Com Complication ons of of SC C Recon onstruction ons Larry - PowerPoint PPT Presentation

Com Complication ons of of SC C Recon onstruction ons 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 oint I Injuries es • Relatively rare ‒ 3% of shoulder girdle injuries ‒ 1% of all dislocations • Etiologies ‒ Atraumatic anterior subluxation o Relatively young (<20) o Hyperlaxity common o Most treated non-operatively ‒ Traumatic o Anterior, posterior, and superior ‒ Degenerative

Surgical Intervention • No consensus on indications or optimal 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 o Great vessels o Esophagus o Trachea • Post-operative ‒ Hardware migration o NEVER use pins, wires o 8 deaths from pin migration ‒ Recurrent instability ‒ Iatrogenic instability (degenerative causes) o 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 or 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 o No pins / K-wires ‒ SC joint pain / Skin sensitivity • Atraumatic instability patients more prone to post- operative complications ‒ Rockwood and Odor (JBJS 1989) o 37 patients (29 non-operatively, 8 operatively) o Good outcome with non-operative management o Most surgically treated patients failed

Post Operative Complications JSES 2014 • 32 open SC graft reconstructions (anchors) • 3 revision surgeries ‒ 2 revision reconstructions ‒ 1 SC debridement

Post-Operative Complications J Ortho Trauma, 2016 • 14 SC graft reconstructions ‒ 12 chronic ‒ 6 posterior dislocations • 6 complications in 5 patients (36%) ‒ Recurrent instability ‒ Wound dehiscence

Post-Operative Complications • Costoclavicular ligament continuity important • Failure to repair or reconstruct risk factor ‒ Rockwood et (JBJS 1997) o Resected medial clavicle in 15 patients o 8 patients with ligament maintained did well o 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

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