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Minimally Invasive Surgery for Sternoclavicular Joint Infection with Osteomyelitis, Large Abscesses, and Mediastinitis. Case Rep Surg 2022; 2022:9461619. [PMID: 36317047 PMCID: PMC9617732 DOI: 10.1155/2022/9461619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Tasnim S, Shirafkan A, Okereke I. Diagnosis and management of sternoclavicular joint infections: a literature review. J Thorac Dis 2020; 12:4418-4426. [PMID: 32944355 PMCID: PMC7475584 DOI: 10.21037/jtd-20-761] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Sadia Tasnim
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ali Shirafkan
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Ikenna Okereke
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, TX, USA
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Agarwal P, Agarwal N, Hansberry DR, Majmundar N, Goldstein IM. Sternoclavicular joint arthropathy mimicking radiculopathy in a patient with concurrent C4-5 disc herniation. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Jang YR, Kim T, Kim MC, Sup Sung H, Kim MN, Kim MJ, Kim SH, Lee SO, Choi SH, Woo JH, Kim YS, Chong YP. Sternoclavicular septic arthritis caused by Staphylococcus aureus: excellent results from medical treatment and limited surgery. Infect Dis (Lond) 2019; 51:694-700. [PMID: 31355687 DOI: 10.1080/23744235.2019.1639810] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- Young-Rock Jang
- a Department of Internal Medicine, Division of Infectious Disease, Gil Medical Center, Gachon University College of Medicine , Incheon , Republic of Korea
| | - Taeeun Kim
- b Department of Internal Medicine, Division of Infectious Diseases, Nowon Eulji Medical Center, Eulji University School of Medicine , Seoul , Republic of Korea
| | - Min-Chul Kim
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Heung Sup Sung
- d Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Mi-Na Kim
- d Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Min Jae Kim
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sung Han Kim
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sang-Oh Lee
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Sang-Ho Choi
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Jun Hee Woo
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Yang Soo Kim
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
| | - Yong Pil Chong
- c Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea
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Kang BS, Shim HS, Kwon WJ, Lim S, Park GM, Lee TY, Bang M. MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis. Skeletal Radiol 2019; 48:259-266. [PMID: 29978244 DOI: 10.1007/s00256-018-3023-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/19/2018] [Accepted: 06/24/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze and identify magnetic resonance imaging (MRI) and clinical findings for the differentiation between infectious arthritis and spondyloarthritis in patients with unilateral sternoclavicular arthritis. MATERIALS AND METHODS We retrospectively collected and evaluated the magnetic resonance (MR) images of 21 patients diagnosed with unilateral sternoclavicular arthritis, including 12 with infection and nine with spondyloarthritis, between 2004 and 2017. Capsular distension, extracapsular fluid collection, periarticular muscle edema, the prevalence and distribution of bone marrow edema, and the prevalence and size of bone erosions were assessed on the MR images. Clinical data were also reviewed. RESULTS Capsular distension was more prominent in patients with infectious arthritis than those with spondyloarthritis (p = 0.002); extracapsular fluid collection and periarticular muscle edema were also more common in infectious arthritis than spondyloarthritis (p < 0.001, respectively); moreover, bone erosions were larger in infectious arthritis than spondyloarthritis (p = 0.023). Other findings significantly associated with infectious arthritis included advanced age (p = 0.007), an elevated C-reactive protein (CRP) level (p = 0.001), and erythrocyte sedimentation rate (ESR) (p < 0.001). The prevalence and distribution of bone marrow edema and the prevalence of bone erosions on MRI, the white blood cell count, and sex showed no significant differences between the two groups. CONCLUSIONS Capsular distension, extracapsular fluid collection, periarticular muscle edema, and the size of bone erosions on MRI, as well as the age, CRP level, and ESR of patients, could be helpful for differentiating infectious arthritis from spondyloarthritis involving the sternoclavicular joint.
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Affiliation(s)
- Byeong Seong Kang
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea.
| | - Hyun Seok Shim
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
| | - Woon Jung Kwon
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
| | - Soyeoun Lim
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
| | - Gyeong Min Park
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
| | - Tae Young Lee
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
| | - Minseo Bang
- Department of Radiology, University of Ulsan College of Medicine, Ulsan University Hospital, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan, 44033, South Korea
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von Glinski A, Yilmaz E, Rausch V, Koenigshausen M, Schildhauer TA, Seybold D, Geßmann J. Surgical management of sternoclavicular joint septic arthritis. J Clin Orthop Trauma 2019; 10:406-413. [PMID: 30828216 PMCID: PMC6383133 DOI: 10.1016/j.jcot.2018.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/10/2018] [Accepted: 05/07/2018] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Alexander von Glinski
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany,Corresponding author at: Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Emre Yilmaz
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States
| | - Valentin Rausch
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Matthias Koenigshausen
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Dominik Seybold
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital, Bochum, Germany,Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States
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Jamil F, Hussain K. Vocal cord palsy as a presenting feature of sternoclavicular joint septic arthritis. J Surg Case Rep 2015; 2015:rju147. [PMID: 25583908 PMCID: PMC4289859 DOI: 10.1093/jscr/rju147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Sternoclavicular joint septic arthritis (SSA) is rare and often difficult to manage condition. The sternoclavicular joint is an unusual site of septic arthritis in healthy persons, but may be commonly involved in intravenous drug users, primary or secondary immunosuppressive disorders, infections or the presence of infected central lines. After thorough literature search, no cases have yet been reported on SSA leading to vocal cord palsy. The following case describes a male patient who presented to hospital with left vocal cord palsy and symptoms consistent with aero-digestive tract malignancy. Radiological examination and subsequent response to treatment demonstrated the only causative pathology to be an ipsilateral septic sternoclavicular joint.
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Affiliation(s)
- Fahad Jamil
- Department of Oral and Maxillofacial Surgery, St George's Healthcare NHS Trust, London, UK
| | - Khalid Hussain
- Department of Otolaryngology, University Hospital Birmingham, Birmingham, UK
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Thomas KS, Ray LI, Giles HW, Nowicki MJ. Sternoclavicular joint arthritis as the initial presentation of Crohn's disease in an adolescent. Clin Pediatr (Phila) 2013; 52:767-9. [PMID: 22511199 DOI: 10.1177/0009922812441672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kathryn S Thomas
- University of Mississippi Medical Center, Jackson, MS 39216, USA
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Shioya N, Ishibe Y, Kan S, Masuda T, Matsumoto N, Takahashi G, Makabe H, Yamada Y, Endo S. Sternoclavicular joint septic arthritis following paraspinal muscle abscess and septic lumbar spondylodiscitis with epidural abscess in a patient with diabetes: a case report. BMC Emerg Med 2012; 12:7. [PMID: 22702399 PMCID: PMC3447652 DOI: 10.1186/1471-227x-12-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 05/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Septic arthritis of the sternoclavicular joint (SCJ) is extremely rare, and usually appears to result from hematogenous spread. Predisposing factors include immunocompromising diseases such as diabetes. CASE PRESENTATION A 61-year-old man with poorly controlled diabetes mellitus presented to our emergency department with low back pain, high fever, and a painful mass over his left SCJ. He had received two epidural blocks over the past 2 weeks for severe back and leg pain secondary to lumbar disc herniation. He did not complain of weakness or sensory changes of his lower limbs, and his bladder and bowel function were normal. He had no history of shoulder injection, subclavian vein catheterization, intravenous drug abuse, or focal infection including tooth decay. CT showed an abscess of the left SCJ, with extension into the mediastinum and sternocleidomastoid muscle, and left paraspinal muscle swelling at the level of L2. MRI showed spondylodiscitis of L3-L4 with a contiguous extradural abscess. Staphylococcus aureus was isolated from cultures of aspirated pus from his SCJ, and from his urine and blood. The SCJ abscess was incised and drained, and appropriate intravenous antibiotic therapy was administered. Two weeks after admission, the purulent discharge from the left SCJ had completely stopped, and the wound showed improvement. He was transferred to another ward for treatment of the ongoing back pain. CONCLUSION Diabetic patients with S. aureus bacteremia may be at risk of severe musculoskeletal infections via hematogenous spread.
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Affiliation(s)
- Nobuki Shioya
- Department of Critical Care and Emergency, Iwate Medical University, Morioka, Japan.
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Chun JM, Kim JS, Jung HJ, Park JB, Song JS, Park SS, Lee HS, Ahn TS. Resection arthroplasty for septic arthritis of the sternoclavicular joint. J Shoulder Elbow Surg 2012; 21:361-6. [PMID: 21872494 DOI: 10.1016/j.jse.2011.05.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 05/18/2011] [Accepted: 05/27/2011] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jae Myeung Chun
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Nusselt T, Klinger HM, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch Orthop Trauma Surg 2011; 131:319-23. [PMID: 20721567 PMCID: PMC3040322 DOI: 10.1007/s00402-010-1178-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Thomas Nusselt
- Department of Orthopaedic Surgery, University of Goettingen Medical Centre (UMG), Georg-August-University, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
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13
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Pradhan C, Watson NFS, Jagasia N, Chari R, Patterson JE. Bilateral sternoclavicular joint septic arthritis secondary to indwelling central venous catheter: a case report. J Med Case Rep 2008; 2:131. [PMID: 18445257 PMCID: PMC2390578 DOI: 10.1186/1752-1947-2-131] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Accepted: 04/29/2008] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Charita Pradhan
- Department of General Surgery, Kings Mill Hospital, Mansfield, UK.
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14
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Mikroulis DA, Verettas DA, Xarchas KC, Lawal LA, Kazakos KJ, Bougioukas GJ. Sternoclavicular joint septic arthritis and mediastinitis. A case report and review of the literature. Arch Orthop Trauma Surg 2008; 128:185-7. [PMID: 17187260 DOI: 10.1007/s00402-006-0273-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Indexed: 10/23/2022]
Abstract
Septic arthritis of the sternoclavicular joint is rare. Its causes have been reported to include immuno-compromizing diseases, intravenous drug abuse, fractures of the clavicle or catheterization of the subclavian vein. We report a case of septic arthritis of the SCJ in a diabetic patient following periarticular injection of steroids in the ipsilateral shoulder, as this route of infection has not been documented, to our knowledge, in the literature to date. We review the literature regarding epidemiology and methods of surgical treatment that have been proposed, and present our own surgical experience. Bacterial infection should always be suspected in cases of SCJ arthritis. If surgery is required, it is important to remember that bony procedures leave vascular structures exposed, making their cover by myoplasty mandatory.
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Affiliation(s)
- Dimitrios A Mikroulis
- Department of Cardiac and Thoracic Surgery, Democritus University of Thrace, Alexandroupolis, Greece
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15
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Bonnevialle N, Gaston A, Loustau O, Bonnevialle P, Mansat P. [Anaerobic sternocostoclavicular septic arthritis: a case report]. REVUE DE CHIRURGIE ORTHOPEDIQUE ET REPARATRICE DE L'APPAREIL MOTEUR 2007; 93:277-82. [PMID: 17534211 DOI: 10.1016/s0035-1040(07)90250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- N Bonnevialle
- Service d'Orthopédie et Traumatologie, CHU Purpan, place du Docteur-Baylac, 31059 Toulouse Cedex.
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Browne JA, Kravet SJ, Cosgarea AJ. Sternoclavicular joint infection and mediastinitis originally attributed to concomitant rotator cuff pathology. Orthopedics 2004; 27:1108-10. [PMID: 15553955 DOI: 10.3928/0147-7447-20041001-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- James A Browne
- Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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Abstract
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).
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Affiliation(s)
- John J Ross
- From Division of Infectious Diseases (JJR), Caritas Saint Elizabeth's Medical Center, Boston, Massachusetts, and Division of Infectious Diseases (HS), University of Iowa Hospitals, Iowa City, Iowa
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18
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Lemos MJ, Tolo ET. Complications of the treatment of the acromioclavicular and sternoclavicular joint injuries, including instability. Clin Sports Med 2003; 22:371-85. [PMID: 12825537 DOI: 10.1016/s0278-5919(02)00102-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Mark J Lemos
- Department of Orthopaedic Surgery, Lahey Clinic, 41 Mall Road, Burlington, Burlington, MA 01805, USA.
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19
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Osaki SI, Nakanishi Y, Andou K, Takano K, Takayama K, Hirota N, Ishibashi T, Hara N. A case of extrapleural empyema. Respirology 2002; 7:83-5. [PMID: 11896906 DOI: 10.1046/j.1440-1843.2002.00359.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 49-year-old man with diabetes mellitus and alcoholic liver cirrhosis presented with dyspnoea and fever. A chest computed tomography scan revealed three areas of loculated pleural effusion. Initially, the patient was thought to have an intrapleural empyema and was treated with intravenous antibiotics and closed drainage. However, as he did not improve, he was then treated with open drainage. During open drainage, the patient was diagnosed to have an extrapleural empyema and improved following open drainage treatment.
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Affiliation(s)
- Shin-ichi Osaki
- Nishi-Fukuoka Hospital, Graduate School of Sciences, Kyushu University, Fukuoka, Japan.
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20
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Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg 2002; 73:427-31. [PMID: 11845854 DOI: 10.1016/s0003-4975(01)03390-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Howard K Song
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia 19104, USA
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21
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Tripathi SP, Massad MG, Mehta VK, Benedetti E, Geha AS. Pneumothorax necessitans presenting as a presternal pneumothoracocele. Ann Thorac Surg 2000; 69:266-7. [PMID: 10654530 DOI: 10.1016/s0003-4975(99)01203-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 31-year-old woman who is an intravenous drug abuser developed sternoclavicular joint infection with mediastinal and subcutaneous tissue abscesses that communicated through an erosion in the manubrium caused by osteomyelitis. Air entrapment from a subsequent apical pneumothorax formed a localized anterior "pneumothoracocele." We referred to this condition as "pneumothorax necessitans," and we suggest including it in the differential diagnosis of anterior chest wall masses.
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Affiliation(s)
- S P Tripathi
- Department of Surgery, The University of Illinois at Chicago, 60612, USA
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22
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Carlos GN, Kesler KA, Coleman JJ, Broderick L, Turrentine MW, Brown JW. Aggressive surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg 1997; 113:242-7. [PMID: 9040616 DOI: 10.1016/s0022-5223(97)70319-2] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although the sternoclavicular joint is an unusual site for infection, thoracic surgeons may preferentially be called on to coordinate management of cases refractory to antibiotic therapy because of the anatomic relationship of this joint to major vascular structures. METHODS Since 1994 we have surgically managed nine sternoclavicular joint infections in eight patients. Associated medical problems were frequent and included diabetes mellitus (n = 2), end-stage renal disease (n = 2), hematologic disorders (n = 2), and multiple joints affected by sepsis (n = 4). Open joint exploration with drainage and débridement with the use of general anesthesia was performed in four patients. The remaining four patients (one with bilateral sternoclavicular joint infections) had computed tomographic evidence of diffuse joint and surrounding bone destruction with infection extending into mediastinal soft tissues. Surgical therapy for these five joint infections involved en bloc resection of the sternoclavicular joint with an ipsilateral pectoralis major muscle covering the bony defect. RESULTS There were two deaths unrelated to the surgical procedure. After a mean follow-up of 20 months, the remaining six survivors (seven joints) have complete healing with no apparent limitation in the range of motion even after en bloc resection. CONCLUSIONS Most cases of early sternoclavicular joint infections will respond to conservative measures. However, when radiographic evidence of infection beyond the sternoclavicular joint is present, en bloc resection, although seemingly aggressive, results in immediate eradication of all infection with negligible functional morbidity. Prolonged antibiotic therapy or continued local drainage procedures appear to have little value in these cases, adding only to patient care costs and the potential sequelae of chronic infections.
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Affiliation(s)
- G N Carlos
- Indiana University School of Medicine, Department of Surgery, Indianapolis 46202, USA
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23
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González Muñoz JI, Córdoba Peláez M, Tébar Boti E, Téllez Cantero JC, Castedo Mejuto E, Varela de Ugarte A. [Surgical treatment of sternoclavicular osteomyelitis]. Arch Bronconeumol 1996; 32:541-3. [PMID: 9019315 DOI: 10.1016/s0300-2896(15)30691-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Osteomyelitis of the sternocosto-clavicular (SCC) articulation is a rare infection usually caused by Staphylococcus aureus and enterobacteria. It usually occurs in individuals with osteoarticular disease or predisposing factors. Prolonged antibiotic treatment and articular puncture are generally accepted. Authors do not agree on an established protocol. We report three cases of SCC septic arthritis in two previously healthy patients with two foci of infection (one perianal abscess and one dental extraction) and in one adult patient with Still's disease. Pain and intense inflammation was referred to the shoulder, with scarce leukocytosis and fever reaching 38 degrees C. The germs responsible were S. aureus, Bacteroides fragilis and B. oralis. Two of the patients had local, regional abscesses. Long-term antibiotic treatment failed in all cases and surgery for SCC resection and myoplasty of the pectoralis major muscle was required. Recovery was good and shoulder and arm mobility was excellent. We propose medical treatment and articular diagnostic-therapeutic puncture as the first line of therapy for this disease. When evolution is poor or when complications appear, such as abscesses or mediastinitis, we conclude that radical debridement and myoplasty of the pectoralis major muscle are indicated.
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Affiliation(s)
- J I González Muñoz
- Servicio de Cirugía Torácica y Cardiovascular, Clínica Puerta de Hierro, Madrid
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