TECHNICAL TRICK A Novel Technique for Ligamentous Reconstruction of the Sternoclavicular Joint Robert J. Gaines, MD,* Frank A. Liporace, MD,† Richard S. Yoon, MD,† and Marlene DeMaio, MD* Summary: The technique presented is a departure from previous attempts to standardize the treatment of sternoclavicular dislocations. It offers stability without requiring extra dissection around vital intrathoracic structures and greatly decreases the risk of migration of the implant used for fixation. Key Words: sternoclavicular joint, dislocation, ligament, reconstruction, Zip Loop, costoclavicular ligament (J Orthop Trauma 2014;28:e65–e69) T he various techniques for reconstruction of the sternocla- vicular joint reflect an absence of our complete understand- ing of the dynamics of this joint. 1–5 The basic anatomy of the joint does not appear complicated as the anterior and posterior capsular ligaments, with the interclavicular ligament maintain- ing the stability in the anterior and posterior directions. The sternocostal and costoclavicular ligaments offer resistance to superior displacement of the clavicle in relation to the ribs and manubrium. 6–8 Previous techniques have focused on using sur- rounding soft tissue as a checkrein to motion either by looping tendon around the first rib and clavicle or by weaving an allograft in a figure-of-8 fashion at the junction of the medial clavicle and manubrium. These techniques serve to replace the anterior capsule or the costoclavicular ligaments. 1–5 Issues common to previous techniques are the require- ment for dissection around the first rib or potential migration of the pins or wires used for fixation. Dissection around the first rib increases the risk of important structures in the surgical field. 2–4 Pins and wires used for fixation around the chest and the shoulder have the potential for dangerous migration that may occur after healing. 9–11 Previous reports have demonstrated the potential for pins and wires, used around the chest and shoulder, to migrate into the vasculature of the thorax or into the spinal canal. 9–11 Button devices con- nected to suture, similar to the ones used in this technique, show rare tendency to migration but may occur over time with breakage of the attached suture. 12 The authors were unable to find reference to migration of a button device used around the thorax. This technique has proven effective in both acute and chronic settings and has been successful in return- ing patients to high levels of activity and military service. TECHNIQUE The patient is prepped in the supine position with space for both the orthopaedic surgeon and the cardiothoracic surgeon at either side of the patients’ chest. (A cardiothoracic surgeon should be scrubbed during the critical portions of the surgery including forming the manubrial tunnels and passage of the graft.) A short L-type incision is formed over the ster- noclavicular joint from 2 cm over the medial clavicle, extend- ing distally over the proximal portion of the manubrium, with the center of the incision curving over the sternoclavicular joint. Sharp dissection is carried to the level of the periosteum of the clavicle and the manubrium. The anterior capsule is entered sharply and reflected superiorly, exposing the intra- articular meniscus. A pointed reduction forceps is then used to elevate the proximal portion of the clavicle superiorly, sub- luxating or frankly dislocating the sternoclavicular joint. The clavicular side of the sternoclavicular repair is prepared first. A 3.5-mm drill bit is used to enter the intramedullary canal of the clavicle through the anteroinferior articular margin. This intra- medullary tunnel is then connected to a 2.5-mm drill hole placed at the superior margin of the clavicle. This space is then developed bluntly and will serve as the tunnel for the passage of a Zip Loop (Biomet) and doubled gracilis graft. Two manubrial tunnels are formed with a 3-mm, fluted, high-speed burr: first, 1 cm from the superior manubrial margin and, second, 1 cm from the lateral border of the manubrium. The burr is used until the intramembranous bone between the tables of the manubrium is reached. Then, 2 corresponding tunnels are formed on the articular side of the manubrium in line with the outer tunnels. After the burr is used to establish the tunnel into the cancellous bone, each tunnel is then connected bluntly by dilation with the tines of a Weber clamp or bone hook (Fig. 1). With the tunnels complete, a gracilis hamstring graft (allograft or autograft) is fashioned on the back table. A simple whipstitch is applied to the free ends of the graft. The graft is then doubled over with the use of a Zip Loop (Biomet). The titanium button of the Zip Loop is then advanced from the Accepted for publication May 7, 2013. From the *Orthopaedic Trauma Service, Naval Medical Center, Portsmouth, VA; and †Division of Orthopaedic Trauma, Department of Orthopeadic Surgery, University of Medicine and Dentistry of New Jersey, Newark, NJ. The authors have no conflict of interest in the preparation of this manuscript. This information has not been previously considered for publication and the technique is the sole concept of the corresponding author. R.J.G and M.D are military service members and employees of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a US Government work as a work prepared by a military service member or an employee of the US Government as part of that person’s official duties. Reprints: Robert J. Gaines, MD, Orthopaedic Trauma Service, Naval Medical Center, Portsmouth, VA 23708 (e-mail: orthogaines@gmail.com). Copyright © 2013 by Lippincott Williams & Wilkins J Orthop Trauma  Volume 28, Number 3, March 2014 www.jorthotrauma.com | e65