By Kendrick, Aaron S Head, Harold D; Rehm, Jason
Surgically managed infections of the sternoclavicular joint have rarely been reported, but general and thoracic surgeons may be consulted to manage such infections. Patients who have demonstrated resistance to antibiotic therapy or have infection extending beyond the joint capsule are best managed by surgical resection. IDEAL TREATMENT FOR sternoclavicular joint (SCJ) infection has been controversial since its earliest recognition. Most patients present with complaints of chest and shoulder pain. Although antibiotic therapy is a typical first-line treatment, eradication of refractory SCJ infection requires surgical resection. Although the etiology of these infections cannot always be discovered, intravenous drug use, distant site infection, diabetes mellitus, and central venous catheter infection have been associated with the development of SCJ infections. This study was undertaken to demonstrate the workup, management, and functional outcomes of patients with SCJ infection.
From October 1997 through May 2006, seven patients were surgically treated for SCJ infection. Patient charts were retrospectively reviewed. Patient information including age, gender, comorbidity, source of infection, and time from onset of symptoms to surgery were collected. Radiographic studies including CT scan, MRI, bone scan, and positron emission tomography (PET) were evaluated to determine detection capabilities. Operative procedure performed, time from initial operation to secondary closure, and operative complication data were compiled and reviewed. Antibiotic selection and duration of treatment were also analyzed. At surgical follow-up patients were evaluated for wound healing, pain, and range of motion of the upper extremity.
Surgical resection was performed after failure of antibiotic therapy. The operation was individualized based on each patient’s preoperative radiographic evaluation and intraoperative findings. In all patients a curved horizontal incision was made over the medial clavicle, extending vertically over the manubrium (Fig. 1). Electrocautery was used to dissect through soft tissues to the clavicle at the lateral extent of the inflammatory process. Dissection using fingertip and right-angle instruments was used to encircle the clavicle, dissecting it free from the underlying vessels and chest wall. A Gigli saw was used to transect the clavicle at the edge of the involved bone, preserving as much normal clavicle as possible. A reciprocating sternal saw was used to divide the involved manubrium vertically in the midline with a lateral “T” into the intercostal space immediately inferior to the inflammatory mass. Intercostal cartilages involved in the inflammatory process were also resected in continuity with the hemimanubrium and medial clavicle. Cultures were obtained and the resected specimen was sent to pathology. The level of manubrial resection was based on the extent of the inflammatory mass. It was resected in the first intercostal space in four patients, in the second intercostal space in one patient, and in the fourth intercostal space in one patient. One patient required bilateral SCJ resection in the first intercostal space. After resection of the SCJ, the wound was irrigated and treated with a negative pressure dressing (NPD) placed to suction. Secondary wound closure was managed by pectoralis muscle advancement flap into the defect created by the initial resection. Extension of the original incision more inferiorly was sometimes necessary to facilitate mobilization of the pectoralis muscle. One or more drains were placed, and the subcutaneous tissues and skin were closed.
SCJ resection was necessitated by infection in seven of nine patients. Two patients who underwent SCJ resection for noninfectious etiology were excluded from the study (rheumatoid arthritis in one patient and metastatic breast cancer in the other). Five of these seven patients were male, and the average age was 59 years.
FIG. 1 . Resection of sternoclavicular joint. Dashed lines indicate sites of division of clavicle, manubrium, and cartilage of first rib.
Clinical evaluation of patients suspected of having SCJ infection consisted of history and physical examination, blood cultures, and radiographic imaging. SCJ infections were the result of Staphylococcus aureus in all seven patients. Two patients had Staphylococcus pneumonia, one had Staphylococcus sepsis, three had Staphylococcus osteomyelitis of the lower extremity (two foot infections and one infected above-knee amputation), and one had Staphylococcus infection after finger surgery. Comorbidity included diabetes in four, obesity in four, hypertension in five, and hypothyroidism in two. Preoperative antibiotics consisted of vancomycin in four patients, nafcillin in one, linezolid in one, and rifampin in one, with an average total duration of treatment of 200 days. Time from onset of symptoms to surgery averaged 46 days.
MRI proved superior to CT scan in the detection of SCJ infections with 100 per cent sensitivity, whereas CT scan was only 83 per cent sensitive (positive in five of six patients). Of note, one patient demonstrated no evidence of SCJ infection or osteomyelitis on initial CT scan whereas follow-up MRI and bone scan were positive. Four patients evaluated with MRI were positive in all cases, with no false negatives. Bone scans were performed in four patients, three that were positive and one that was negative. One patient was evaluated with PET because of intolerance to MRI and equivocal results with a bone scan. PET demonstrated inflammatory arthritis of the right SCJ.
There were no complications in these seven patients, nor were there any recurrent infections. The average time to pectoralis flap closure was 6 days (range, 4-11 days). Average time from wound closure to discharge was 4.7 days (range, 2-10 days). At follow-up the patient’s wound, pain, and upper extremity range of motion were evaluated. Average follow-up time from hospital discharge was 5.2 weeks. Despite this aggressive resection of a portion of the sternum, the medial clavicle and involved rib components, patients seen at follow-up reported no significant limitation of motion or pain. Six of seven patients reported no limitation of motion of the affected upper extremity. Only one patient demonstrated limited shoulder adduction at 6 months postoperatively as a result of adhesive capsulitis. All patients demonstrated either improving pain or no pain at all.
The SCJ is a synovial lined space consisting of the inferior portion of the medial head of the clavicle, a notch on the upper/ lateral manubrium, and the cartilage of the first rib.1 The SCJ forms the only true skeletal articulation between the upper extremity and the thorax. Ligaments surround the SCJ anteriorly, posteriorly, superiorly, and inferiorly.2 This joint contains a meniscus. Most menisci have limited blood supply, especially at their periphery.3 This limited blood flow to the meniscus of the SCJ joint may contribute to infection refractory to antibiotics and conservative therapy.
Although SCJ infection is uncommon, its intractability and progression despite prolonged antibiotic therapy requires aggressive intervention. Presentation of SCJ infection is variable, yet most data support an insidious and indolent course, often extending months in duration. Bayer and Chow4 report eight patients, most with a history of intravenous drug use, whose clinical onset of symptoms was greater than or equal to 1 month from presentation. The average duration of symptoms prior to surgery in our patients was more than 6 weeks. Most patients complain of shoulder pain, or chest pain involving the sternal area. In our series, five patients reported sternal chest wall pain and two complained of shoulder pain.
The use of intravenous drugs is the most cited source of SCJ infections. Ross and Shamsuddin5 reviewed 170 patients reported to have SCJ septic arthritis, and the most frequent source noted in their series was intravenous drug use (21%). Diabetes mellitus, distant site infections, and central venous catheters have also been associated with the development of SCJ infections. Although comorbidity certainly has a role in predisposing patients to SCJ infection, not all patients have a significant medical history. Bar- Natan and Salai6 found the incidence of SCJ infections in previously healthy adults to be 0.5 per cent of all admissions for bone and joint infections. Complications such as osteomyelitis (5%), chest wall phlegmon or abscess (25%), and mediastinitis (15%) are serious sequelae of SCJ infections.5 In contrast to primary osteomyelitis of the clavicle, occasionally seen in children, secondary osteomyelitis is quite rare.7
Imaging and detection of SCJ infection and associated osteomyelitis is essential. Although a high index of suspicion is valuable, delay in treatment can have deleterious outcomes. Teece and Fishman8 reported that spiral CT scans provided imaging that was superior to standard CT scans in defining the extent of disease. CT scans can depict intramedullary and soft tissue gas, sequestra, sinus tracts, and foreign bodies. CT scanning is insufficient, however, for assessment of the activity of the infectious process. Because of its high sensitivity in the detection of bone marrow changes, MRI can provide detailed information regarding the extent and activity of the process through detection of the intramedullary site of infection and its complications. MRI can also be used to distinguish soft-tissue involvement, allowing differential diagnosis.9 Initial treatment usually consists of antibiotics appropriate to the source of infection and results of blood cultures or needle aspirations, and control of the primary site of infection. Septic arthritis of the SCJ may be successfully treated in this fashion; however, the development of osteomyelitis necessitates surgical intervention. Failure of antibiotics to control fever and cellulitis leading to progression of the SCJ phlegmon, or radiographic findings of osteomyelitis are evidence of refractory SCJ infection best managed surgically. Such aggressively destructive infections are usually associated with S. aureus, which was the causative organism in all patients in our series. The decision to intervene surgically is generally made in response to failure of antibiotics to improve the SCJ inflammatory process and associated pain, and is dependent on the observations and judgment of the managing physician and consulting surgeon. Gonzalez Munoz and Cordoba Pelaez10 adopted a protocol proposing medical treatment and articular diagnostic-therapeutic puncture as the first line of therapy. When complications such as abscess or mediastinitis occurred, radical debridement was undertaken.
In a review of 180 reported cases of septic arthritis, Ross and Shamsuddin5 reported that surgery was performed in 102 of 174 patients (58%). Limited debridement was performed in 48 of these 102 surgical patients, and 54 patients underwent resection, including 13 in whom limited debridement failed.
Aggressive operative management including resection of the SCJ and involved ribs, NPD, and subsequent pectoralis flap closure has provided a successful surgical strategy for the eradication of these serious infections. The NPD has proved to be quite beneficial after debridement, by controlling contaminated or infected wounds and achieving healthy, vascularized tissue beds. Animal studies of NPD have documented reduced bacterial counts, increased granulation tissue, and improved wound perfusion. Deva and Buckland1 ‘ demonstrated that NPD at a mean suction of 75 to 1 25 mm Hg results in more rapid healing in acute wounds and reduces bacterial counts. Delayed flap reconstruction can be subsequently performed for complete wound closure, thus obliterating the dead space and providing well-vascularized tissue for delivery of antibiotics to the wound bed.
Acus12 evaluated long-term results of medial clavicle excision with regard to function, pain, cosmesis, and complications. Fifteen patients (18-64 years old) were evaluated at an average of 4.6 years after the procedure. Fourteen of 15 patients received significant relief of pain after an average resection of 2.9 cm of the medial clavicle. Burkhart and Deschamps13 reported that 21 of 26 patients were asymptomatic, free of infection, and experienced no limitation of range of motion at a median follow-up of 25 months. These data were similar to that published by Carlos and Kesler,14 who found at a mean follow-up of 20 months that surviving patients had no limitation in strength or range of motion of the ipsilateral limb and had no recurrent or persistent infection. Therefore, in a majority of cases reviewed in the literature, surgical resection of the infected SCJ appears to have little detrimental impact on upper extremity function.
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AARON S. KENDRICK, D.O.,* HAROLD D. HEAD, M.D.,[dagger] JASON REHM, M.D.[double dagger]
From the * General Surgery Service, [dagger] Thoracic Surgical Service, and [double dagger] Plastic and Reconstructive Surgery Service, Department of Surgery, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee
Presented during Poster Grand Rounds at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Savannah, GA, February 10-13, 2007.
Address correspondence and reprint requests to Aaron S. Kendrick, D.O., c/o Research Coordinator, University of Tennessee College of Medicine-Chattanooga, Department of Surgery, 979 East Third Street, Suite B-401, Chattanooga, TN 37403. E-mail: [email protected]
Copyright Southeastern Surgical Congress Jul 2007
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