Aggressive surgical management of sternoclavicular joint infections

The Nomadic Bug: A Case Report of Salmonella Septic Arthritis of Sternoclavicular Joint in a Healthy Patient

In an otherwise healthy adult, septic arthritis of the sternoclavicular joint is very uncommon. Usually, individuals with a history of intravenous drug usage or those with impaired immune systems are affected. The usual mode of spread is hematogenous spread or direct spread via neighbouring sources of infection. We report a rare case of mediastinitis and lung empyema preceded by sternoclavicular septic arthritis in an otherwise healthy 49-year-old woman due to Salmonella sp. Radiological imaging showed left sternoclavicular joint collection with bone destruction. The literature only contained reports of two prior occurrences of sternoclavicular joint septic arthritis caused by Salmonella. If diagnosed early, patients usually respond to medical treatment such as aspiration and antibiotics, as was the case with our patient.

Disseminated Penicillin-Resistant Streptococcus pneumoniae Infection: A Case Report

An invasive pneumococcal disease involving sternoclavicular joint arthritis, lumbar spondylodiscitis, and muscular abscesses caused by penicillin-resistant Streptococcus pneumoniae has not been reported previously. We successfully treated a 57-year-old man with this condition using surgical drainage and debridement, and laminectomy/fenestration, in combination with the administration of two IV antimicrobial drugs based on blood culture results. Clinical resolution was obtained after decompression of the lumbar spine, with minimal restriction of the left lower limb. This treatment approach should be considered depending on the pathogen, underlying host factors, and the severity of the disease.

Minimally Invasive Surgery for Sternoclavicular Joint Infection with Osteomyelitis, Large Abscesses, and Mediastinitis

Background

Sternoclavicular joint infections require en bloc resection for radical cure; however, this aggressive procedure may result in multiple adverse events. Therefore, performing minimally invasive surgery is desirable. In this report, we describe a case of sternoclavicular joint infection complicated by osteomyelitis, large abscesses, and mediastinitis that was successfully treated with incision and drainage. Case Presentation. A 42-year-old man with no medical history presented to our hospital with complaints of painful swelling in the left chest wall and acute dyspnea. Computed tomography revealed arthritis of the left sternoclavicular joint, osteomyelitis of the clavicle and sternum, anterior mediastinitis, and abscesses in the neck, chest wall, and retrosternal and extrapleural spaces. Gram staining of the aspirated pus revealed clusters of gram-positive cocci. A diagnosis of Staphylococcus aureus sternoclavicular joint infection with locoregional spread was made. Emergency surgery was performed following adequate resuscitation. A skin incision was made in the second intercostal space. The joint capsule was widely opened, necrotic tissue was curetted, and closed suction drains were placed in the abscess cavities and connected to a negative pressure system. The wound was then closed using primary sutures. The postoperative course was uneventful. Methicillin-sensitive Staphylococcus aureus was cultured from the pus. The patient was discharged on postoperative day 14. Osteomyelitis worsened within a few weeks after surgery but recovered with wound management and six weeks of antibiotic therapy. The patient has had no recurrence of infection for two years.

Conclusions

Incision and drainage proved to be an effective minimally invasive surgical treatment for sternoclavicular joint infection with osteomyelitis, large abscesses, and mediastinitis caused by methicillin-sensitive Staphylococcus aureus.

Functional Disability Associated With Proximal Clavicle Resection and Pectoralis Flap Transposition for Sternoclavicular Joint Infections

BACKGROUND

Sternoclavicular joint infections (SCJI) are increasing with the opioid crisis and increased intravenous drug abuse (IVDA). Proximal clavicle resection with subsequent pectoralis muscle transposition is part of the treatment of such infections, but the long-term effects on shoulder function are not clear.

METHODS

This report presents a consecutive series of 15 cases of SCJI treated with proximal clavicle resection and pectoralis muscle flap coverage. Patient-reported outcomes were recorded using the Shoulder Disability Questionnaire (SDQ) developed by van der Heijden et al.

RESULTS

The average age of patients was 50 years (range, 23-73 years), with nearly half being male (7/15). Of these patients, 3 were lost to follow-up, 1 was excluded due to subsequent shoulder surgery for an unrelated problem, and another was excluded due to subsequent medical issues that precluded a reliable history. Recurrence was noted in 1 patient with ongoing IVDA. Average length of follow-up was 12 months (range, 8-19 months). The long-term shoulder disability was minimal (mean score of 6 ± 9). Among patients with IVDA, however, the long-term shoulder disability was significantly higher (mean score of 33 ± 16, P < .05).

CONCLUSIONS

In cases where the SCJI was attributed to IVDA, the long-term shoulder disability score was significantly higher, despite resolution of infection. Possible explanations include the self-reporting nature of the SDQ and the well-documented issues with chronic pain in patients with opioid dependency.  Of the patients lost to follow-up, 2 of 3 had infections attributed to IVDA, highlighting the difficulty of meaningful follow-up in this vulnerable patient population.

Nonsurgical management of Fusobacterium necrophorum sternoclavicular septic arthritis: a case report

BACKGROUND

To date, the gold-standard treatment for sternoclavicular septic arthritis has been surgery due to the high failure and complication rates of medical treatment. In particular, presentation of Fusobacterium sternoclavicular septic arthritis has been rarely reported and very sparsely investigated, and only one other case report of septic arthritis caused by this pathogen exists in literature.

CASE PRESENTATION

We report a case of an otherwise healthy 38-year-old Caucasian woman who presented with sternoclavicular septic arthritis as a complication of Fusobacterium necrophorum mediastinitis. Our patient underwent successful management through nonstandard, conservative treatment of 7 weeks of intravenous piperacillin + tazobactam followed by 6 weeks of oral amoxicillin + clavulanic acid.

CONCLUSION

We highlight a case of the rare presentation of Fusobacterium necrophorum sternoclavicular septic arthritis that did not require surgical intervention for successful management. Though infection of the sternoclavicular joint is unusual, it continues to be seen in thoracic surgery, and there are increasing numbers of antibiotic-resistant organisms. This case broadens insight into the clinical course and treatment of such conditions. The success of conservative management in this case aligns with the similar nonsurgical course of the one previous report of Fusobacterium sternoclavicular septic arthritis occurrence. Thus, further discussion and thought for reevaluating the current standard practice of surgery for sternoclavicular joint infection is suggested. Our case supports assessing a patient's overall health, causative organism, and extent of infection in interventional course and taking the feasibility of conservative management into more weighted consideration.

A multi-institutional analysis of sternoclavicular joint coverage following osteomyelitis

Background

Sternoclavicular joint (SCJ) osteomyelitis is a rare pathology requiring urgent intervention. Several operative approaches have been described with conflicting reports. Here, we present a multi-institutional study utilizing multiple surgical pathways for SCJ reconstruction.

Methods

A multi-institutional retrospective cohort study was conducted to identify patients who underwent surgical repair for sternoclavicular osteomyelitis between 2008 and 2019. Patients were stratified according to reconstruction approach: single-stage reconstruction with advancement flap and delayed-reconstruction with flap following initial debridement. Demographics, operative approach, type of reconstruction, and postoperative outcomes were analyzed.

Results

Thirty-two patients were identified. Mean patient age was 56.2±13.8 years and 68.8% were male. The average body mass index (BMI) was 30.0±8.8 kg/m². The most common infection etiologies were intravenous drug use and bacteremia (both 25%). Fourteen patients (43.8%) underwent one-stage reconstruction and 18 (56.2%) underwent delayed twostaged reconstruction. Both single and delayed-stage groups had comparable rates of reinfection (7.1% vs. 11.1%, respectively), surgical site complications (21.4% vs. 27.8%), readmissions (7.1% vs. 16.6%), and reoperations (7.1% vs. 5.6%; all P>0.05). The single-stage reconstruction group had a significantly lower BMI (26.2±5.7 kg/m² vs. 32.9±9.1 kg/m²; P<0.05) and trended towards shorter hospital length of stay (11.3 days vs. 17.9 days; P=0.01).

Conclusions

Both single and delayed-stage approaches are appropriate methods with comparable outcomes for reconstruction for SCJ osteomyelitis. When clinically indicated, a single-stage reconstruction approach may be preferable in order to avoid a second operation as associated with the delayed phase, and possibly shortening total hospital length of stay.

The Preferred Treatment of Sternoclavicular Joint Infections: A Systematic Review

The treatment of sternoclavicular joint infection is a topic of controversy. This systematic review aims to evaluate the preferred treatment of sternoclavicular joint infections. A literature search using PubMed/MEDLINE®/Embase databases was conducted to identify publications on the surgical management of sternoclavicular joint infections. Case reports and studies without surgical management were excluded. The outcomes of interest included patient demographics, comorbidities, infectious etiologies, radiographic features, surgical management, and complications. Sixteen articles met the inclusion criteria. The mean age of the subjects was 53.4 years; there was a predominance of males (65%), and a minority of the subjects were obese (15%). The most common infectious etiology was methicillin-susceptible Staphylococcus aureus (MSSA) (48%). CT scan was reported in 46% of cases. The most common treatment was surgical resection of the joints (85%), followed by muscle flap closure of the wounds (54.2%). The complication rate ranged from 0-40%. Specifically, recurrence of infection was low with resection of the joint, followed by muscle flap closure. Given the heterogeneity of the methodology and inconsistency in the outcomes, a meta-analysis could not be performed. Overall, the current literature favors the resection of the sternoclavicular joint as the gold standard treatment. Closure of the wound using muscle flap seems to adequately treat this problem without any major untoward events.

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 septic arthritis caused by Staphylococcus aureus: excellent results from medical treatment and limited surgery

Background: Aggressive surgery such as en bloc joint resection is favored for treating uncommon sternoclavicular (SC) septic arthritis, based on expert opinion and small case series. We analyzed the clinical characteristics and treatment outcomes of patients with Staphylococcus aureus SC septic arthritis treated medically or with limited surgery. Methods: All adult patients with this septic arthritis at the Asan Medical Center between September 2009 and December 2016 were reviewed. Limited surgery was defined as simple incision, drainage, and debridement of the infected joint. Results: Of 22 patients enrolled, 11 received medical treatment only, and 11 underwent limited surgery, and none underwent aggressive surgery. Most patients (73%) had underlying predisposing conditions such as infection at a distant site, diabetes and liver cirrhosis, and none had intravenous drug abuse or HIV infection. Complications such as chest wall and/or neck abscess, clavicular and/or sternal osteomyelitis were identified in 18 patients (82%). Patients with chest wall and/or neck abscesses tended more often to undergo limited surgery than patients without such abscesses (73% vs. 27%, p = .09). The median duration of intravenous antibiotics was 35 days (IQR, 25-46 days). Treatment was successful in all cases. In a median 53-week follow-up (IQR, 8-171 weeks), there was no relapse of arthritis or joint deterioration. Conclusions: Medical treatment alone or with limited surgery could be successful therapeutic strategies for complicated S. aureus SC septic arthritis in selected patients.

Surgical management of sternoclavicular joint septic arthritis

INTRODUCTION

Infections of the sternoclavicular joint (SCJ) account for less than 1% of all joint infections. There are no standardized diagnostic and therapeutic algorithms defined in literature. This study intended to report the risk factors, the bacterial spectrum, the extent and localization and the clinical outcome of SCJ infections.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of 13 patients (8 men, five women, mean age 37.6 years) with SCJ infections between Januray 1st 2008 and October 30th 2015 for clinical parameters and radiological studies. All patients were interviewed during their follow-up along with clinical examination and assessing the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH).

RESULTS

Nine patients presented with local chest pain and swelling; in 4 patients, the prevalent symptom was pain without local signs of inflammation. Full blood count revealed a mean leukocytosis of 15 × 10⁹ L and a mean CRP of 21.0 mg/dl. Approximately 61.5% reported known diabetes mellitus. 10 patients presented an involvement of surrounding structures. All patients received a preoperativ CT scan. Each patient was treated via SCJ resection without intraoperative complications. Primary wound closure was possible in all cases. The mean follow-up was 95 days. Wound culture revealed Staphylococcus aureus in all patients. Pathological examination affirmed acute osteomyelitis in 7 patients. Four patients required the intensive care of which 2 patients died from septic shock. Recurrent infection was encountered in 3 patients who underwent revision surgery. Mean DASH Score was 18.7.

CONCLUSION

CT should be routinely obtained to recognize the possible extends to the surrounding structures. SCJ resection can result in satisfactory clinical results and should be considered in cases of extended infections including the surrounding structures. Empiric antibiotic coverage should contain cephalosporin or extended-spectrum penicillin. Inappropriate or less-invasive surgical procedures may cause recurrencent infections, especially in cases of osteomyelitis.

48-year-old Man with Fevers, Chest Pain, and a History of Substance Abuse

A 48-year-old male with a history of intravenous (IV) drug use presented to the emergency department (ED) for an area of mild pain and erythema on his chest. He was then triaged to the urgent care, or fast track, area of the ED. He was well appearing with normal lab findings and vital signs, but his workup revealed mediastinitis with osteomyelitis of the manubrium and clavicles, a surgical emergency. His treatment course included IV antibiotics and operative intervention with thoracic surgery. The patient looked too good to be sick, yet he had a life-threatening infection.

Sternoclavicular joint

The sternoclavicular joint is a saddle shaped, synovial joint and is the only skeletal articulation between the axial skeleton and the upper limb. Here, a reviewis provided of the anatomy, biomechanics, traumatic and atraumatic conditions, and management options for the various conditions described.

Septic arthritis of the sternoclavicular joint: A unique late complication after tracheostomy

BACKGROUND

Septic arthritis of the sternoclavicular joint is a rare infection associated with significant morbidity and mortality. Several risk factors for septic arthritis have been reported in the literature ranging from immunodeficiency to intravenous drug use.

CASE PRESENTATION

A 63-year-old male previously treated for synchronous squamous cell carcinomas of the epiglottis and floor of mouth presented with tenderness and swelling of the sternoclavicular joint two months after tracheostomy decannulation. Computed tomography and bone scans confirmed the diagnosis of septic arthritis of the sternoclavicular joint. The patient's clinical course, surgical treatment, and management considerations are discussed here.

CONCLUSION

Septic arthritis of the SCJ is a rare but serious infection. Once diagnosed, septic arthritis of the SCJ should be promptly treated to prevent further morbidity and mortality.

Swellings of the sternoclavicular joint: review of traumatic and non-traumatic pathologies

The sternoclavicular joint (SCJ) is an integral part of the shoulder girdle that connects the upper limb to the axial skeleton.

Swelling of the SCJ is commonly due to trauma, degeneration, infections and other disease processes that affect synovial joints.

This review also focuses on uncommon conditions that could affect the SCJ, including SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, Friedrich’s disease and Tietze syndrome.

The scope of this review is limited to the analysis of the current evidence on the various conditions affecting the SCJ and also to provide an algorithm to manage these conditions.

Cite this article: EFORT Open Rev 2018;3:471-484. DOI: 10.1302/2058-5241.3.170078

Treatment for sternoclavicular joint infections: a multi-institutional study

BACKGROUND

Sternoclavicular joint (SCJ) infections are rare and difficult to manage. Surgery is necessary for treatment.

METHODS

A retrospective chart review of the university hospital and Veterans Administration (VA) hospitals of all patients treated for SCJ infections since 2001 was conducted. Fifteen [15] patients were identified and evaluated for the types of infections, risk factors, treatments and survival.

RESULTS

All 15 patients were symptomatic including: pain [13], erythema [9], purulent drainage [3], fever greater than 38.3 °C [2], and leukocytosis [9]. The associated medical problems included: diabetes mellitus (DM), hypertension (HTN) and renal failure. All patients underwent intraoperative joint resection. Sixty-seven percent (67%) of intraoperative wound cultures grew staphylococcus aureus. Fourteen patients were discharged on intravenous antibiotics. The follow-up ranged between 1 week-11 months. Thirteen patients are currently alive without infection. Two patients died: 1 of sepsis and 1 of unknown causes after discharge.

CONCLUSIONS

Symptomatic SCJ infections require surgical intervention. The most common organism was staphylococcus aureus.

A three-stage procedure using bone transportation for the treatment of sternoclavicular infectious arthritis

Background

Sternoclavicular joint (SCJ) infectious arthritis is a rare disease. A standard treatment for SCJ infection has not been established. This study aimed to assess the clinical outcomes of a three-stage procedure with bone transportation (BT) for treating SCJ infectious arthritis.

Methods

Six patients (mean age 39.5 years) with chronic SCJ infectious arthritis were included in the study. The patients underwent a three-stage treatment between January 2009 and December 2012, and results were analyzed retrospectively. Following debridement, immediate flap closure was conducted, and BT of the clavicle was performed to fill the gap using a monolateral external fixator. SCJ reconstruction with a tendon autograft was performed, and the external fixator was finally removed. Clinical outcomes were evaluated using Disabilities of the Arm, Shoulder, and Hand (DASH) scores and Constant scores. The average follow-up period was 16 months (range 12–36 months).

Results

The DASH scores decreased from 53.6 ± 4.9 preoperatively to 24.4 ± 3.1 postoperatively. The Constant scores for pain, activity level, positioning, strength, and range of motion were significantly high after the treatment. The total Constant score improved from 32.5 ± 5.8 preoperatively to 76.7 ± 6.4 postoperatively. All patients were satisfied with the therapeutic effect. No complications occurred.

Conclusions

The three-stage procedure with BT improves shoulder function and movement and relieves pain. It is an effective and safe method for treating SCJ infectious arthritis.

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.

Simplified Method for Treating Osteomyelitis of the Sternoclavicular Joint

Osteomyelitis of the sternoclavicular joint is a rare yet challenging problem. It is commonly treated by resection and a muscle flap. We report a case that was treated with single-stage resection of both the sternoclavicular joint and part of the sternum followed by implantation of calcium sulfate beads impregnated with antibiotics and primary closure without a muscle flap. A single-stage debridement with resection for osteomyelitis of the sternoclavicular joint and primary closure with calcium sulfate beads impregnated with antibiotics may be an option when dealing with this difficult clinical problem.

[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.

Case Report: Rare occurrence of Pseudomonas aeruginosa osteomyelitis of the right clavicle in a patient with IgA nephropathy

We describe the case of a 47 year old patient with proven primary IgA nephropathy who presented with osteomyelitis of the medial end of the right clavicle. The patient was not on immunosuppressive medications. He underwent aspiration curettage and CT scan of the clavicle which yielded pus that grew Pseudomonas aeruginosa. Following treatment with appropriate antibiotic therapy the patient presented a complete recovery of the lesion with no loss of renal function. This case highlights the importance of positive cultures in the choice of the appropriate therapy in an extremely rare case of an immunocompetent patient with osteomyelitis of the clavicle.

Treatment of sternoclavicular joint osteomyelitis with debridement and delayed resection with muscle flap coverage improves outcomes

The objective of this study was to evaluate the efficacy of various treatment options for sternoclavicular joint osteomyelitis. We evaluated patients with a diagnosis of sternoclavicular joint osteomyelitis, treated at our hospital from 2002 to 2012. Four treatment options were compared. Three out of twelve patients were successfully cured with antibiotics alone (25%). Debridement with or without negative pressure therapy was successful for one of three patients (33%). Simultaneous debridement, bone resection, and muscle flap coverage of the acquired defect successfully treated one of two patients (50%). Debridement with delayed bone resection and muscle flap coverage was successful in five of five patients (100%). Osteomyelitis of the sternoclavicular joint is a rare disease that has become more prevalent in recent years and can be associated with increasing use of long-term indwelling catheters. Initial debridement with delayed bone resection and pectoralis major muscle flap coverage can effectively treat sternoclavicular joint osteomyelitis.

Resection arthroplasty for septic arthritis of the sternoclavicular joint

BACKGROUND

Treatment for septic arthritis of the sternoclavicular (SC) joint with concomitant osteomyelitis of the clavicle often requires joint resection rather than simple incision and drainage. We evaluated the effectiveness of resection arthroplasty for patients with septic arthritis of the SC joint.

METHODS

We retrospectively reviewed 10 patients who underwent resection arthroplasty for SC joint septic arthritis between 1996 and 2008. The mean patient age was 52.8 ± 10.5 years (range, 40-72 years), the mean symptom duration before surgery was 16.9 days (range, 2-60 days), and the mean follow-up period was 35.4 ± 42.2 months (range, 10-108 months). Diagnoses were based on physical examination, laboratory tests, and radiologic studies including magnetic resonance imaging. Each patient had concomitant osteomyelitis of the clavicle. In addition, 4 patients had mediastinitis and 1 had osteomyelitis of the adjacent ribs. All patients underwent SC joint resection and intramedullary ligament reconstruction, followed by intravenous antibiotics for 4 to 8 weeks. Intraoperative cultures were positive in 6 patients.

RESULTS

All infections resolved, with only 1 patient having complications-systemic sepsis and pneumonia. The mean ranges of motion were 146° of forward flexion (range, 135°-155°) and 48° of external rotation (range, 40°-55°), with the internal rotation level ranging from T5 to L3. The mean superior migration of the clavicle was 1.5 mm (range, 0-4 mm), and the mean visual analog pain score was 1.4 ± 0.7 (range, 0-2).

CONCLUSION

Resection arthroplasty in patients with septic SC joints results in relatively good shoulder function.

Sternoclavicular joint infection: a comparison of two surgical approaches

BACKGROUND

This study compares conventional open debridement with the recently proposed flap closure technique for sternoclavicular joint infection.

METHODS

This is a retrospective review of patients undergoing surgery for sternoclavicular joint infection during the last 7 years.

RESULTS

Twenty patients underwent 35 operations for sternoclavicular joint infection from 2002 to 2009. The debridement and open wound procedure (10 of 20 patients, 50%) involved debridement of the clavicle, manubrium, and first rib and open wound care. The joint resection and flap closure procedure (10 of 20 patients, 50%) involved partial resection of the clavicle, manubrium, and first rib, with immediate (9 of 10) or early (1 of 10) wound closure with pectoralis major advancement flap. The two groups were comparable in comorbidities, duration of symptoms, radiologic findings, and microbiologic results. Despite an approach of planned reoperation for wound care, the open group had fewer mean procedures performed per patient (1.6±0.7 versus 1.9±1.6), owing to fewer unplanned procedures (0 versus 0.8 procedures/patient) than the flap group. The incidence of wound complications (hematoma, seroma) was lower in open patients (0 of 10 versus 5 of 10). The median length of hospitalization was shorter in the open group (5.5 versus 10.5 days), but all open patients (10 of 10; 100%) required prolonged wound care compared with 2 of 10 (20%) in the flap group. The only hospital mortality occurred in the flap group. Eventual wound healing was satisfactory in all survivors.

CONCLUSIONS

For sternoclavicular joint infection, a single-stage resection and muscle advancement flap leads to a higher incidence of complications. Debridement with open wound care provides satisfactory outcomes with minimal perioperative complications but requires prolonged wound care.

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 joint infection necessitating through skin and lung parenchyma

Infections of the sternoclavicular joint associated with extensive local soft tissue involvement or abscess formation often require surgical debridement and drainage. This condition typically presents with joint pain, local erythema, and swelling. This case demonstrates the simultaneous extension of a sternoclavicular joint infection into the left upper pulmonary lobe and through the overlying skin.

Arthroscopic excision of sternoclavicular joint

We report an unusual case of chronic inflammatory arthropathy involving the sternoclavicular joint. Arthroscopic debridement of the sternoclavicular joint cavity was accompanied with the arthroscopic excision of the medial end of clavicle. Twelve months post-surgery the patient is asymptomatic with no signs of recurrence and a full pain free range of movement.

Bilateral sternoclavicular joint septic arthritis secondary to indwelling central venous catheter: a case report

Introduction

Septic arthritis of the sternoclavicular joint is rare, comprising approximately 0.5% to 1% of all joint infections. Predisposing causes include immunocompromising diseases such as diabetes, HIV infection, renal failure and intravenous drug abuse.

Case presentation

We report a rare case of bilateral sternoclavicular joint septic arthritis in an elderly patient secondary to an indwelling right subclavian vein catheter. The insidious nature of the presentation is highlighted. We also review the literature regarding the epidemiology, investigation and methods of treatment of the condition.

Conclusion

SCJ infections are rare, and require a high degree of clinical suspicion. Vague symptoms of neck and shoulder pain may cloud the initial diagnosis, as was the case in our patient. Surgical intervention is often required; however, our patient avoided major intervention and settled with parenteral antibiotics and washout of the joint.

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.

[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.

Operative treatment of the painful sternoclavicular joint: a new technique using interpositional arthroplasty

This study presents the results of a new surgical technique, resection of the medial end of the clavicle and interposition of the sternal head of the sternocleidomastoid muscle, that was used for the treatment of 17 painful sternoclavicular (SC) joints, 14 of which were available for review. The etiology of the pain was primary or posttraumatic degenerative arthritis in 10, osteitis condensans in 2, and SC joint infection in 2. The results of surgery, evaluated with the Rockwood SC joint rating scale and examination of the patients, were determined at a mean follow-up of 46 months. Results were excellent in 4 shoulders, good in 6, fair in 3, and poor in 1. All of the fair and poor results occurred in workers' compensation patients. Interposition arthroplasty performed in conjunction with resection of the medial clavicle proved to be a safe and effective method of treatment for the painful, degenerative or septic SC joint.

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.

Complications of the treatment of the acromioclavicular and sternoclavicular joint injuries, including instability

Treatment of AC joint injuries and SC joint injuries continues to evolve. The risk of complications of both the operative and nonoperative management of these injuries can be minimized by the treating physician if the physician thoroughly evaluates and understands the problem. Making an accurate diagnosis of the underlying pathology and then selecting the appropriate treatment for this will minimize the risk of an associated complication. Paying attention to detail and using the appropriate technique before any operative intervention is chosen will decrease the risk of failure and complication. Close follow-up and early detection of complications will lead to less severe sequelae. AC joint injuries are more common and operative management is accepted for specific indications. Most Orthopaedic Surgeons are comfortable treating these. SC joint injuries are less common and nonoperative treatment is the mainstay. As our approach to these complex problems evolves, we must keep a wary eye towards avoiding and minimizing the complications of the new techniques.

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.

The sternocostoclavicular joint: normal and abnormal features

Many physicians are unfamiliar with the characteristics of the sternocostoclavicular joint (SCCJ). Disorders of the SCCJ, although common, frequently escape recognition. Computed tomography (CT) with thin slices and no gap is at presentthe best means of investigating the SCCJ. CTfeatures in normal subjects have been described in detail; some are misleading. The most common SCCJ disorder is degenerative disease manifesting as osteoarthritis or as periarticular lesions causing antero-medial dislocation of the clavicle. Septic arthritis is the most severe disorder and can lead to mediastinitis. All inflammatory joint diseases, including spondyloarthropathies, can affect the SCCJ. SCCJ involvement is a typical component of the osteoarticular manifestations seen in patients with palmoplantar pustulosis.

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.

Spiral CT and three-dimensional CT of musculoskeletal pathology. Emergency room applications

Spiral CT is a fast and effective modality for evaluating a wide variety of musculoskeletal abnormalities in the emergency department setting. The role of spiral CT in evaluating musculoskeletal trauma and musculoskeletal inflammation and infections is discussed, as is the use of multiplanar and three-dimensional imaging.