SC Joint Reconstruction | Gracilis Tendon Autograft

In this video, SC joint reconstruction with a Gracilis tendon autograft is discussed by shoulder surgeon Peter Millett, MD. The stability of the sternoclavicular joint is achieved by surrounding ligaments, which consist of the intra-articular meniscal band, the interclavicular ligament, the costoclavicular ligament at the joint capsule. Injuries to the SC joint are rare, comprising 3% of all shoulder girdle injuries. This type of joint injury mainly occurs after high-energy trauma caused by motor vehicle crashes and sports injuries.

Indication SC joint reconstruction includes failure of acute closed reduction of posterior dislocations because of their potential mediastinal compression. The surgical options for SC joint reconstruction include:

- Graft reconstruction techniques using subclavius tendon, semitendinosus tendon, palmaris longus tendon or fascia lata graft
- Plate reconstruction using a Balser plate
- Transosseous tension band technique using PDS cord
- Resection arthroplasty
- Combination of the afromentioned techniques

In current literature, there are only small case series available and there is no gold standard procedure defined to date. In this video, shoulder surgeon Dr. Peter Millett presents the SC joint reconstruction technique using a gracilis tendon autograft as biologic augmentation. This technique is preferred for acute and chronic SC instability as it enhances biological healing particularly important in chronic cases. This technique has also been shown to provide superior biomechanical properties to those of the intramedullary ligament reconstruction and subdavius tendon reconstruction techniques.

The SC joint reconstruction technique using a Gracilis tendon autograft are as follows:

1. Making the landmarks
2. Surgical Approach
3. Exposure of the SC joint and opening of the joint capsule
4. Circumferntial capsular release and release to the sternocloidomastoid muscle attachments
5. Removal of the intra articular strenoclavicular disc
6. Mobilization of the clavicule so that the malleable retractor can be put under clavicle/sternum before drilling the bone tunnels
7. Harvesting the gracilis tendon and preparation with sutures
8. Creation of 2 tunnels on the sternum and the proximal clavicle at he level of the condylar flair
9. shuttling of the graft in a figure of 8 configuration using shuttle sutures
10. Knotting the two ends of the graft together and securing with 4 Ethibond sutures
11. Testing of stability
12. Dr. Millett usually inject demineralized bone matrix around the tunnel to enhance healing of the tendon in the bone tunnel
13. Closure of the capsular joint and skin

One of the most important parts of this procedure occurs with a Malleable retractor that is placed under the mobilized sternum in order to avoid any injury of the retrosternal structures. K-wires are placed and overfilled at the appropriate location in order to avoid fractures: approx. 1 cm from the lateral sternal border and 1 cm distance between the 2 drill holes.

The rehabilitation for an SC joint reconstruction using a Gracilis tendon autograft uses protected passive range of motion for the first 6 weeks. Active motion at 6 weeks. Strengthening begins 10-12 weeks post-surgically. Return to sports at 6 months.