Eur J Cardiothorac Surg 2006;29:119-121
© 2006 Elsevier Science NL
Arthrodesis for osteoarthritis of the manubriosternal joint
Ahmed Al-Dahiri
*
,
Ian Pallister
Department of Trauma and Orthopaedics, Morriston Hospital, Swansea SA6 6NL, UK
Received 28 July 2005;
received in revised form 3 October 2005;
accepted 7 October 2005.
* Corresponding author. Tel.: +44 1792 703166; fax: +44 1792 703166. (Email: ahmeddahiri{at}hotmail.com).
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Abstract
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Osteoarthritis of the manubriosternal joint is rare. The diagnosis is not easy to make, and more serious causes of chest pain have to be ruled out first. We report one case that was treated with arthrodesis of the manubriosternal joint using double locking screw compression plating (LCP) with excellent results. Pre-operative CT-scan images with 3D reconstruction were used to measure the screw length and the drill stop depth. In this case report, we have shown that arthrodesis can be an effective way of treating osteoarthritis of the manubriosternal joint, when other measures fail. Furthermore, the use of a locking compression plate with appropriate and careful pre-operative planning affords a safe surgical technique, rapid pain relief and ultimately sound and asymptomatic union of the joint.
Key Words: Manubriosternal joint • Osteoarthritis • Arthrodesis
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1. Case report
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A 55-year-old heavy manual worker was presented with a 5-year history of gradually worsening pain and swelling around the upper sternal area. The pain was exacerbated by exercise, coughing and sneezing and was not related to posture. The pain affected his ability to work and disturbed his sleep. His previous medical history included non-insulin-dependent diabetes mellitus. Examination revealed a swollen and extremely tender manubriosternal joint (MSJ), with tenderness over both 2nd costochondral joints. Extremes of shoulder abduction and flexion aggravated his symptoms. The general examination was otherwise unremarkable. His blood parameters were within normal range. X-ray examination revealed degenerative changes in the MSJ. This was confirmed by a CT-scan with 3D reconstruction which showed marked osteoarthritic changes at the MSJ (Fig. 1
). Initially, the patient was treated with non-steroidal anti-inflammatory drugs, which resulted in little improvement in his pain. He was then offered physiotherapy, followed by X-ray guided intra-articular steroid injection. The patient reported minimal initial response to this treatment. However, his symptoms recurred within few weeks and hence the operative option was offered, which the patient was keen to take because of the severity of pain and the resultant handicap.
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2. Operation
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Pre-operative planning was carried out using the CT-scan images with 3D reconstruction to measure the screw length and the drill stop depth.
The operation was performed with the patient supine. The sternum and the angle of Louis were exposed through a midline thoracic incision. Excisional arthroplasty of both 2nd sternocostal joints was performed. The manubriosternal articulation was curetted and the remaining degenerate cartilage removed. Hypertrophic bone at the site of the arthritic MSJ was removed, morselized and replaced as an autologous bone graft. The MSJ was finally fixed with a five-hole and a six-hole locking compression plates (LCP Synthes, UK) that were contoured and secured with a mixture of uni- and bicortical screws. This achieved absolute stability of the MSJ (Fig. 2
).
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Fig. 2. Plain X-rays showing solid fixation of the manubriosternal joint with locking compression plates.
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3. Progress
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The patient was discharged home 5 days post-operatively. On discharge, he graded his pain as 2/10, as compared to 10/10 prior to the operation. He was allowed to use his arms freely for activities requiring no effort. After 6 weeks, he slowly resumed his normal activities. After 3 months, he returned to work for light duties for a month, after which he resumed normal activities, including heavy manual work. The patient was very pleased with the outcome of the surgery.
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4. Discussion
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Osteoarthritis (OA) is a chronic disorder characterized by softening and disintegration of articular cartilage, with reactive phenomena such as vascular congestion and osteoblastic activity in the subarticular bone, new growth of cartilage and bone (osteophyte) at the joint margins, and capsular fibrosis [1].
The manubriosternal joint is a secondary cartilaginous joint (symphysis) in which the articular surfaces are covered with a thin lamina of hyaline cartilage and there is an intervening disc of fibrocartilage. Frequently (30%), cavitation appears in the disc so that the joint may appear to be synovial, but this is simply a degenerative change that does not alter the fact that the joint is a symphysis [2]. This probably accounts to the involvement of the MSJ in systemic diseases such as rheumatoid arthritis (RA), OA, ankylosing spondylitis, gout, and psoriatic arthritis. In RA, for example, the MSJ is commonly involved, but it rarely gives rise to symptoms [3]. On the other hand, it was reported that up to 32% of patients with OA had what was described as major radiological changes affecting the MSJ, but there were no reports as to how many of these were symptomatic [4]. Isolated involvement of the MSJ in degenerative joint disease is rare and may pose a diagnostic dilemma in which other more serious causes of chest pain need to be ruled out first.
Joint arthrodesis is a known operative option in osteoarthritis. Lièvre and Bauman performed curettage of the joint surface in two cases of isolated MSJ arthrosis with good results in only one [5]. Litchman and colleagues reported performing arthrodesis of the MSJ in a case of post-traumatic degenerative arthrosis of the MSJ. In that procedure, they carried out resection of a portion of the joint and reversing a sliding bone graft to traverse the joint. They reported a satisfactory outcome with regard to pain relief, but the patient could not return to heavy manual work afterwards [5]. Shewring and Carvell also reported performing arthrodesis of the MSJ for recurrent gout. In this report, the arthrodesis was performed through a transverse incision with only bone grafting done without joint fixation [6].
In this case, excision arthroplasty was feasible, but would have resulted in a defect in the chest wall that could have resulted in obvious cosmetic and functional deficit in the chest. The LCP, on the other hand, offers fixed angle stability as the screws lock in the plate. Therefore, it is theoretically a sound choice in a fixation which cannot be firmly immobilized because of respiration. Furthermore, loosening and migration of the metalwork is unlikely because that would require all the screws on one side of the arthrodesis to fail at the same time which is a remote possibility. The arthrodesis is further strengthened by the use of autologous bone graft which provides the added advantage of avoiding the risks associated with donor site problems after a formal bone graft procedure. The use of mixed unicortical and bicortical screws with proper pre-operative planning using the CT-scan images with 3D reconstruction is a safe option.
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References
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- Kelly WN, Harris ED, Ruddy S, Sledge CB. 5th ed.. Textbook of rheumatology. vol. 1. WB Saunders; 1997p. 1383.
- Sinnatamby CS. Last's anatomy regional and applied. 10th ed.. Churchill Livingstone; 1999p. 175.
- Double A, Clarke AK. Symptomatic manubriosternal joint involvement in rheumatoid arthritis. Ann Rheum Dis 1989;48(6):516-517.[Abstract/Free Full Text]
- Verschuuren J, Goei The HS, Schreutelkamp I, Houben HM, Burla F, de Korte P, Veldhuyzen van Zanten O. Radiological abnormalities of the manubriosternal joint in patients with rheumatoid arthritis and osteoarthritis. Scand J Rheumatol 1987;16(2):139-142.[Medline]
- Litchman HM, Silver CM, Simon SD, Tamura H. Post-traumatic degenerative arthrosis in the manubriosternal joint. Clin Orthop 1969;67:111-115.[Medline]
- Shewring DJ, Carvell JE. Arthrodesis for recurrent manubriosternal gout. J Bone Joint Surg [Br] 1991;73(2):391.
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Abstract
1. Case report
