Isolated sternoclavicular joint arthritis in heroin addicts and/or HIV positive patients: three cases

Surgical Management of Sternoclavicular Joint Infection

Sternoclavicular joint infection is rare and tends to present insidiously in debilitated and immunocompromised patients. Between August 1996 and July 1998, we managed 7 patients with 8 sternoclavicular joint infections. Three were women. Their age ranged from 42 to 63 years. Five of the patients had significant associated medical conditions. Six patients, including 1 with bilateral involvement, underwent surgical resection, which consisted of radical excision of the involved joint, medial third of the clavicle, first and second ribs and adjacent muscular wall, and part of the manubrium. All of them underwent delayed reconstruction with either pectoralis major or latissimus dorsi flaps. There was 1 operative mortality from continuing sepsis from another source. All the surviving patients showed no sign of local recurrent infection and no functional deficits at follow-up. We conclude that infection of the sternoclavicular joint often presents late in debilitated patients. Medical therapy often fails in these cases. Radical excision is effective in eradicating the septic focus, and functional results after reconstruction are excellent.

[Infectious arthritis of sternoclavicular joint: surgical approach to the issue]

AIM

To study the features of occurrence, diagnosis, clinical course of infectious arthritis of sternoclavicular joint, as well as to develop differentiated therapeutic tactics depending on the clinical form and stage of disease.

MATERIAL AND METHODS

It was analyzed treatment of 18 patients with infectious arthritis of sternoclavicular joint aged 27 to 88 years who were hospitalized for the period 2008-2014. Acute or chronic forms were determined depending on clinical course and serous arthritis, para-articular phlegmon and osteoarthritis--according to nature of tissue damage. Hypothermia and blunt trauma were often preceded to onset of disease. Diabetes and drug addiction were present as comorbidities. Also disease as the variant of purulent metastasis in case of sepsis was noted. Bone scintigraphy, CT and magnetic resonance imaging are the most informative.

RESULTS

Infectious arthritis of sternoclavicular joint often had hematogenous origin, and Staphylococcus aureus was the most common cause. At the stage of serous arthritis antibacterial therapy was effective. Incision and drainage were performed urgently in case of para-articular phlegmon. Sternoclavicular joint resection was performed usually in 2-3 months after subsidence of inflammation.

Diagnostics of septic arthritis in the sternoclavicular region: 10 consecutive patients and literature review

BACKGROUND

Septic arthritis in the sternoclavicular (SC) region is rare and may be difficult to diagnose clinically and radiologically. It mainly affects immunocompromised persons, and can clinically be misinterpreted as tumor and rheumatic disorders. Lacking radiological reference standard, a multimodality approach may contribute to a prolonged diagnostic process.

PURPOSE

To describe the diagnostics of septic arthritis in the SC region.

MATERIAL AND METHODS

Between 2001 and 2011 10 patients with Staphylococcus infection in the SC region were investigated in our institution. Clinical, biochemical, radiological, and microbiological findings were studied retrospectively; all CT and MR examinations were re-evaluated.

RESULTS

Initial radiography in nine patients and ultrasonography in six patients were inconclusive resulting in supplementary MRI and/or CT. Five patients examined by MRI were immediately diagnosed with septic arthritis whereas CT in five patients led to the diagnosis in only one. Three were subsequently diagnosed by MRI, but delayed more than 2.5 weeks, and one was diagnosed by surgery. The median time to diagnosis was 1.5 weeks. The delay caused by imaging was 0 days to 11.5 weeks (median 0 days). By re-evaluation overlooked complications included mediastinitis in seven patients (three diffuse, four localized), and abscesses and pleuritis each in four patients.

CONCLUSION

Awareness of infection in the SC region is important to avoid diagnostic delay. MRI is proposed as the initial imaging procedure.

[Anaerobic sternocostoclavicular septic arthritis: a case report]

Septic arthirtis of the sternocostoclavicular joint is exceptional and usually occurs in immunodeficient subjects. The clinical presentation may be misleading, a rheumatoid disease often being suggested. We report a case of secondary joint infection caused by anaerobic bacteria and discuss the diagnostic problems involved as well as the disease course and the therapeutic options proposed in the literature. The diagnosis calls upon computed tomography and magnetic resonance imaging, leading to joint needle aspiration. Appropriate imaging enables an assessment of the anatomic damage and is useful for guiding surgical treatment under adapted antibiotic coverage.

Atraumatic disorders of the sternoclavicular joint

The sternoclavicular joint is the diarthrodial articulation between the axial and appendicular skeletons. It is subject to the same disease processes that occur in joints, including degenerative arthritis, rheumatoid arthritis, infection, and subluxation. Most of these conditions present with swelling of the joint, which may be associated with pain and/or tenderness. Plain radiographs can demonstrate changes on both sides of the joint. Because of variations in anatomy, computed tomography scans and magnetic resonance images are often necessary to clarify the pathology. With the exception of acute infection, most conditions can be managed nonsurgically, with joint resection reserved for patients with persistent symptoms.

Sternoclavicular septic arthritis: review of 180 cases

We review 170 previously reported cases of sternoclavicular septic arthritis, and report 10 new cases. The mean age of patients was 45 years; 73% were male. Patients presented with chest pain (78%) and shoulder pain (24%) after a median duration of symptoms of 14 days. Only 65% were febrile. Bacteremia was present in 62%. Common risk factors included intravenous drug use (21%), distant site of infection (15%), diabetes mellitus (13%), trauma (12%), and infected central venous line (9%). No risk factor was found in 23%. Serious complications such as osteomyelitis (55%), chest wall abscess or phlegmon (25%), and mediastinitis (13%) were common. Staphylococcus aureus was responsible for 49% of cases, and is now the major cause of sternoclavicular septic arthritis in intravenous drug users. Pseudomonas aeruginosa infection in injection drug users declined dramatically with the end of an epidemic of pentazocine abuse in the 1980s. Sternoclavicular septic arthritis accounts for 1% of septic arthritis in the general population, but 17% in intravenous drug users, for unclear reasons. Bacteria may enter the sternoclavicular joint from the adjacent valves of the subclavian vein after injection of contaminated drugs into the upper extremity, or the joint may become infected after attempted drug injection between the heads of the sternocleidomastoid muscle. Computed tomography or magnetic resonance imaging should be obtained routinely to assess for the presence of chest wall phlegmon, retrosternal abscess, or mediastinitis. If present, en-bloc resection of the sternoclavicular joint is indicated, possibly with ipsilateral pectoralis major muscle flap. Empiric antibiotic therapy may need to cover methicillin-resistant Staphylococcus aureus (MRSA).

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.

Degenerative sternoclavicular arthritis and hyperostosis

Symptomatic arthritic involvement of the sternoclavicular joint is relatively uncommon and can be a result of distant trauma, infection, and sternocostoclavicular hyperostosis, post-menopausal arthritis, condensing osteitis of the proximal clavicle, or secondary to an underlying arthropathy. Patients with degenerative osteoarthritis due to trauma most commonly have had either an anterior or posterior dislocation, subluxation, or periarticular fracture. Medical claviculectomy with or without ligamentous stabilization is indicated only in situations of painful primary and secondary rheumatoid arthritis, or in patients with neoplastic lesions. Numerous authors have recommended surgical reconstruction but few have reported series larger than two or three cases. This article reviews a few specific arthropathy conditions about the sternoclavicular joint and discusses their nonoperative and operative management.

Bone and joint infections in injection drug users

Skeletal infections in injection drug users have an insidious onset, present with indolent symptoms, and often occur in unusual locations. Unless physicians are familiar with the disease entities unique to the injection drug user, the diagnosis is frequently delayed. Systemic signs of infection are often lacking. The organisms causing the infection represent a wide spectrum; hence, empiric therapy is not generally recommended. Plain-film radiographs are of little help for early diagnosis. Imaging studies, especially radionucleotide studies and CT or MR imaging scans, can help localize the site of infection. For etiologic diagnosis of these infections, bone biopsy or needle aspiration of the involved bone or joint is required. The choice of antibiotic agent should be based on culture results and the antimicrobial susceptibility of the causative organism. Treatment may also involve surgical drainage or débridement of affected structures. Failure to manage acute bone and joint infection aggressively inevitably leads to chronic, often incurable, infection. Successful therapy requires a team approach including the internist and consultants from orthopedic surgery, infectious diseases, and substance abuse counselors.

Current presentation and optimal surgical management of sternoclavicular joint infections

BACKGROUND

Infection of the stemoclavicular joint is unusual, and treatment of this entity has not been standardized. We sought to characterize the current presentation and optimal management of this disease.

METHODS

We retrospectively reviewed the records of the last 7 patients undergoing operation for suppurative infections of the stemoclavicular joint at this institution. Patients were interviewed regarding upper extremity function after formal joint resection.

RESULTS

Predisposing factors were common and included diabetes mellitus (n = 2), clavicular fracture (n = 1), human immunodeficiency virus infection (n = 1), immunosuppression (n = 1), and pustular skin disease (n = 1). All patients presented with local symptoms including clavicular mass and tenderness. Diagnosis and evaluation were facilitated by cross-sectional imaging. Organisms isolated included Staphylococcus aureus, group G streptococcus, and Proteus and Propionibacterium species. Antibiotic therapy and simple drainage and debridement were generally ineffective, leading to recurrence of infection in 5 of 6 patients treated initially in this manner. Six patients were treated with resection of the stemoclavicular joint and involved portions of first or second ribs with soft tissue coverage by advancement flap from the ipsilateral pectoralis major muscle. Response to this therapy was excellent, with cure in all patients, no wound complications, and excellent upper extremity function at long-term follow-up.

CONCLUSIONS

Aggressive surgical management including resection of the sternoclavicular joint and involved ribs with pectoralis flap closure would appear to be the preferred treatment for all but the most minor infections of the sternoclavicular joint. This approach has minimal impact on upper extremity function.

HIV infection-associated inflammatory musculoskeletal disorders

Inflammatory musculoskeletal complaints are relatively common during the course of HIV infection, although they tend to be more frequent during late stages. The clinical spectrum is varied, ranging from arthralgias to distinct rheumatic disorders, such as Reiter's syndrome and psoriatic arthritis. The therapeutic management often poses a challenge, although most patients respond to conventional first- and second-line anti-inflammatory medications.

Musculoskeletal infections in patients with human immunodeficiency virus infection

Musculoskeletal infections constitute an unusual clinical manifestation in patients with human immunodeficiency virus (HIV) infection. Available information about patients' characteristics and their clinical course has been obtained mainly from case reports and small retrospective studies. Our retrospective study is the largest in the literature providing detailed information about the clinical and laboratory characteristics of HIV-infected patients with different musculoskeletal infections. We identified 30 patients with various infections of the musculoskeletal system during a 5-year period among a cohort of 3,000-4,000 HIV-infected patients, and we describe them along with all cases of musculoskeletal infections in patients with HIV reported in the literature since 1985. Septic arthritis was the most commonly reported infection of the musculoskeletal system. It usually affects young men with a median CD4 count of 241. The exact contribution of a previous history of intravenous drug abuse in the pathogenesis of septic arthritis is unclear from the present and previous studies. Staphylococcus aureus was the most commonly isolated agent (31.3%). Numerous atypical pathogens were also identified as causes of septic arthritis. Approximately 90% of patients recovered with appropriate antibiotic treatment. Osteomyelitis was a more serious infection which also affected young individuals but with lower CD4 counts (median, 41). Half the cases were due to atypical mycobacteria. The mortality rate in the previously reported cases and in our series was high (20%). Pyomyositis is an increasingly recognized infection of the striated muscles in HIV-infected patients. It affects almost exclusively males with advanced HIV infection (median CD4 count, 24). Most cases are due to Staphylococcus aureus (67%). Drainage of the involved muscle(s) accompanied by proper antibiotic treatment resulted in resolution of the infection in the majority of patients (90%). Although the incidence of musculoskeletal infections in patients with HIV from this and previous studies appears to be low (0.3%-3.5%), these infections add a significant morbidity and mortality in the affected individuals. Better understanding of their pathogenesis and clinical course would aid the proper diagnosis and management of these infections.