of Clinical Studies

                  No.
Author(s)         Shoulders        Follow-Up   Procedure

Ferrandez et      Six acute        2.5 yrs     Valpeau sling,
al., (41) 1988    subluxations                 3 wks

                  Six acute        2.5 yrs     Capsule repair
                  dislocations                 with K-wire
                                               fixation

Franck et         10 acute         > 1 yrs     Balser plate,
al., (42) 2003    dislocations:                removed at 3
                  seven ant,                   mos
                  three post

Rockwood et       Six chronic      5.7 yrs     Resect 1.5 cm
al., (14) 1997    without prior                medial
                  surgery                      clavicle, tie
                                               capsule and
                                               disc into
                                               medullary
                                               canal, repair
                                               capsule

                  Six chronic      10.1 yrs    Resect 1.5 cm
                  with prior                   medial
                  surgery                      clavicle, tie
                                               capsule and
                                               disc into
                                               medullary
                                               canal, repair
                                               capsule

Bae et al.,       Nine chronic     55 mos      Graft (8
(43) 2006         anterior                     semitendinosus,
                  Avg age 15.9                 1 sternocleido-
                  yrs                          maastoid
                                               fascia) woven
                                               in figure-of-
                                               eight through
                                               two drill
                                               holes in
                                               manubrium and
                                               two in
                                               clavicle

Abiddin et        Eight            4.5 yrs     Two suture
al., (44) 2006    shoulders,                   anchors in
                  two acute,                   manubrium,
                  six chronic,                 sutures in
                  seven                        clavicle,
                  anterior, one                repair capsule
                  posterior

Armstrong         Seven            39.7 mos    Use medial
and Dias, (45)    shoulders,                   sternocleido-
2007              chronic                      mastoid as
                                               graft, leave
                                               attached to
                                               manubrium,
                                               through drill
                                               hole in
                                               clavicle
                                               Repair capsule

Author(s)         Results                   Complications

Ferrandez et      Excellent results for     None
al., (41) 1988    pain, mobility,
                  resumption of work

                  Four shoulders with       Two cheloid scars
                  residual deformity, one   One mediastinal K-wire
                  with small prominence     migration

                  Five with normal
                  motion, one with
                  moderate limitation
                  All resumed work

Franck et         Avg Constant score        One seroma
al., (42) 2003    90.2+ -6.6
                  One sternoclavicular
                  arthritis

Rockwood et       Six excellent results     None
al., (14) 1997    on their scale

                  Two excellent, three      None
                  fair, one poor

Bae et al.,       Avg SST score, 11.4       None
(43) 2006         (maximum, 12)

Abiddin et        Mean Oxford               Two reoperations, one
al., (44) 2006    score 15.75 (12 best,     after fall from horse,
                  60 worst)                 one after failure at 1
                                            year, revision failed
                  Mean Constant Score       at 3 yrs.
                  74.88 (100 best)

Armstrong         Two stable shoulders,     Two transient scar
and Dias, (45)    four transient            sensitivity
2007              subluxation, one
                  instability limiting
                  sports

SST, Simple Shoulder Test

Table 2 Overview of Biomechanical Studies

Author           Technique                   Results

Thomas et al.,   "Safe" repair with two      50 kg anterior force
(46) 2000        sutures passed through      caused 50% subluxation of
                 drill holes in manubrium    joint repaired both with
                 and clavicle Suture         No. 5 Ethibond and PDS
                 around clavicle and first
                 rib                         50 kg anterior force
                                             caused 75% subluxation of
                                             joint repaired both with
                                             No. 5 Ethibond and PDS

Spencer and      Subclavian tendon through   Peak load 75.6 [+ or -]
Kuhn, (47)       drill holes in medial       19.0 N anterior 51.5
2004             clavicle                    [+ or -] 28.9 N posterior

                 Capsule and disc into       Peak load 84.6 [+ or -]
                 medullary canal             45.7 N anterior 85.0
                                             [+ or -] 22.8 N posterior

                 Figure-of-eight             Peak load 230.3 [+ or -]
                 semitendinosus graft        146.1 N anterior 241.4
                 through two drill holes     [+ or -] 49.7 N posterior
                 in clavicle and two in
                 manubrium                   (p = 0.004 relative to
                                             intramedullary anterior)

                                             (p = 0.004 relative to
                                             both intramedullary and
                                             subclavian posterior)

PDS, polydioxone suture.
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