Clinical manifestations, treatment outcomes, and risk factors for sternoclavicular septic arthritis

Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach

OBJECTIVES

Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining.

METHODS

An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes.

RESULTS

A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis.

CONCLUSIONS

This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Sternoclavicular Septic Arthritis and Surgical Intervention: A Case Report

Management of septic arthritis is an area of controversy, especially in rare locations like the sternoclavicular joints. In this case report, we present a case of septic sternoclavicular joint, which was resistant to medical treatment and deteriorated during the treatment course. Although medical treatment has proven effective based on previous literature, some cases will still not benefit from it. In this case, our patient responded significantly to surgical treatment regarding upper limb function, faster infection eradication and rehabilitation, and shorter hospitalization and antibiotics duration.

Sternoclavicular septic arthritis in a healthy adult: A case report and a review of the literature

Sternoclavicular joint septic arthritis is rare and commonly associated with specific risk factors. We report the case of a 58-year-old female with no previous medical or surgical history who presented complaining of a warm, indurated mass overlying the right sternoclavicular joint. Computed tomography of the chest showed erosion of the sternal end of the clavicle and the manubrium sternum associated with thickening of the synovium and a sternoclavicular joint space narrowing, suggestive of an infective process. Intraoperative finds a purulent collection extending both over the clavicle and the sternum. Limited destruction of small parts of the sternoclavicular joint was noted. The abscess was drained. Simple debridement and limited curettage were preferred to en bloc resection given the limited size of necrotic tissues. Sternoclavicular joint septic arthritis is a condition with significant morbidity and potential mortality. All medical practitioners must maintain a high degree of suspicion, even in healthy patients, as it can lead to serious complications.

Innovative Surgical Concept for Septic Sternoclavicular Arthritis: Case Presentation of a Simultaneous Joint Resection and Stabilization with Gracilis Tendon Graft Including Literature Review

INTRODUCTION

Septic arthritis of the sternoclavicular joint (SCJ) is a rarity in everyday surgical practice with 0.5 - 1% of all joint infections. Although there are several risk factors for the occurrence of this disease, also healthy people can sometimes be affected. The clinical appearance is very variable and ranges from unspecific symptoms such as local indolent swelling, redness or restricted movement of the affected shoulder girdle to serious consequences (mediastinitis, sepsis, jugular vein thrombosis). Together with the low incidence and the unfamiliarity of the disease among practicing doctors in other specialties, this often results in a delay in the diagnosis, which in addition to a significant reduction in the quality of life can also have devastating consequences for the patient.

PATIENT AND METHOD

According to a stage-dependent procedure, the therapy strategies range from antibiotic administration only to radical resection of the SC joint and other affected structures of the chest wall in severe cases with the following necessity for flap reconstruction. The aspect of possible post-interventional instability after resection of the SCJ receives little or no attention in the current literature. In the present case report of a 51-year-old, otherwise healthy gentleman with isolated monoarthritis of the right SCJ with Escherichia coli (E. coli) shortly after two prostatitis episodes, the possibility of a new surgical approach with a one-stage eradication and simultaneous stabilization of the SCJ is presented. Therefore, a joint resection including extensive debridement is performed while leaving the posterior joint capsule and inserting an antibiotic carrier. In the same procedure, the SCJ is then stabilized with an autologous gracilis tendon graft by using the "figure of eight" technique, which has become well established particularly for anterior instabilities of the SCJ in recent years.

RESULTS AND CONCLUSION

One year after operative therapy, the patient presented symptom-free with an excellent clinical result (SSV 90%, CS89 points, CSM 94 points, TF 11 points, DASH 2.5 points). It is concluded that in selected cases with an infection restricted to the SCJ without major abscessing in the surrounding soft tissues, the demonstrated procedure leads to good and excellent clinical results with stability of the joint. If the focus of infection and germ are known, stabilization using an autologous graft can be carried out under antibiotic shielding. To the best of the authors' knowledge, this surgical procedure has not yet been described in the current literature. Depending on the extent of the resection, an accompanying stabilization of the SCJ should be considered to achieve stable conditions and an optimal clinical outcome.

Diagnosis and management of sternoclavicular joint infections: a literature review

The sternoclavicular joint (SCJ) is anatomically and clinically significant considering its proximity to important neuro-vascular structures like the subclavian vessels and the phrenic nerve. Infections of this joint masquerade multiple disorders, delay diagnosis and spread to the bone and deep tissues. There is no standardized workup and treatment protocol for sternoclavicular joint infections (SCJI) as defined in literature. Here, we review the existing literature to understand the current knowledge of the diagnosis and treatment of SCJI. We searched English publications in PubMed and included clinical trials, case reports, case series, retrospective cohort studies, literature and systematic reviews after excluding non-infectious etiology of SCJ pathologies. There are many risk factors for SCJI, such as immunocompromised status, intravenous drug use, trauma and arthropathies. But a large percentage of patients with disease have none of these risk factors. SCJIs can present with fever, joint swelling, immobility, and rarely with vocal cord palsy or dysphagia. While Staphylococcus aureus causes over 50% of SCJI cases, other pathogens such as Pseudomonas and Mycobacterium are frequently seen. When diagnosed early, the infection can be medically managed with antibiotics or joint aspirations. Most cases of SCJI, however, are diagnosed after extensive spread to soft tissue and bones requiring en-bloc resection with or without a muscle flap. Complications of undertreatment can range from simple abscess formation to mediastinitis, even sepsis. SCJIs are rare but serious infections prompting early detection and interventions. Most cases of SCJI treated adequately show complete resolution in months while retaining maximum functionality. Key features of proper healing include aggressive physiotherapy to prevent adhesive shoulder capsulitis and decreased range of motion.

Sternoclavicular Joint Septic Arthritis and Anterior Mediastinal Mass in a Young Athlete: Possible Immune-modulatory Effect of Growth Hormone

Septic arthritis of sternoclavicular joint (SCJ) is a rare disease, however, not uncommon in patients who abuse intravenous drugs. It can present with a wide range of manifestations that can pose diagnostic challenges, which can result in a delay in diagnosis and treatment. Over the last few decades, there is a surge in the use of nonprescription recombinant human growth hormone (rhGH) by the young healthy population and athletes for its purported ergogenic effects. Furthermore, we lack quantitative information about the adverse effects of the chronic use of rhGH in a healthy population due to the scarcity of epidemiological data. We are reporting a case of a young male athlete who was chronically using the subcutaneous rhGH formulation to build lean body mass, and presented with septic arthritis of right SCJ due to methicillin-sensitive Staphylococcus aureus (MSSA) complicated by a necrotic inflammatory response involving the mediastinum which infiltrated the apical lung parenchyma. The clinical presentation masqueraded as the mediastinal mass raising the suspicion of mediastinal malignancy. Histological analysis of the tissue of SCJ and mediastinal area revealed no malignant cells but a lymphocyte-predominant inflammatory response with germinal centers was observed, which was an atypical response to MSSA bacterial infection. We have reviewed the literature to elucidate the immune-modulatory effect of rhGH, as the chronic use of rhGH by our patient probably has contributed to an atypical immune response to MSSA. The patient was treated with an extended duration of parenteral antibiotics and multiple incision and debridements to achieve complete resolution of infection over the next six months. This is a unique case of septic arthritis of right SCJ in a patient on chronic subcutaneous rhGH which masqueraded as a mediastinal mass raising concern of malignancy; moreover, it highlights the probable immune-modulatory role of rhGH which instigated an atypical immune response to MSSA infection.

Escherichia coli bacteremia with secondary seeding in the sternoclavicular joint: A case report and literature review

Introduction

Septic arthritis of the sternoclavicular joint (SCJ) is a rare phenomenon in healthy individuals. It is generally described in patients with predisposing risk factors such as diabetes mellitus, intravenous drug use, immunosuppression, chronic liver disease and central venous catheters.

Case report

We describe a case of Escherichia coli related SCJ septic arthritis in an otherwise healthy adult with review of the literature.

Discussion

There were only two previous reports of patients with E. coli and to our knowledge, this is the third case of a patient with SCJ septic arthritis secondary to E. coli without predisposing factors. A review of literature on SCJ septic arthritis among otherwise healthy adults showed that pain and redness of the SCJ are the most common presentation symptoms, with Staphylococcus aureus being the most common causative organism. More than half of these patients required surgical intervention for associated complications, but all patients had complete recovery with appropriate treatment with no reported mortality.

Conclusions

SCJ infection is rare and has a significant morbidity. It should be identified and treated properly to avoid the development of complications. Imaging studies are used to assist in making the diagnosis, and culture results help to identify the pathogen.