Primary pyogenic arthritis of sterno-clavicular joint

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

Septic arthritis of the sternoclavicular joint (SCJ) is an atypical and rarely seen clinical condition. The prognosis for patients with SCJ septic arthritis is often poor. The objective of this study was to compare clinical characteristics between SCJ and non-sternoclavicular joint (NSCJ) septic arthritis and to identify independent risk factors for SCJ septic arthritis. A total of 450 adult patients diagnosed with septic arthritis during the January 2002 to December 2013 study period were included in this retrospective cohort study. Patient characteristics, clinical manifestations, and treatment outcomes were examined. Univariate and multivariate analysis was performed to identify potential risk factors for SCJ septic arthritis. Thirty-three (7.3%) of 450 patients had SCJ septic arthritis and the remaining 417 patients had NSCJ. Oligoarthritis or polyarthritis were seen more often in SCJ patients than in NSCJ patients (55 vs. 19%; p < 0.05). Abscess formation and bacteremia were more commonly found at presentation in the SCJ group than in the NSCJ group (18 vs. 8%; p < 0.05 for abscess formation; and, 53.1 vs. 26.6%; p < 0.05 for bacteremia). In multivariate analysis, extra-articular infection (OR 2.7, 95% CI 1.2-6.4; p = 0.02), cirrhosis (OR 1.9, 95% CI 1.1-3.3; p = 0.02), and malignancy (OR 3, 95% CI 1.1-7.8; p = 0.03) were independent risk factors for SCJ septic arthritis. SCJ septic arthritis is an uncommon septic arthritis that frequently presents with local and systemic complications. Factors found to be significantly associated with SCJ septic arthritis were extra-articular infection and immunocompromised host. A high index of suspicion in high-risk patients is the key to achieving improved outcomes.

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.

Surgical management of sternoclavicular septic arthritis

INTRODUCTION

Septic arthritis of the sternoclavicular joint (SCJ) is a rare condition and has many diagnostic and therapeutic standards. The purpose of this study was to evaluate our experience with surgical and diagnostic management to provide a surgical pathway to help surgeons treat this disease.

METHOD

We retrospectively reviewed five patients who were managed surgically between 1999 and 2007. All patients underwent structured diagnostic and treatment protocols. The functional outcome was evaluated using the Constant Score.

PATIENTS

The patients had the following underlying medical conditions: laryngeal cancer, port-explantation linked to a rectum carcinoma, spondylodiscitis, and brain stem infarct with reduced general condition; one patient had no underlying medical problems. Three patients underwent a simple incision, debridement and drainage, and two patients underwent an extended intervention with partial resection of the sternoclavicular joint. The mean duration of follow-up was 29 months (range 24-36 months). All patients had well-healed wounds without signs of reinfection. The Constant Score for the functional outcome at the time of the last follow-up was 76 points (range 67-93 points). All patients recovered completely from SCJ disease.

CONCLUSION

Our recommendations for the management of septic arthritis of the sternoclavicular joint include standard treatment steps and assessments. The early stages of infection can be managed by simple incision, debridement and drainage. In advanced stages of infection, a more radical intervention is preferable.

Sternoclavicular septic arthritis in a previously healthy patient: a case report and review of the literature

Sternoclavicular septic arthritis is an unusual event in healthy patients. Cases have been reported in diabetes mellitus patients, intravenous drug abusers and patients affected by rheumatoid arthritis. We report a case of this unique infection that occurred in a patient who was not at risk of septic arthritis. Through this case and a review of the literature, we discuss the difficulty of diagnosing this disorder, and the consequences of delayed treatment in terms of life-threatening outcomes and therapeutic options.

[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.

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).

Sternoclavicular infectious arthritis in previously healthy adults

OBJECTIVE

To define characteristics of sternoclavicular infection (SCI) in previously healthy patients.

METHODS

SCI in a previously healthy man is reported along with 4 similar cases found by surveying the hospital's database; 22 previously reported cases were culled from the literature and summarized.

RESULTS

The frequency of SCI in healthy adults was 0.5% of all bone and joint infections admitted to the hospital. The clinical and bacteriologic features were similar to previous reports in nonselected SCI patients. Computerized tomography (CT) scan, arthrocenthesis, and biopsy were required for diagnosis. Complications included abscess formation, mediastinitis, and sepsis. The majority of patients were treated by surgical drainage and antibiotics. The final outcome was good, without mortality or long-term morbidity.

CONCLUSIONS

Although SCI is a rare infection in healthy adults, it should be considered in the differential diagnosis of a painful sternoclavicular joint. Prompt diagnosis and appropriate treatment of SCI results in excellent outcome in most cases.