Functional Outcomes After Total Claviculectomy as a Salvage

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Functional Outcomes After Total Claviculectomy as a Salvage
Procedure. A Series of Six Cases
Sumant G. Krishnan, Shadley C. Schiffern, Scott D. Pennington, Michael Rimlawi and Wayne Z. Burkhead, Jr.
J Bone Joint Surg Am. 2007;89:1215-1219. doi:10.2106/JBJS.E.01436
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BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Functional Outcomes After Total
Claviculectomy as a Salvage Procedure
A Series of Six Cases
By Sumant G. Krishnan, MD, Shadley C. Schiffern, MD,
Scott D. Pennington, MD, Michael Rimlawi, DO, and Wayne Z. Burkhead Jr., MD
Investigation performed at the Shoulder Service, The Carrell Clinic, Dallas, Texas
Background: Total claviculectomy has been used for the treatment of tumor, infection, nonunion, and vascular compromise. Given its limited indications, few reports on the outcome after claviculectomy exist. The purpose of the present
study was to evaluate the function of the shoulder, with use of a modern scoring system, after total claviculectomy.
Methods: A retrospective review of the records of six patients who had undergone unilateral claviculectomy was performed after an average duration of follow-up of 5.7 years. The indication for surgery had been an infection at the site
of a clavicular nonunion for three patients, nonunion with subclavian vein compression for two, and pain after a failed
medial clavicular excision for one. The preoperative and postoperative evaluations included testing of the range of
motion, strength, and stability as well as determination of the American Shoulder and Elbow Surgeons score on the
basis of a functional questionnaire.
Results: Range of motion was improved slightly or unchanged following claviculectomy. The mean American Shoulder
and Elbow Surgeons score improved from 18 (range, 5 to 35) preoperatively to 88 (range, 75 to 95) postoperatively.
The mean pain level (with 0 indicating no pain and 10 indicating the worst pain) decreased from 9.5 preoperatively to
1.5 postoperatively. Postoperatively, strength testing showed improvement from grade 4− (of 5) to 5 in all planes
tested except extension (in which it remained at grade 4). Patient satisfaction was high, with a mean of 9.0 on a 10point scale. There were five complications, including one subclavian vein laceration requiring vascular repair, two
deep infections, and two superficial infections.
Conclusions: Despite a high complication rate, the functional outcomes following claviculectomy were good in this
group of six patients. Total claviculectomy may be a useful salvage procedure for clinical situations in which the restoration of normal clavicular osseous anatomy is impossible. Patients can expect acceptable pain relief and few or no
deficits in activities of daily living.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
T
he function of the clavicle can be broadly divided into
protective and structural aspects. While the protective
aspect of clavicular function with respect to the great
vessels and brachial plexus is widely accepted, the necessity of
the clavicle for function in activities of daily living, including
heavy overhead work, has been debated1-6. The human clavicle
theoretically facilitates positioning and the creation of a stable
platform for the upper extremity in three dimensions7. Its absence, however, does not always preclude full motion of the
glenohumeral and scapulothoracic articulations.
Absolute indications for claviculectomy are rare. Relative indications have included tumor, vascular compression or
injury, infection, symptomatic malunion and nonunion, and
unipolar or bipolar dislocation1,5,8-10. In the early 1990s, Rock-
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor
a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center,
clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or
associated.
J Bone Joint Surg Am. 2007;89:1215-9 • doi:10.2106/JBJS.E.01436
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wood and Wirth reported on patients with persistent symptoms following claviculectomy and recommended preserving
the clavicle11. Other studies have shown acceptable results following claviculectomy6,10,12-14. However, objective data on patient outcomes are lacking in the literature. The purpose of the
present study was to evaluate shoulder function, with use of a
modern scoring system, in six patients who had undergone total claviculectomy.
Materials and Methods
rom 1998 to 2001, six patients underwent unilateral total
claviculectomy at our institution. The patients included
four women and two men with an average age of thirty-seven
years (range, twenty-five to forty-six years). The dominant arm
was involved in four cases. The patients were followed for an average of 5.7 years (range, four to seven years). All patients underwent a careful preoperative evaluation, including testing and
documentation of the range of motion, strength, and stability.
They also filled out a functional questionnaire, which was used
to calculate the American Shoulder and Elbow Surgeons (ASES)
score. They also rated their pain on a scale of 0 to 10 (with 0
representing no pain and 10 representing the worst pain). The
records were reviewed retrospectively, and all patients returned
for detailed examination by an independent orthopaedic surgeon and a licensed physical therapist. They again rated their
pain on the same scale and rated their satisfaction with the procedure on a scale of 0 to 10 (with 0 representing “unsatisfied”
and 10 representing “completely satisfied”).
The indications for surgery included painful symptomatic nonunion after one or more attempts at open reduction
and internal fixation in two patients, intractable infection in
three, and regrowth after a partial medial claviculectomy (performed because of painful and unstable residual clavicular
bone with neurovascular compression after failed sternoclavicular joint reconstruction followed by failed partial medial
claviculectomy) in one. All patients had been operatively
managed previously, with an average of three operative procedures (range, one to six procedures) having been performed
prior to claviculectomy. Despite the number of previous procedures, all of the patients in this group had a functioning trapezius at the time of surgery. Five patients with nonunion had
a history of tobacco use of more than one pack per day for an
average of fourteen years.
Statistical analysis was performed with analysis of variance for quantitative values and with a chi-square test for
qualitative values. The level of significance was set at p < 0.05.
F
Surgical Technique
The clavicle was exposed through a curvilinear extensile approach that followed the contour of the bone from the sternoclavicular joint to the acromioclavicular joint (Fig. 1). The
musculofascial envelope and periosteum were incised in one
layer along with the anterior aspects of the acromioclavicular
and sternoclavicular ligaments. Careful blunt dissection was
then carried out circumferentially, and the clavicle was gently
disarticulated and elevated out of its bed (Fig. 2). A vascular
Fig. 1
Photograph showing the extensile approach to the clavicle.
surgeon was available on standby throughout the procedure.
After removal of the clavicle, the wound was irrigated
thoroughly. The deltopectoral, trapezial, and sternocleidomastoid myofascial sleeves were meticulously repaired over a
Jackson-Pratt drain with #2 Vicryl absorbable sutures (EthiconJohnson and Johnson, Somerville, New Jersey). A first-generation
cephalosporin was administered preoperatively and was continued for twenty-four hours. The drain was removed at twentyfour to forty-eight hours.
The patients wore an arm sling for three to six weeks.
Passive range of motion was allowed at three weeks, and active
range of motion was started at six weeks. Theraband exercises
in all planes were commenced at two months and progressed
as tolerated. Shoulder shrugs and wall push-ups were encouraged. Formal physical therapy was not employed, and all patients were maintained on a home exercise program for a
minimum of six months after surgery. This program involved
thrice-weekly maintenance range-of-motion and resistance
exercises for all shoulder girdle muscles.
Results
emographic data from the six patients are shown in Table
I. Preoperatively, the mean active range of motion was
155° (range, 110° to 170°) of elevation, 60° (range, 35° to 80°)
of external rotation, and 50° (range, 30° to 80°) of internal rotation. The mean ASES score was 18 (range, 5 to 35), and the
mean pain level was 9.5 (with 0 representing no pain and 10
representing the worst pain). Strength ranged from 4− to 5 in
all planes tested.
Postoperatively, the mean active range of motion was not
significantly different from the preoperative range, with an average of 160° (range, 125° to 170°) of elevation, 65° (range, 45°
D
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TABLE I Demographic Data on the Patients
Side of
Involvement
Number of
Previous
Procedures
Case
Gender,
Age (yr)
Smoker
1
M, 46
Yes
Dominant
Infection at the site
of nonunion
4
Open reduction and internal fixation, open reduction and internal fixation with allograft, irrigation
and débridement and open reduction and internal
fixation with iliac crest bone graft, irrigation and
débridement
2
F, 43
Yes
Nondominant
Nonunion with subclavian
vein stenosis
1
Open reduction and internal fixation
3
F, 25
Yes
Nondominant
Infection at the
site of nonunion
4
Open reduction and internal fixation, irrigation and
débridement × 3
4
F, 46
Yes
Dominant
Infection at the site of
nonunion with subclavian
artery compression
6
Open reduction and internal fixation, open reduction and internal fixation with allograft, open reduction and internal fixation with iliac crest bone graft,
hardware removal, irrigation and débridement × 2
5
F, 35
No
Dominant
Pain after failed partial
medial claviculectomy
2
Sternoclavicular reconstruction with Dacron tape
(failed), medial claviculectomy to the costoclavicular ligaments
6
M, 29
Yes
Dominant
Nonunion with subclavian
vein occlusion
1
Open reduction and internal fixation
Diagnosis
to 80°) of external rotation, and 70° (range, 50° to 80°) of internal rotation. The mean ASES score was 88 (range, 75 to 95) (p <
0.03). The mean pain score was 1.5. Compared with the normal
side, strength was grade 5 in all planes except for extension (in
which it remained at grade 4). The mean satisfaction score was
9.0 (with 0 representing “unsatisfied” and 10 representing
Previous Procedures
“completely satisfied”). All patients stated that they would undergo this procedure again (Table II).
Radiographically, the involved scapula was an average of
1 cm more inferior and 1.6 cm more medial than the contralateral, normal scapula as determined on the basis of comparative measurements of the heights of the superomedial
Fig. 2
Photograph showing subperiosteal elevation of the clavicle out of its bed.
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TABLE II Preoperative and Postoperative Findings
Active Anterior
Elevation
External
Rotation
Internal
Rotation
Pain Score*
(points)
ASES Score†
(points)
Postop.
Satisfaction
Score‡ (points)
Case
Preop.
Postop.
Preop.
Postop.
Preop.
Postop.
Preop.
Postop.
Preop.
Postop.
1
160°
165°
70°
65°
70°
70°
10
3
22
75
7
2
170°
170°
50°
65°
80°
80°
9
0
14
95
10
3
170°
170°
80°
80°
50°
50°
9
2
35
92
9
4
110°
125°
35°
45°
40°
80°
10
1
5
88
9
5
170°
170°
75°
75°
30°
75°
9
1
17
94
10
6
150°
160°
50°
60°
30°
65°
10
2
15
84
9
*0 represents no pain and 10 represents the worst pain. †ASES = American Shoulder and Elbow Surgeons. ‡0 represents “unsatisfied” and
10 represents “completely satisfied.”
corners and the distance between the coracoid and spinous
processes, respectively.
One significant vascular injury occurred. During the
dissection of the proximal part of the clavicle in a patient with
known subclavian compression, a rent was created in the superior aspect of the subclavian vein. The vascular surgeon on
call performed a primary repair, and no postoperative anticoagulation therapy was given. Twenty-nine months postoperatively, the patient was symptom-free and was very satisfied
with the result. Four patients had an infection (prevalence,
67%). Of these, two had a deep infection that required aggressive treatment with surgical débridement and primary closure
over drains as well as intravenous antibiotics and two had a
superficial infection that was treated with oral antibiotic therapy alone. However, only one postoperative infection (which
required surgical débridement) occurred among the three patients who had initially presented with chronic intractable infection. All of the infections resolved, and all four patients
reported a high degree of satisfaction at the time of the most
recent follow-up.
Discussion
urd described the performance of complete claviculectomy as early as 19129. He later reported on several other
clavicular resections, with excellent results15. While midshaft
clavicular osteotomy is a standard surgical technique for exposure of the underlying subclavian vessels and brachial plexus,
total claviculectomy also has been used as an approach for vascular surgery1 and as a definitive treatment for tumors, infections, fractures, and nonunions of the clavicle6,10,12-14. In 1986,
Wood reviewed the literature as well as the results for five patients and concluded that the clavicle is an accessory to the osseous skeleton6. That study was primarily a case report study.
Subsequent reviews by Rockwood and Wirth, in a survey
form, noted the anecdotal experience of the American Shoulder and Elbow Surgeons with this problem and concluded that
claviculectomy was not a benign procedure11. Their conclusion
was that the clavicle should be preserved if possible.
G
Partial claviculectomies of both the medial and lateral
halves of the clavicle have been reported to yield good, but not
symptom-free, results. In those series, patients continued to
complain of clicking and pain at the resected end of the
clavicle1. The cosmetic appearance of the resected end was also
a source of relative dissatisfaction among these patients, causing a prominence in the anterior chest region. In the present
series, total claviculectomy was performed for one patient after the failure of a previous partial medial claviculectomy.
That patient had presented with a recurrence of neurovascular
compression and pain due to regrowth of 5 cm of the clavicle
at the site of a previous resection.
In the present series, total claviculectomy appears to
have restored range of motion, created minimal strength deficits, and provided durable pain relief in this relatively young
cohort of patients. However, this procedure is not without difficulties, as evidenced by the high rate of complications in the
present study (with three of our six patients having a major
complication). The close proximity to the major subclavian
vessels puts these structures at risk during the surgical approach. Immediately available vascular surgery backup is recommended in case injury to the vessels occurs. Four infections
(two deep and two superficial) occurred in our six patients.
This finding was likely due to the large dead space created by
the resection, the history of multiple operations and previous
infection in many of the patients, and the relatively superficial
nature of the clavicle. Rather than administering prophylactic
antibiotics and considering the resection curative in patients
with a previous history of infection, we recommend obtaining intraoperative culture specimens and administering postoperative antibiotics until the results of culture are returned,
even in quiescent cases.
In all six of our patients, the trapezius was functional.
We believe that the most important contraindication to claviculectomy is trapezius dysfunction, which can lead to severe
functional loss and a drooping of the shoulder with thoracic
outlet-type symptoms that may be exacerbated by removing
the osseous strut of the clavicle.
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An interesting finding of our review of the demographic
data for this small cohort was that five of the six patients were
smokers. While direct links between smoking and either
fracture-healing or infection cannot be firmly established, it is
interesting that these patients required the radical salvage operation of a total claviculectomy for the treatment of a previously unreconstructable problem. Additional study into the
effects of smoking on nonoperatively and operatively treated
clavicular fractures is currently under way.
It is hoped that the results of the present study will allow
surgeons to inform patients of the potential outcome of this
operation should it be deemed necessary. Despite the high rate
of complications, including one complication that was potentially life-threatening, all patients in the present series were
highly satisfied with the functional outcome at the time of the
most recent follow-up and stated that they would undergo the
procedure again. Our data are compatible with the majority of
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the reports on this subject. The outcomes demonstrated in
our patient population seem to indicate that patients can expect acceptable pain relief and few deficits in activities of daily
living. Claviculectomy should be kept in the armamentarium
of orthopaedic and vascular surgeons for use in clinical situations in which the restoration of normal clavicular osseous
anatomy is impossible. „
Sumant G. Krishnan, MD
Shadley C. Schiffern, MD
Scott D. Pennington, MD
Michael Rimlawi, DO
Wayne Z. Burkhead Jr., MD
Shoulder Service, The Carrell Clinic, 9301 North Central Expressway, Suite 400, Dallas, TX 75231. E-mail address for S.G. Krishnan:
[email protected]
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