Recurrent anterior sternoclavicular joint subluxation: long-term implant-related recurrence Gavin S. Hautala, MD * , Srinath Kamineni, MD, BSc, FRCS Department of Orthopaedic Surgery and Sports Medicine, Elbow Shoulder Research Center, University of Kentucky, Lexington, KY, USA article info Keywords: Sternoclavicular joint instability subluxation dislocation EndoButton FiberWire Sternoclavicular joint (SCJ) instabilities are rare, and traumatic sternoclavicular injuries comprise only 3% of all shoulder injuries, with anterior dislocations more common than posterior disloca- tions. 9 Despite the direction of dislocation, it is currently recom- mended to attempt closed reduction to prevent poor long-term clinical outcomes. 17 However, closed reduction is successful in only 38% of attempts, 10 and despite successful closed reduction, residual instability often remains. If closed reduction does not work, then open treatment should be considered. A significant amount of force, directed from a posterolateral direction, axially applied to the acromioclavicular joint on a fixed torso, is required to disrupt and anteriorly dislocate this joint. Although there are various stabilization techniques with varied results described in the literature, none have taken into account the configuration of the ligaments and the force vector of translation at the SCJ. We describe a technique that incorporates fixation in conjunction with a reversal of the displacing force vector. Case report A 17-year-old male student complained of pain in the SCJ after completing bench presses in the gym. He had no relevant medical or surgical history. This pain continued and gradually became worse over the next few months. The patient felt pain and a sense of anterior instability and clicking with overhead activities at the SCJ, which progressed when performing simple activities of daily living. The joint reduced spontaneously initially and by self- manipulation later, and finally, it was difficult to manually reduce and was extremely painful. After 4 months, the patient saw 2 shoulder surgeons, who advised continued nonoperative manage- ment. He then attended our practice because of continued and severely debilitating symptoms. He presented with a frequently irreducible and painful SCJ that significantly affected his activities of daily living and disturbed his sleep, and he regularly took time off work because of pain. Physical examination findings showed laxity in the anterior direction with palpation of the right medial clavicle and sponta- neous subluxation with overhead shoulder motion (Fig. 1). This required manual digital compression to reduce. No esophageal or tracheal manifestations were noted, and the region was neuro- vascularly intact. No other physical findings were evident, with a normal acromioclavicular joint and glenohumeral joint. The results of plain radiographs and computed tomography scans were unre- markable. Because the pain and subluxation worsened despite nonoperative treatment for a total of 6 months and the patient needed to return to his manual work, the decision to perform reduction and stabilization with surgery was made. Operative technique A 5-cm horizontal incision was made centered over the SCJ with layered dissection protecting the larger cutaneous nerves and elevation of the platysma muscle down to the SCJ. A horizontal incision was made through the anterior capsule and its ligaments with these structures elevated from the anterior aspect 2 cm on either side of the SCJ, dissecting meticulously over the superior aspect and then the posterior aspect of the joint (Fig. 2). The lateral 50% of the sternal footprint of the sternocleidomastoid was * Corresponding author: Dr. Gavin S. Hautala, MD, Department of Orthopaedic Surgery and Sports Medicine, Elbow Shoulder Research Center, University of Kentucky, 740 S Limestone, Ste K401, Lexington, KY 40536-0284, USA. E-mail address: gha273@uky.edu (G.S. Hautala). Contents lists available at ScienceDirect JSES International journal homepage: www.jsesinternational.org https://doi.org/10.1016/j.jses.2019.10.105 2468-6026/© 2019 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). JSES International 4 (2020) 55e58