Where Are We Now?Sternoclavicular joint instability problems generally areavoided by orthopaedic surgeons. Many consider thisregion to be the purview of thoracic surgeons, given theproximity to the great vessels in the mediastinum. How-ever, patients often visit orthopaedic surgeons for recurrentinstability of this joint or for symptomatic sternoclaviculararthritis. We usually start with nonoperative approaches,but surgery sometimes enters the conversation. What is thebest surgical procedure for sternoclavicular joint instabil-ity? The answer is difficult to discern considering injuriesto this joint are rather rare. Large clinical trials do not exist,but the literature is replete with case reports and case ser-ies. We may seek guidance from the biomechanicsliterature; if so, the work of Spencer and Kuhn [2] is per-haps most relevant. They compared a tendon weave withtwo other reported stabilization techniques: subclaviustenodesis and the Rockwood technique. They found thetendon weave to be the strongest stabilization technique,but this approach involved bicortical drilling through thesternum and medial clavicle, which is not in the ‘‘wheel-house’’ of most orthopaedic surgeons—even those withshoulder and elbow fellowship training.Where Do We Need to Go?The technique described by Gardeniers and colleagues is anovel approach to address sternoclavicular joint instability.That said, the use of polydioxyanone (PDS) in and aroundthe shoulder girdle is not new. The material has been usedin early transglenoid capsulorraphies for glenohumeralinstability and to stabilize high-grade acromioclavicu-lar joint separations with a coracoclavicular cerclage. Italso has been used to stabilize acute sternoclavicular jointdislocations using the ‘‘safe’’ technique described byThomas et al. [3]. The ‘‘safe’’ technique, like the techniquedescribed by Gardeniers et al., is intriguing. It avoidspenetration of the dorsal surfaces of the sternum andclavicle and similarly obviates the risk of mediastinalinjury. However, eight of 39 patients in the current studyhad recurrent instability, which somewhat decreases one’senthusiasm to use this technique.How Do We Get There?The ideal approach would be an appropriately powered andrandomized clinical trial comparing the tendon graft figure-of-eight reconstruction, the PDS-envelop plasty, and the‘‘safe’’ method. This would need to be a multicenter study,as these cases are not particularly common. However, until