Sternoclavicular Joint Infection Research Articles

Treatment for sternoclavicular joint infections: a multi-institutional study.

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

BackgroundSternoclavicular 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.MethodsSix 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).ResultsThe 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.ConclusionsThe 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 Infections

Infections of the sternoclavicular joint (SCJ) respond poorly to nonoperative management and typically require resection. We examined presenting characteristics and outcomes after surgical management of SCJ infections, reviewing a 20-year single-institution experience. From January 1992 to December 2012, 40 patients (age, 57 ± 12 years; 70% male) underwent resection of an infected SCJ. Sternal infections after cardiac surgery were excluded. Clinical features, microbiology, recurrence, survival, and functional impairment were assessed. Infection was documented by the surgeon, and supported by tissue culture. Clinical presentation and treatment course were obtained by review of medical records. The functional assessment was determined by phone interviews using the validated QuickDASH outcome measure. Mortality data were gathered from the medical record. Pain was the presenting symptom in 93% of patients. Staphylococcal species were isolated in 73% of tissue specimens. Fifteen patients (37%) underwent primary closure and 25 patients (63%) underwent closure by secondary intention with application of negative-pressure wound therapy. There were four recurrences (10%), one after primary closure and three in the secondary intention group. No deaths occurred within 30 days of operation, and 5-year survival was 67%. Functional assessment using the QuickDASH outcome measure revealed minimal loss in upper extremity function after the procedure (preoperative score, 10 ± 3; postoperative score, 19 ± 6.8; n= 11). There was no difference in functional outcome comparing primary closure versus secondary intention (19 ± 4.4 versus 20 ± 8.2; p= 0.64). Septic arthritis of the SCJ is routinely managed surgically at many centers. We report that primary closure with a muscle flap can achieve similar outcomes to secondary intention in selected patients. Furthermore, patients experienced minimal functional impairment at long-term follow-up.

Sternoclavicular Joint Infection Treated with Debridement, Vancomycin-Loaded Calcium Sulfate, and Partial Pectoralis Muscle Flap: A Case Report.

We report the case of a forty-six-year-old man with a left sternoclavicular joint infection that was treated effectively with surgical debridement, the implantation of vancomycin-loaded calcium sulfate, a partial pectoralis major muscle flap, and two weeks of intravenous antibiotics. Sternoclavicular joint infection is a rare problem that has received little attention in the orthopaedic literature. The combined surgical procedure detailed here provided good soft-tissue coverage, avoided the potential toxic effect of prolonged systemic antibiotic therapy, and resulted in a good clinical outcome.

An Unusual Cause of Chest Pain in a Young Healthy Female

BackgroundInfection of the sternoclavicular joint is an uncommon disease that is usually seen in patients with underlying risk factors such as prior trauma, intravenous drug use, or diabetes mellitus. The true pathophysiology remains unknown, but underlying bacteremia has been found in a number of cases. Without proper diagnosis and treatment, severe complications such as mediastinitis, sepsis, or death can occur. Case ReportThis is a case of spontaneous stenoclavicular septic arthritis in an otherwise healthy female. The patient's lack of risk factors and minimal examination findings highlight the unusual nature of the case, as well as the challenges it presents in making an early diagnosis. Why Should an Emergency Physician Be Aware of this Condition?Emergency physicians should consider sternoclavicular joint infections in patients who present to the emergency department with chest pain, even in patients without risk factors. They should especially consider the diagnosis in patients with suspected musculoskeletal etiologies or in those with return visits for chest pain. Although most patients do well with treatment, the infection can be life threatening without appropriate interventions.

Surgical management of severe spontaneous sternoclavicular joint infections

Surgical management of severe spontaneous sternoclavicular joint infections

Septic arthritis of the sterno-clavicular joint as a cause of dysphagia: a report of two cases and review of literature

Septic arthritis of sterno-clavicular joint is a rare entity which is often associated with predisposing conditions like intravenous drug abuse and diabetes. Its prevalence in healthy subjects with absence of medical co-morbidities has been sporadically reported. Due to the rarity of the condition, diagnosis is often delayed predisposing the patients to serious complications. Clinical suspicion supported by haematological and radiological investigations is needed for early diagnosis. Dysphagia as a complication of sterno-clavicular joint infection has not been reported. In this study, we report a case of sterno-clavicular joint infection causing dysphagia and review the literature with regards to aetiology, predisposing factors and treatment options. The aim of this study is to highlight the importance of early diagnosis in suspected cases of septic arthritis of sterno-clavicular joint and institution of intravenous antibiotics.

Chest Wall Mass

Chest wall masses are relatively uncommon in clinical practice. The chest wall contains a number of distinct tissues, including skin, fat, muscle, bone, cartilage, lymphatics, blood vessels, and fascia. Each of these component tissues has the capability of producing either a benign or a malignant primary chest wall mass. Initial clinical evaluation includes careful history-taking; CT scans; MRI; and fine-needle aspiration as the former cannot always distinguish between malignant and benign masses. The benign primary masses of the chest wall are described and include infectious masses such as sternal infections; sternoclavicular joint infections; and osteomyelitis of the rib. Benign neoplasms of the chest wall are listed and include bone and cartilage neoplasms such as osteochondromas and chondromas. Malignant primary masses of the chest wall are listed and include soft tissue sarcomas; plasmacytoma; chondrosarcoma; and synovial sarcomas. Secondary chest wall masses are also defined as direct extensions of a malignancy from a contiguous organ. Breast and lung cancer are the most common. The initial evaluation centers on staging the underlying disease. Figures show a sternoclavicular joint infection; a CT scan showing sternoclavicular joint infection; and a chest wall sarcoma. Tables describe the classification of primary and secondary chest wall masses; benign neoplasm of the chest wall by site of origin; and primary malignant chest wall masses according to tissue of origin. This chapter contains 11 figures, 3 tables, 57 references, 5 Board-styled MCQs, and 1 Teaching Slide Set.

Delayed surgical intervention of sternoclavicular joint infection with increased complications

Delayed surgical intervention of sternoclavicular joint infection with increased complications

Descending necrotizing mediastinitis and sternoclavicular joint osteomyelitis

Descending necrotizing mediastinitis is usually associated with cervical or odontogenic infections. We describe a patient with blunt trauma to the chest 2 years earlier, and a slowly developing chest wall hematoma 18 months prior to admission, complicated by chronic sternoclavicular joint osteomyelitis, eventually leading to descending mediastinitis. Thoracotomy with drainage of the mediastinal spaces and multiple procedures for the sternoclavicular joint infection were successful. The rarity of this association and undefined optimal management prompted this report.

Diagnostic yield of CT-guided sampling in suspected sternoclavicular joint infection

To determine the prevalence of infection diagnosed by percutaneous computed tomography (CT)-guided sternoclavicular (SC) sampling in cases of suspected joint infection. A retrospective search was performed in reports of SC joint CT-guided biopsies in adults from July 1992 to July 2012. We reviewed medical records, radiology, microbiology, laboratory, and surgical reports. A positive result was defined as demonstration of a pathogenic organism, either by microscopy or growth in culture, confirming the diagnosis of SC joint infection. A negative result was defined as the absence of such findings. Patients in whom sampling was unsuccessful or not subjected to microbiology were excluded. In addition, CT images were reviewed by the consensus of two musculoskeletal radiologists. A total of 41 patients (mean age 57.1 years) underwent CT-guided SC joint sampling, 27 of whom underwent microbiology studies. Sampling was performed using core biopsy alone in 19%, fine needle aspiration alone in 44%, and aspiration combined with core biopsy in 37%. Positive results were found in 52% (14/27) of patients. Related diseases and predisposing conditions for infection were found in 79% of positive patients. Negative results were found in 48% (13/27) of patients. There were no procedure-related complications. The dominant CT findings were soft tissue swelling (negative group), and effusion and/or capsular hypertrophy/distension (positive group). CT-guided sampling is a safe procedure with positive microbiological cultures in slightly more than half of cases.

Sternoclavicular Joint Infection: Classification of Resection Defects and Reconstructive Algorithm

BackgroundAggressive treatment of sternoclavicular joint (SCJ) infection involves systemic antibiotics, surgical drainage and resection if indicated. The purpose of this paper is to describe a classification of post resectional SCJ defects and highlight our reconstructive algorithm. Defects were classified into A, where closure was possible often with the aid of topical negative pressure dressing; B, where parts of the manubrium, calvicular head, and first rib were excised; and C, where both clavicular, first ribs and most of the manubrium were resected.MethodsTwelve patients (age range, 42 to 72 years) over the last 8 years underwent reconstruction after SCJ infection. There was 1 case of a type A defect, 10 type B defects, and 1 type C defect. Reconstruction was performed using the pectoralis major flap in 6 cases (50%), the latissimus dorsi flap in 4 cases (33%), secondary closure in 1 case and; the latissimus and the rectus flap in 1 case.ResultsAll wounds healed uneventfully with no flap failure. Nine patients had good shoulder motion. Three patients with extensive clavicular resection had restricted shoulder abduction and were unable to abduct their arm past 90°. Internal and external rotation were not affected.ConclusionsWe highlight our reconstructive algorithm which is summarised as follows: for an isolated type B SCJ defect we recommend the ipsilateral pectoralis major muscle for closure. For a type C bilateral defect, we suggest the latissimum dorsi flap. In cases of extensive infection where the thoracoacromial and internal mammary vessels are thrombosed, the pectoralis major and rectus abdominus cannot be used; and the latissimus dorsi flap is chosen.

What's Eating your Wishbone? Sternoclavicular Septic Arthritis with Osteomyelitis

This manuscript describes the presentation of a patient with sternoclavicular joint infection, with a brief discussion on the diagnosis and treatment of this rare septic arthritis. [West J Emerg Med. 2012;13(6):497-498]

Quiz: Sternoclavicular Joint Swelling in a Previously Healthy Adult

A 77-year-old woman was admitted to our department because of 30-day history of low grade fever (up to 38.5°C) and pain in the left sternoclavicular joint. Twenty days before admission a progressively worsening swelling of the area occurred. She did not report any trauma and apart from low grade fever, the patient had also general symptoms such as loss of appetite, weakness and malaise. Her past medical history revealed only mild arterial hypertension. The patient had never received any kind of immunosuppression in the past whereas, there was no history of tuberculosis, diabetes mellitus, iv drug abuse, immune dysfunction or other known risk factors which have been associated with the presence of sternoclavicular joint infection (SCJI) [1]. She had been treated previously by her own general practitioner for 10 days before admission with oral beta-lactam antibiotic and cephalosporin without any improvement. On admission, physical examination revealed a dolorous, inflammatory lesion of the left sternoclavicular joint (Figure 1) and movement limitation of the left arm, whereas there was no ascites or peripheral lymphadenopathy. Laboratory work-up showed only moderate elevation of CRP (5.7 mg/dL; upper normal limit < 1 mg/dL), increased erythrocyte sedimentation rate (ESR; 66 mm/1h), positive tuberculin test (20 mm) while chest x-ray was normal. MRI of the area showed mild osteomyelitis of the clavicle and cellulitis of the surrounding tissues with no effusion at SCJ. The CT scans of the thorax, upper and lower abdomen and retroperitoneal space revealed no lymphadenopathy or pulmonary lesions. After drawing several sets of blood cultures, treatment with daptomycin was started at a dose of 8 mg/kg/day. We chose daptomycin as unfortunately in our area the rates of communityand hospital-associated methicillin resistant Staphylococcus aureus (MRSA) infections have been increased from 14.5% in 2000 up to 40-50% in 2006 and 65% in 2007-2009 [2,3]. Therefore, in our practice we usually manage severe infections of soft tissues, bone or spine initially with vancomycin, teicoplanin or daptomycin until a positive culture with sensitivity tests was obtained [4].

Editorial commentSurgical management of sternoclavicular joint infection

Editorial commentSurgical management of sternoclavicular joint infection

Surgical management of sternoclavicular joint infection

Sternoclavicular joint (SCJ) infections are rarely encountered and their management is not well standardised. We reviewed our experience with the management of this condition in order to evaluate the role of surgery in the management of the SCJ infection and to provide an algorithm for its treatment. It is a multicentre study in which we retrospectively reviewed the data files of the patients who were referred to us for surgical management of SCI infection. From March 2003 to June 2009, 14 patients (12 men and two women) were treated surgically for infected SCJ. No patients were found in the paediatric age group. Mean age was 49.8 years with a range between 26 and 77 years. All patients were symptomatic. The prevalent symptom was either anterior chest wall swelling (21%) or pain (29%); while 50% of them presented with both swelling and pain. Associated risk factors were elicited in 12 patients (86%) while it could not be identified in two patients (14%). These risk factors were in the form of drug addiction in three patients, diabetes mellitus (DM) in four, chronic renal failure (CRF) in three patients and two patients had both DM and CRF. Surgical management was performed in all patients in the form of either incision and drainage in two patients (14%); or SCJ curettage in three patients (21%), while resection of the SCJ was done in nine patients (62%). Mean postoperative hospital stay period (PHS) was 8.1 days (range: 5-30 days). All of them are alive and free of symptoms in follow-up. Surgery was found to be curative with good results for those patients with SCJ infection that did not respond to a full course of intravenous antibiotic therapy. Surgical options include incision and drainage, curettage or SCJ resection. The type of surgical procedure depends on the radiological findings, presentation, severity of the infection and intra-operative findings. In our experience, complex muscle flap reconstruction was not necessary following SCJ resection.

Sternoclavicular Joint Infection: A Comparison of Two Surgical Approaches

Sternoclavicular Joint Infection: A Comparison of Two Surgical Approaches

Sternoclavicular Joint Infection: A Comparison of Two Surgical Approaches

This study compares conventional open debridement with the recently proposed flap closure technique for sternoclavicular joint infection. This is a retrospective review of patients undergoing surgery for sternoclavicular joint infection during the last 7 years. 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. 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.

Invited Commentary

Puri and associates [1] provide a thorough review of the risk factors, cause, and pathologic consequences of the uncommon but challenging problem of sternoclavicular joint infection [1]. Resection of the joint and necrotic tissue is the most effective treatment when boney destruction and significant local phlegmon is present. Pairolero and colleagues [2] appropriately stated in his important contribution to the management of sternal infections to “follow the same time-honored principles of wound healing elsewhere: the wound must be drained adequately; all necrotic tissue, devascularized tissue, and foreign material must be removed; and all residual space must be obliterated” [2].

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.