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Com Complication

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• f SC

C Recon

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Larry D. Field, MD Mississippi Sports Medicine and Orthopaedic Center Jackson, MS

Disclosures

The following relationships exist:

• 1. Royalties and stock options
• None
• 2. Consulting income
• Smith & Nephew
• 3. Research and educational support
• Arthrex
• Mitek
• Smith & Nephew
• 4. Other support
• None

SC SC Joi

• int I

Injuries es

• Relatively rare

‒ 3% of shoulder girdle injuries ‒ 1% of all dislocations

• Etiologies

‒ Atraumatic anterior subluxation

• Relatively young (<20)
• Hyperlaxity common
• Most treated non-operatively

‒ Traumatic

• Anterior, posterior, and superior

‒ Degenerative

Surgical Intervention

• No consensus on indications or
• ptimal method
• Multiple techniques

‒K-Wires (historical only) ‒Plates ‒Trans-osseous sutures ‒Graft reconstruction techniques

Surgical Indications Key

• Posterior dislocations - Serious complications rare

‒ Closed/Open reduction often recommended

• Anterior instability and degenerative causes

‒ Most complications iatrogenic ‒ Non-operative skillful neglect often warranted

“These patients can prove to be, if surgery is performed, a great embarrassment to the surgeon.” Carter R. Rowe, MD

Surgical Complications

• Intra-operative

‒ Injury to mediastinal structures

• Great vessels
• Esophagus
• Trachea
• Post-operative

‒ Hardware migration

• NEVER use pins, wires
• 8 deaths from pin migration

‒ Recurrent instability ‒ Iatrogenic instability (degenerative causes)

• Following medial clavicle

resection

‒ SC joint arthritis following reconstruction ‒ Infection

Intra-Operative Complications

• Rare
• Mediastinal structures close

proximity

‒“Jungle of Structures” ‒Most authors recommend cardiothoracic surgeon be present

• r available
• Intimate knowledge of anatomy

imperative

JSES 2013

• CTs of 49 consecutive patients

‒ Presented to ER with neck complaints

• Measurements of mediastinal

structures from SC joints recorded

• Nearest average anatomic

structure distance ‒ 6.0 mm (Brachiocephalic vein)

• Some CTs showed structures only 1mm away
• No “safe zone” could be identified

Post-Operative Complications

• Serious complications relatively uncommon

‒ Recurrent instability ‒ Hardware complications

• No pins / K-wires

‒ SC joint pain / Skin sensitivity

• Atraumatic instability patients more prone to post-
• perative complications

‒ Rockwood and Odor (JBJS 1989)

• 37 patients (29 non-operatively, 8 operatively)
• Good outcome with non-operative management
• Most surgically treated patients failed

Post Operative Complications

• 32 open SC graft

reconstructions (anchors)

• 3 revision surgeries

‒2 revision reconstructions ‒1 SC debridement

JSES 2014

Post-Operative Complications

• 14 SC graft reconstructions

‒ 12 chronic ‒ 6 posterior dislocations

• 6 complications in 5 patients (36%)

‒ Recurrent instability ‒ Wound dehiscence

J Ortho Trauma, 2016

Post-Operative Complications

• Costoclavicular ligament

continuity important

• Failure to repair or

reconstruct risk factor

‒ Rockwood et (JBJS 1997)

• Resected medial clavicle in

15 patients

• 8 patients with ligament

maintained did well

• 7 without ligament

preservation/reconstruction faired poorly

Post-Operative Complications

• Costoclavicular ligament

preservation

‒ Do not over-resect clavicle ‒ Consider stabilizing clavicle to first rib if unrepairable

• Analogous to CC ligaments at

AC joint

‒ CC ligaments preserved or reconstructed to maintain AC joint stability

Summary

• Serious complications relatively uncommon

‒ Some life threatening ‒ Cardiothoracic surgeon available ‒ Avoid pins/wires

• Detailed knowledge of anatomy vital
• Indications for surgery very important
• Preserve/reconstruct costoclavicular ligament as

necessary

Thank You