Osteomyelitis of the clavicle

Surgical configurations of the pectoralis major flap for reconstruction of sternoclavicular defects: a systematic review and new classification of described techniques

OBJECTIVES

The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction.

METHODS

EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures.

RESULTS

The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b).

CONCLUSION

There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.

Reconstruction of sternoclavicular defect with completely detached pectoralis major flap

Sternoclavicular joint infection is very rare. Osteomyelitis is a known complication of septic sternoclavicular joint. Once this condition is diagnosed, aggressive management including antibiotic and surgical debridement is warranted. Patients are often left with sizeable sternoclavicular defects that may need surgical reconstruction. In this report, we describe the use of a completely detached pectoralis major flap for the reconstruction of a large sternoclavicular defect after resection for osteomyelitis. Briefly, after the debridement of the infected sternoclavicular joint, the pectoralis major was detached from its sternoclavicular attachments and further detached from the humeral attachments rendering it completely detached on a vascular pedicle. The muscle was advanced to cover the defect and secured. Patient recovered well without any surgery related complication. She retained good use of the ipsilateral upper extremity. The pectoralis major can be completely detached to provide ample coverage for sternoclavicular joint reconstruction if needed.

Whole clavicle sequestration from chronic osteomyelitis in a 10 year old boy: A case report and review of the literature

Chronic osteomyelitis is a childhood disease and so it is not uncommon to diagnose it in a 10 year old boy who is suffering from pains and discharging sinuses from the left shoulder girdle. What is not common is the involvement of the clavicle in this infective process and even more uncommon is for the whole length of the clavicle to sequester. This case report describes a rare case of chronic osteomyelitis of the left clavicle in which the entire length was removed as a sequestrum during surgery. And despite the removal of an entire length of the clavicle in the patient, there was no functional deficit and there was also no shoulder asymmetry.

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Chronic osteomyelitis is common in childhood and clavicular involvement is less common than femur, tibia or humerus.

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In this clavicular osteomyelitis, the entire bone was sequestered.

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It is not absolutely important to have huge involucrum before sequestrectomy since it is not a weight bearing bone.

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The whole sequestered clavicle was necessarily removed despite the thin involurcum.

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Regardless, the removal of the entire bone was not associated with functional deficit or shoulder asymmetry.

Bilateral clavicle osteomyelitis: A case report

INTRODUCTION

Osteomyelitis of the clavicle is rare. Infection occurs from hematogenous spread or trauma. In adults infection is usually secondary due to an exogenous cause such as open fractures, surgery (iatrogenic) or spread from local tissue with infection.

PRESENTATION OF CASE

The case is presented here of a 50-year old female with bilateral clavicular fractures, who was operated on with open reduction and internal fixation. At the 6-month follow-up, she had complaints of bilateral osteomyelitis which was successfully treated with resection of the infected segment of the bone, and antibiotic impregnated collagen.

DISCUSSION

Predisposing factors include diabetes, intravenous drug abuse, tuberculosis or immune suppression. Management involves the removal of bone fixation, debridement of the bone and if there is a defect, coverage with a muscle flap is applied.

CONCLUSION

In cases of clavicular osteomyelitis where infection continues despite debridement and antibiotic therapy, excision of the sequestered clavicular section is a successful treatment approach and has been seen to improve quality of life without any functional loss.

Sternoclavicular joint osteomyelitis following head and neck surgery

OBJECTIVES/HYPOTHESIS

To review all reported cases of sternoclavicular joint (SCJ) osteomyelitis following head and neck surgery.

STUDY DESIGN

Retrospective case review.

METHODS

PubMed search and one additional case from our institution.

RESULTS

Twelve cases were reviewed, and the following recommendations are suggested: risk factors for SCJ osteomyelitis should be identified; early and prompt diagnosis of SCJ osteomyelitis is warranted; tracheostoma care and careful examination of the skin should not be neglected; meticulous screening for cancer recurrence is imperative; if SCJ infection is suspected, cancer recurrence must be ruled out with biopsies; and surgical debridement is considered the gold standard of treatment. Administration of newer-generation antibiotics is a reasonable choice when the infection is detected early, as is maintaining a low threshold for surgical treatment if disease persists or progresses.

CONCLUSIONS

Osteomyelitis of the SCJ following head and neck surgery is uncommon and must be distinguished from malignancy with biopsies. Early diagnosis and treatment are imperative. Laryngoscope, 2010.

Clavicular osteomyelitis: a rare complication after surgery for head and neck cancer

Clavicular osteomyelitis (COM) is a rarely described disease entity, occurring especially after head and neck surgery. We herein report the ninth case according to the English language literature and describe the pertinent diagnostic and therapeutic measures to treat this complication. A 63-year-old Caucasian male underwent total laryngectomy and partial pharyngectomy for a post-radiotherapy recurrence of a T2 hypopharyngeal cancer. He presented multiple systemic (cardiovascular problems, previous pneumonectomy, malnutrition) and local-regional (previous radiotherapy, neck dissection, tracheostomy) factors favoring postoperative complications. Sixteen days after surgery, he developed a painful swelling with overlying erythematous skin at the level of the medial portion of the left clavicle. A purulent discharge from the adjacent stomal dehiscence was also noted. COM, suspected on the base of patient's history and clavicular inspection, was confirmed by CT scan. Surgical debridement allowed for definitive diagnosis, ruling out any possible suspicion of stomal recurrence or secondary localization to the clavicle. Cultures from the debrided bone sequestra grew Streptococcus pyogenes Group A and allowed for proper targeting of antibiotic therapy, which was carried out for 4 weeks after surgery. Four years after surgery the patient is tumor-free and does not show any sequela related to the COM or its treatment. COM is a rarely encountered complication after major head and neck surgery. Nevertheless, prompt diagnosis and treatment are mandatory due to the potential life-threatening evolution of this condition.

Split pectoralis major muscle flap reconstruction after clavicular-manubrial resection

Resection of the clavicular head and clavicular-manubrial junction is required in cases of chronic osteomyelitis or tumor. This article describes a technique for soft tissue coverage in an infected or irradiated area after resection using a split pectoralis major rotational muscle flap.

Osteomyelitis of the clavicle: clinical, radiologic, and bacteriologic findings in ten patients

Most lesions of the clavicle are traumatic and pose few diagnostic difficulties. Nontraumatic clavicular lesions, on the other hand, are rare and frequently present problems in diagnosis. This report reviews the clinical, radiologic, and bacteriologic findings in ten patients, six of whom were diagnosed as having acute osteomyelitis and four chronic osteomyelitis. The differential diagnosis of clavicular osteomyelitis is also discussed. The clinical duration of the infectious process in these patients ranged from 2 weeks to 1.5 years. All patients presented with pain; six had fever, three had localized swelling or a mass, and three had soft tissue abscesses. The radiographic findings also varied: the lesion was predominantly sclerotic in four patients, lytic in three, and mixed in two patients; in the one patient in whom magnetic resonance imaging was the only imaging study performed, these features could not be properly evaluated. Periosteal reaction was detected in three patients. Staphylococcus aureus was the causal organism in four patients, while in the remaining six patients different microorganisms were cultured, including Coccidiodes immitis and Mycobacterium tuberculosis. Six patients required biopsy for final diagnosis. Although clavicular osteomyelitis is rare, particularly in adults, it should be considered in the differential diagnosis of a clavicular lesion. The final diagnosis often depends on the results of biopsy and cultures.

Near-fatal complications of tracheotomy infections and their prevention

Infectious complications of tracheotomy range from minor to potentially fatal. Three cases are presented: clavicular osteomyelitis; innominate artery blowout with mediastinitis; and the first reported case of necrotizing fasciitis involving the chest wall related to tracheotomy infection. All patients were debilitated, with one diabetic and another steroid-dependent. Infectious sequelae occurred as late as 8 weeks following tracheotomy. The mechanism, treatment, and prevention of tracheotomy infections are reviewed. Indications for the creation of a permanent but reversible tracheostome should be expanded to prevent infections in debilitated or immunosuppressed patients in whom decannulation is unlikely.

Inflammatory hyperostosis and sclerosis of the clavicle

Six cases with chronic inflammatory hyperostotic and sclerotic changes of the clavicle are reported. No causative organisms could be detected. Four patients had involvement of other bones including the thoracic spine, the femur, the tibia and the sternal end of the other clavicle. These may be classified as having "chronic recurrent multifocal osteomyelitis" (CRMO). The remaining two patients with similar clavicular changes might have an, as yet, unifocal CRMO.

Life-threatening clavicular osteomyelitis in two debilitated patients

Two cases are presented of immunologically compromised patients who developed acute pyogenic clavicular osteomyelitis from direct spread of a contiguous focus. Each patient's condition declined despite antibiotic therapy drainage procedures until survival was in doubt. Both showed striking reversal of their conditions and recovery when an aggressive surgical debridement (total claviculectomy) was performed. Acute pyogenic osteomyelitis of the clavicle is uncommon and rarely reported. The special implications in our patients of this disease of the adapted therapy are discussed.