Management of sternoclavicular joint infections

Surgically managed infections of the sternoclavicular joint have rarely been reported, but general and thoracic surgeons may be consulted to manage such infections. Patients who have demonstrated resistance to antibiotic therapy or have infection extending beyond the joint capsule are best managed by surgical resection.

[Tuberculosis of the sternoclavicular joint]

Tuberculosis is seen in every part of the body, but sternoclavicular joint tuberculosis is rare. We report a case of tuberculosis of the sternoclavicular joint in 70-year-old woman having complained of the right sternoclavicular joint swelling. She had a previous history of pulmonary tuberculosis, and visited her doctor for right sternoclavicular joint swelling on February 2006. A chest CT scan showed a low density area with destructive osseous changes in the right sternoclavicular joint. Definite diagnosis could not be done by twice needle biopsy, but we diagnosed her as tuberculosis of the sternoclavicular joint based on the clinical course and the findings of the examination. As her condition did not improve after 3 months treatment with anti-tuberculous drugs, we conducted therapeutic surgical procedure. Definite diagnosis of sternoclavicular joint tuberculosis was made on the basis of the presence of mycobacteria in the histological specimen and PCR-TB positive result. We kept the wound opened and continued administration of anti-tuberculous drugs, and her condition does not deteriorate. Tuberculosis should be considered in case of a patient with arthritis and previous history of tuberculosis, even if it is seen in rare location. Diagnostic and therapeutic surgical procedure should be taken into consideration, if there is no improvement of the condition after a diagnosis of bone and joint tuberculosis, and the administration of chemotherapy for tuberculosis.

Staphylococcal septic synovitis of the sternoclavicular joint with retrosternal extension

Bacterial arthritis of the sternoclavicular joint is an uncommon disorder caused by a variety of microorganisms. Both Gram-positive and Gram-negative bacteria have been identified as etiologies of an acute suppurative arthritis, whereas a few other bacteria such as mycobacteria and treponemes have been incriminated in chronic disease of the sternoclavicular joint. We recently treated a patient with staphylococcal synovitis of the sternoclavicular joint, which is the 24th recorded in the literature. His illness was complicated by a retrosternal abscess, soft tissue abscess of the chest, septic bursitis, and lumbosacral discitis. He recovered after 6 weeks of nafcillin therapy without any residual infection. Six previous patients with extension into the substernal space and mediastinum have been described. Staphylococcal infection of the sternoclavicular joint, although usually confined to the joint, can be associated with sepsis and metastatic abscess formation as well as substernal extension even in immunocompetent individuals.

Sternoclavicular joint pseudo-tumour: a case report and literature review

This case report describes the development of a post-treatment enlargement of the sternoclavicular joint, diagnosed as a pseudo-tumour, in a patient who had previously undergone radical neck dissection and post-operative radiotherapy for metastatic mucoepidermoid carcinoma. Although pseudo-tumour has been previously reported in the surgical literature, it remains an uncommonly recognized condition. We present a review of the literature and discuss the condition's pathogenesis. We also highlight its importance to both the surgeon and the oncologist when considering the differential diagnosis of a swelling in the clavicular region, typically occurring following radical surgery for malignant disease in the neck.

Posterior sternoclavicular dislocations: a review of management and complications

Posterior sternoclavicular dislocations are relatively uncommon injuries. Nevertheless, these dislocations are associated with potentially fatal injuries to the mediastinum and the great vessels. Medial clavicle physeal injury with posterior dislocation may present with a similar clinical picture in younger patients. There is a wide variety of techniques for managing these injuries. In this article, we review recent techniques for reducing and managing posterior sternoclavicular dislocations.

Stress fracture of the clavicle associated with sternocostoclavicular hyperostosis

We report a case of stress fracture of the clavicle associated with sternocostoclavicular hyperostosis. A 60-year-old man sustained a stress fracture of the right clavicle with no history of trauma. On radiography, hyperostosis of the anterior chest wall and ankylosis of the sternoclavicular joint were evident in addition to the fracture. Fracture healing was uneventful after 2.5 months. Ankylosis of the sternoclavicular joint may have caused increased stress at the midshaft of the clavicle by daily activity or minor trauma. Such a fracture is a rare complication of sternocostoclavicular hyperostosis.

Septic arthritis as a late complication of carcinoma of the breast

OBJECTIVES

To see if a past history of radiation therapy is a risk factor for septic arthritis.

METHODS

We retrospectively searched our records of 282 patients with septic arthritis and found 10 cases of septic arthritis post-radiotherapy, all in females. We analysed our group, correlating them with the literature. We also compared our patients with a group of septic arthritis patients without radiation therapy.

RESULTS

Nine had had radiation therapy for carcinoma of the breast. The shoulder joint was involved in six and the sternoclavicular joint in three. The tenth patient had had brachytherapy and radiation for carcinoma of the cervix and presented with septic arthritis of the hip. The mean age of the patients was 69 yr (49-82 yr). The mean time elapsed since radiation was 16 yr (3-34 yr). Twenty-three cases of shoulder septic arthritis in patients without past radiation therapy were selected for comparison. The five patients with past radiation therapy had fever less often and a longer time lapse before diagnosis. They required longer antibiotherapy. However, this prevented neither bone destruction nor relapse.

CONCLUSIONS

In our study, a past history of radiation therapy was observed in 6/50 infections of the shoulder, 3/5 infections of the sternoclavicular joint, 6/23 cases of septic arthritis of the shoulder and all cases of septic arthritis of the sternoclavicular joint for females. Radiation therapy seems to be a risk factor for septic arthritis. Diagnosis would be aided by a greater awareness of the clinical and radiological features of this septic arthritis.

Anterior subluxation after reduction of a posterior traumatic sterno-clavicular dislocation: a case report and a review of the literature

Sternoclavicular dislocations represent a rare injury. Based on our clinical experience with a patient showing an anterior subluxation after reduction of a posterior traumatic dislocation, we review the literature. The emergent reduction of the dislocation is mandatory, always keeping in mind the potentially devastating neurovascular complications. If the treatment of a residual anterior instability remains controversial, a residual posterior instability should be treated by a surgical procedure. The optimal treatment depends mainly on each surgeon's choice and practice.

Pseudomonas sternoclavicular pyarthrosis

Most cases of Pseudomonas pyarthrosis affecting the sternoclavicular joint have been reported in immunosuppressed intravenous drug users. We report a case of Pseudomonas pyarthrosis in a man who was otherwise immunocompetent, except for his age. A 66-year-old white man presented to the clinic with a 1-month history of right-sided shoulder and arm pain associated with swelling of the upper part of the chest in the region of the right sternoclavicular joint. The chest radiograph revealed opacity in the right superior mediastinum. Computed tomography scan of the chest confirmed a mass in the right sternoclavicular region with associated osteolysis of the clavicular head. A needle biopsy of the mass was negative for malignancy. An open biopsy specimen showed evidence of chronic inflammation without evidence of malignancy, and culture of the tissue grew Pseudomonas aeruginosa. The patient's symptoms improved after extensive incision and drainage of the affected area followed by treatment with antibiotics for 6 weeks.

Atraumatic retrosternal dislocation of the clavicle

Atraumatic retrosternal dislocation of the clavicle is an exceedingly rare event and three out of four previously reported cases lack any radiological evidence. We report the case of a 30-year-old male patient who presented an atraumatic retrosternal dislocation of the clavicle without a history of previous injury and underlying pathology. The diagnosis was delayed and established by a CT scan ten days after and initial presentation of the symptoms. A successful, stable, closed reduction under general anaesthesia was performed ten days after the initial presentation, having a cardiothoracic surgeon immediately available. There was no recurrence and the patient remains asymptomatic 18 months later.

Bilateral retrosternal dislocation and hypertrophy of medial clavicular heads with compression to brachiocephalic vein

A 36-year-old woman with effort dyspnea for 2 years, venous congestion of the left arm for 6 months and who did not have a history of a thoracic trauma was hospitalized. Posterior bilateral dislocation of the sternoclavicular joints and compression of the brachiocephalic vein were diagnosed and conformed by computed tomography (CT). The joint could not be reduced because of the old dislocation and destruction of the joint in the operation. The heads of the clavicles were resected and the vein compression was eliminated. Six weeks later, venous congestion disappeared and the brachiocephalic vein was patent.

Sternoclavicular joint septic arthritis manifesting as a neck abscess: a case report

Septic arthritis of the sternoclavicular joint is an uncommon condition, and the diagnosis can be missed until a complication occurs. The sternoclavicular joint is more often involved in ankylosing spondylitis, degenerative arthritic conditions (i.e., rheumatoid arthritis and osteoarthritis), and primary and secondary metastatic conditions. The patient described in this case report came to the otolaryngology department on two occasions for treatment of a unilateral cutaneous neck abscess. The correct diagnosis was not made until the second visit. The author reviews the clinical course, diagnosis, and treatment of this uncommon disease.

Sternoclavicular joint infection in an adult without predisposing risk factors

Septic arthritis of the sternoclavicular joint (SCJ) is an uncommon condition and it has been associated with numerous predisposing factors. We describe a rare case of SCJ infection due to Staphylococcus aureus in an adult without known underlying predisposing conditions and in which recovery was achieved with medical therapy alone.

Surgical management of sternoclavicular joint infections

OBJECTIVE

Sternoclavicular joint infections are rare, and their management is controversial. We reviewed our experience with the surgical management of this condition.

METHODS

From August 1988 to August 2001, 26 patients (16 men and 10 women) were treated surgically for infected sternoclavicular joints. The median age was 56 years (range, 20-77 years). Patients who had a recent previous median sternotomy were excluded.

RESULTS

All patients were symptomatic. Pain was present in 21 patients, swelling in 14 patients, fever in 11 patients, and erythema in 9 patients. Associated conditions included recent or ongoing infections in other areas in 12 patients (pneumonia in 4 patients, multiple joint infections in 2 patients, and other in 6 patients) and an indwelling central venous catheter in 1 patient. Five patients had a history of trauma in the region of the joint. Four patients had prior joint incision and drainage. Unilateral sternoclavicular joint resection was done in 18 patients, bilateral resection in 2 patients, and incision and drainage with debridement in 6 patients. Wound culture results were positive in 24 patients, and the most common organism isolated was Staphylococcus aureus (n = 17). Eleven patients had transposition of the ipsilateral pectoralis major muscle to obliterate residual space and to reconstruct the chest wall. Two (7.7%) patients had complications, and 1 died (operative mortality, 3.8%). Follow-up was complete in all 25 operative survivors and ranged from 2 months to 10 years (median, 25 months). Twenty-one patients are alive without symptoms, infection, or limitations in range of motion. Four patients have died as a result of causes unrelated to their joint infections.

CONCLUSIONS

Symptomatic sternoclavicular joint infections often require surgical intervention. Surgical resection combined with muscle transposition provides effective long-term outcome.

Spontaneous sternoclavicular joint infections

Spontaneous sternoclavicular (SC) joint infections are uncommon. Most cases of contained SC joint infections respond well to conservative treatment measures such as intravenous antibiotics and local drainage. However, some cases are more extensive, extending beyond the boundaries of the joint capsule, occasionally involving the anterior chest wall and mediastinum. We report our experience with 3 patients with spontaneous advanced SC joint infections. Radical surgical treatment seemed to provide the best control of this infection.

[Anterior chest wall examination reviewed]

Anterior chest wall involvement is not infrequently observed within inflammatory arthropaties, particularly if one considers seronegative spondyloarthritides and SAPHO syndrome. Physical examination is unreliable and conventional X-rays analysis is an unsatisfactory tool during diagnostic work-up of this region. Scintigraphic techniques yield informations both on the activity and on the anatomical extent of the disease while computerized tomography visualize the elementary lesions, such as erosions, which characterize the process. Moreover, when available, magnetic resonance imaging couple the ability to finely visualize such lesions with the possibility to show early alterations and to characterize the "activity" of the disease, presenting itself as a powerful tool both for diagnosis and follow-up. This review briefly shows the applications of imaging techniques for the evaluation of the anterior chest wall focusing on what has been done in the SAPHO syndrome which can be considered prototypical for this regional involvement since it is the osteo-articular target mainly affected by the disease.

[Primary septic arthritis of the sterno-clavicular joint]

Septic arthritis of the sternoclavicular joint (SCJ) is an uncommon form of arthritis generally occurring in immuno-compromised patients with contiguous or distant foci of infection and central venous catheters. Septic SCJ arthritis in previously healthy subjects is a very rare occurrence requiring a high index of suspicion for the diagnostic assessment. We report here one patient without predisposing factors presenting Staphylococcus aureus SCJ infection.