Post-traumatic osteomyelitis of the clavicle: A case report and review of literature

Garrè Sclerosing Osteomyelitis of the Clavicle: Clinical Results after Clavicular Resection

(1) Background: Chronic non-bacterial osteomyelitis (CNO), also known as sclerosing osteomyelitis of Garrè, is a rare inflammatory bone disease with a specific clinical picture, uncertain pathogenesis, and no consensus on an effective treatment. Most frequently affecting other long bones, CNO may rarely involve the clavicle. The aim of this study was to present the results of a series of patients affected by CNO of the clavicle treated with total and partial clavicula resection. In addition, a literature review of different types of treatment of CNO was performed. (2) Methods: We retrospectively reviewed three patients with Sclerosing Osteomyelitis of Garre' of the clavicle treated with partial resection of the clavicle (one) and with total clavicular resection (two). (3) Results: Patients (two female and one male) were an average age of 35.7 years at the time of the operation. At the 4-year follow-up, the mean active ROM was: 143° forward flexion, 133° abduction, 42° external rotation with an internal rotation of two patients at the interscapular level and one patient at the lumbosacral junction. The mean ASES score was 92/100 (range 87-100). In the literature review, after screening the abstracts and full texts for eligibility, 34 studies met the inclusion criteria. Conclusions: Partial or total clavicular resection resulted an effective treatment of CNO of the clavicle. The procedure seems to be particularly indicated after the failure of more conservative treatments.

Similarities and Differences between Clavicular Bacterial Osteomyelitis and Nonbacterial Osteitis: Comparisons of 327 Reported Cases

Background

Currently, both clavicular bacterial osteomyelitis (BO) and nonbacterial osteitis (NBO) remain not well understood owing to their much lower incidences. This study is aimed at summarizing similarities and differences between clavicular BO and NBO based on comparisons of literature-reported cases.

Methods

We searched the PubMed and Embase databases to identify English published literature between January 1^st, 1980, and December 31^st, 2018. Inclusion criteria were studies evaluating clinical features, diagnosis, and treatment of clavicular BO and NBO, with eligible data for synthesis analysis.

Results

Altogether, 129 studies with 327 patients were included. Compared with BO, clavicular NBO favored females (P < 0.001) and age below 20 years (P < 0.001) and mostly presented in a chronic phase (disease term exceeding 2 months) (P < 0.001). Although local pain and swelling were the top two symptoms for both disorders, fever, erythema, and a sinus tract were more frequently found in BO patients (P < 0.01). Although they both favored the medial side, lesions in the clavicular lateral side mostly occurred in BO patients (P = 0.002). However, no significant differences were identified regarding the serological levels of white blood cell count (P = 0.06), erythrocyte sedimentation rate (P = 0.27), or C-reactive protein (P = 0.33) between BO and NBO patients before therapy. Overall, the BO patients achieved a statistically higher cure rate than that of the NBO patients (P = 0.018).

Conclusions

Females, age below 20 years, and a long duration of clavicular pain and swelling may imply NBO. While the occurrence of a sinus tract and lesions in the lateral side may be clues of BO, inflammatory biomarkers revealed limited values for differential diagnosis. BO patients could achieve a better efficacy than the NBO patients based on current evidence.

Clavicular Osteomyelitis Secondary to Candida Parapsilosis Infection

Candida parapsilosis osteomyelitis is a rare diagnosis. Candidal infection can occur via hematogenous or local spread. A localized swelling around a bony structure should raise clinical suspicion. Diagnosis is made by a combination of imaging modalities and biopsy. Anecdotal case reports have been reported in medical literature and treatment guidelines are very limited. Treatment modality includes a combination of surgical debridement and antifungal therapy.

Clinical characteristics and treatment of clavicular osteomyelitis: a systematic review with pooled analysis of 294 reported cases

BACKGROUND

It is usually difficult to diagnose clavicular osteomyelitis (OM), and treatment is delayed because of its rarity. This study aimed to summarize clinical characteristics and treatment of this disease.

METHODS

We searched the PubMed and Embase databases to identify English studies that reported on clavicular OM from January 1980 through December 2016. Effective data were pooled for analysis.

RESULTS

In total, 111 studies comprising 294 cases (bacterial OM, 146; nonbacterial OM, 148) were included, with a sex ratio of 1.89:1 indicating female predilection. Overall, the median age at diagnosis was 16 years. The acute to chronic phase ratio was 0.30, with a median symptom duration of 4 months. The most frequently reported symptom was pain (192 cases), followed by swelling (151 cases) and fever (52 cases). Altogether, 86.94% cases of single-site involvement were reported, with the medial side being the most common site (69.95%). The erythrocyte sedimentation rate achieved the highest positive rate (74.44%) before treatment. The total positive rate of culture for bacterial OM was 81.82%, with Staphylococcus aureus being the most frequently detected pathogen (44.70%). The average cure rate was 83.52%, with no significant difference between surgical (89.70%) and nonsurgical (79.63%) cases (P = .079).

CONCLUSIONS

Clavicular OM, predominant in female patients and young people, usually occurred at a chronic stage. Pain was the most frequent symptom, with the medial side being the most involved site. The erythrocyte sedimentation rate may be a helpful indicator for diagnosis. Regardless of surgery or nonsurgery, most patients achieved a favorable prognosis.

Cutibacterium (formerly Propionibacterium) acnes clavicular infection

Cutibacterium (formerly Propionibacterium) acnes^{13, 16} is a slow growing, gram-positive bacteria that is naturally found in higher concentrations as skin flora on the chest and back, as well as in other areas with greater numbers of hair follicles.^{25, 37} Most of the reported cases of C. acnes shoulder girdle infection follow arthroplasty surgery,^{18, 20, 26, 27, 32, 35} which then often requires debridement, administration of intravenous antibiotics, and surgical revision of the implanted device.^{12, 15, 21, 28-30} In a recent study, 56% of 193 shoulder revisions had a positive culture, 70% of which grew C. acnes.³⁰ Despite the relatively common presumed association of C. acnes humeral osteomyelitis with prosthetic infection, infection of the scapula or clavicle secondary to C. acnes is rare.^{4, 23, 36} Osteomyelitis of the clavicle involving any organism is also an uncommon event that can arise spontaneously via presumed hematogenous spread, or secondary to open fractures or internal fixation.^{6, 33} The most commonly found organism in clavicular osteomyelitis is Staphylococcus aureus.⁹ We here report two cases of clavicular infection secondary to C. acnes that were not associated with implants.

Quantitative and qualitative analysis of bone flap resorption in patients undergoing cranioplasty after decompressive craniectomy

OBJECTIVE: Autologous bone cranioplasty after decompressive craniectomy entails a notable burden of difficult postoperative complications, such as infection and bone flap resorption (BFR), leading to mechanical failure. The prevalence and significance of asymptomatic BFR is currently unclear. The aim of this study was to radiologically monitor the long-term bone flap survival and bone quality change in patients undergoing autologous cranioplasty. METHODS: The authors identified all 45 patients who underwent autologous cranioplasty at Oulu University Hospital, Finland, between January 2004 and December 2014. Using perioperative and follow-up CT scans, the volumes and radiodensities of the intact bone flap prior to surgery and at follow-up were calculated. Relative changes in bone flap volume and radiodensity were then determined to assess cranioplasty survival. Sufficient CT scans were obtainable from 41 (91.1%) of the 45 patients. RESULTS: The 41 patients were followed up for a median duration of 3.79 years (25th and 75th percentiles = 1.55 and 6.66). Thirty-seven (90.2%) of the 41 patients had some degree of BFR and 13 (31.7%) had a remaining bone flap volume of less than 80%. Patients younger than 30 years of age had a mean decrease of 15.8% in bone flap volume compared with the rest of the cohort. Bone flap volume was not found to decrease linearly with the passing of time, however. The effects of lifestyle factors and comorbidities on BFR were nonsignificant. CONCLUSIONS: In this study BFR was a very common phenomenon, occurring at least to some degree in 90% of the patients. Decreases in bone volume were especially prominent in patients younger than 30 years of age. Because the progression of resorption during follow-up was nonlinear, routine follow-up CT scans appear unnecessary in monitoring the progression of BFR; instead, clinical follow-up with mechanical stability assessment is advised. Partial resorption is most likely a normal physiological phenomenon during the bone revitalization process.

Complicated acute haematogenous osteomyelitis with fatal outcome following a closed clavicle fracture-a case report and literature review

Among adults, post-traumatic osteomyelitis following a closed fracture is a rarely described entity in the literature, with the involvement of the clavicle bone being particularly uncommon. Early diagnosis and treatment of clavicular osteomyelitis is crucial to prevent serious consequences such as sepsis, mediastinitis and haemorrhage from the great vessels. A 54-year-old male patient presented to the emergency department complaining of fatigue and limited mobility after having fallen and hit his head and right shoulder 10 days previously. No major injury was found during the diagnostic procedure, and the patient was discharged. 2 weeks later, the patient returned with clinical signs of right upper arm cellulitis and probable sepsis. Diagnostic ultrasound imaging and MRI of the right upper arm, as well as re-examination of the X-ray image, confirmed acute complex osteomyelitis of the right clavicle following an overlooked clavicle fracture. Microbiological analysis confirmed clavicular osteomyelitis caused by Escherichia coli septicaemia. Despite prompt treatment with i.v. antibiotics and surgery, the patient's condition rapidly deteriorated and he passed away. Our case demonstrates the critical importance of early diagnosis and appropriate treatment of a closed fracture. Late diagnosis may lead to severe complications, such as complicated osteomyelitis and sepsis, and even a fatal outcome. Furthermore, a brief literature review is presented of previously reported acute osteomyelitis following a closed fracture, including evidence of affected bone and isolated pathogens. Although uncommon, osteomyelitis should be considered a possible cause of a deteriorating clinical condition in patients with a history of recent trauma.

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.

Tubercular osteomyelitis of the lateral-third of the clavicle

An elderly women with a chronic history of pain and swelling of the right clavicle was investigated. She also had constitutional symptoms. Clinical examination showed mild inflammatory signs over the lateral one-third of the clavicle and the swelling was hard. Clavicle X-ray showed a lytic lesion in the lateral-third of the clavicle and MRI revealed a focal hyperintense area with cortical breach involving the superior cortex of the clavicle. The diagnosis was confirmed as tubercular osteomyelitis after the biopsy, which showed chronic granulomatous inflammation, and the culture was positive for Mycobacterium tuberculosis. Pain resolved by 6 weeks, swelling by 4 months and complete radiological resolution was seen at 15 months after the initiation of antitubercular therapy. No deficit in function was seen. No relapse was noted at 1-year follow-up.

Infection in Orthopaedics

Infection in orthopaedic trauma patients is a common problem associated with significant financial and psychosocial costs, and increased morbidity. This review outlines technologies to diagnose and prevent orthopaedic infection, examines implant-related infection and its management, and discusses the treatment of post-traumatic osteomyelitis. The gold standard for diagnosing infection has a number of disadvantages, and thus new technologies to diagnose infection are being explored, including multilocus polymerase chain reaction with electrospray ionization-mass spectrometry and optical imaging. Numerous strategies have been employed to prevent orthopaedic infection, including use of antibiotic-impregnated implant coatings and cement; however, further research is required to optimize these technologies. Biofilm formation on orthopaedic implants is attributed to the glycocalyx-mediated surface mode of bacterial growth and is usually treated through a secondary surgery involving irrigation, debridement and the appropriate use of antibiotics, or complete removal of the infected implant. Research into the treatment of post-traumatic osteomyelitis has focused on developing an optimal local antibiotic delivery vehicle, such as antibiotic-impregnated polymethylmethacrylate (PMMA) cement beads or bioabsorbable bone substitute (BBS) delivery systems. As these new technologies to diagnose, prevent and treat orthopaedic infection advance, the incidence of infection will decrease and patient care will be optimized.

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.

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.

Tubercular Osteomyelitis Clavicle: A Case Report

INTRODUCTION

Osteomyelitis of the clavicle is a rare entity particularly in adults. Most infective lesions of the clavicle are traumatic and are not difficult to diagnose. Nontraumatic clavicular lesions, on the other hand, are rare and are difficult to diagnosis. It can also occur as a complication of head and neck surgery and subclavian catheter placement.

CASE REPORT

We describe this case in a 61-year-old male who presented with a discharging sinus since 2 years at his left shoulder tip with purulent discharge. Clinicoradiologically, patient was diagnosed as a case of pyogenic osteomyelitis of the lateral end of the clavicle. However, biopsy proved it to be a tubercular osteomyelitis.

CONCLUSION

Discharging sinus along with secondary infection made diagnosis difficult and delayed appropriate treatment. Thus, as skeletal tuberculosis (TB) can mimic any bony pathology, TB has to be included in the differential diagnosis especially at unusual sites.

Medium-term results after total clavicle resection in cases of osteitis: a consecutive case series of five patients

PURPOSE

Claviculectomy is a rare and poorly described event in the surgical therapy of diseases of the clavicle. We present a case series and functional results of patients who underwent total claviculectomy.

METHODS

From 1995 to 2006 a total of 26 patients diagnosed with osteitis of the clavicle underwent surgery in our unit. Of these, five patients (all female) needed a total resection of the clavicle in order to ensure permanent healing from infection. The data collection was prospective. The data gathered preoperatively and at follow-up included clinical examinations, laboratory findings, radiographs and the Constant shoulder scores. The mean follow-up period was 7.5 months.

RESULTS

The surgical concept described was able to eliminate infection in all cases studied within an average hospital stay of 13.4 days (8-18 days). Only one patient showed complications; suffering from chronic pain syndrome requiring surgical revision. After total resection of the clavicle four of five patients showed very good functional results. The average Constant score showed a significant increase from 82 before surgery to 95 at follow-up.

CONCLUSIONS

The surgical technique described for total claviculectomy, along with the insertion of local antibiotic beads, was able to eliminate infection in every case. Good functional results and a low complication rates were observed. For good functional results and the permanent elimination of infection, adjacent joints have to be addressed, the periosteal tube should be preserved and early functional treatment is essential.

[Medium-term results of surgical treatment for osteitis of the clavicle]

AIM

Osteitis of the clavicle is rare and not well described in the international literature. We describe a concept of surgical treatment with medium-term observations.

METHOD

A total of 22 patients (12 women, 10 men; BMI Ø 24.6 kg/m(2), age Ø 48 years) with osteitis of the clavicle were included in the series. The treatment regime consisted of a surgical approach. Data collection was prospective. Data gathered preoperatively and at follow-up included clinical examination, laboratory findings, radiographs and the Constant scoring system. The mean follow-up period was 13.3 (3-53) months.

RESULTS

The described surgical concept was able to permanently eliminate infection in all cases studied. Surgical revisions were required in six patients. The average Constant score showed a significant increase from 66 to 84 at follow-up. Patients also showed good functional results after total resection of the clavicle.

CONCLUSION

The reported treatment regime provides reliable results in terms of eliminating infection with good clinical results. Neighboring joints were frequently also involved in the infection and needed to be surgically addressed.