Ann Thorac Surg 1996;61:225-227
© 1996 The Society of Thoracic Surgeons
Case Report
Primary Sternal Osteomyelitis
Jeffrey C. Lin, MD,
Scott R. Miller, MD,
Alan B. Gazzaniga, MD
Division of Cardiothoracic Surgery, Department of Surgery, University of California, Irvine, Medical Center, Orange, California
Accepted for publication July 14, 1995.
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Abstract
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A case report of primary sternal osteomyelitis, a rare clinical entity, is presented. Treatment of primary sternal osteomyelitis is antibiotics and complete debridement of the infected bone and anterior periosteum. If the posterior sternal periosteum is not involved, it should be left intact. The defect can be covered with skeletal muscle flaps, which improves healing and minimizes recurrence. This approach led to a complete and timely cure.
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Introduction
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A 36-year-old woman presented to the emergency room with a 2-week history of a painful chest mass over the sternum. The mass had been steadily enlarging for 2 weeks before presentation and had become increasingly tender and painful. The pain increased with movement and deep inspiration and occasionally radiated to the right axilla. History was significant for a motor vehicle accident 3 years before presentation, where she suffered blunt chest trauma with no known fractures. She denied any recent trauma.
Upon examination, the patient was afebrile, vital signs were stable, and she was in no apparent distress. A warm, tender 8.0 x 8.0-cm midsternal fluctuant mass was palpable. No erythema was evident. There was also tender, shoddy right axillary lymphadenopathy and tattoos over the shoulder and anterior chest. The remainder of the physical examination was unremarkable.
White cell count was 8,100/µL with a normal differential; test results for human immunodeficiency virus were negative. Chest roentgenograms were unremarkable. Aspiration revealed purulent fluid with gram-positive cocci in pairs. Intravenous nafcillin was given and, under local anesthesia, a 6-cm midline incision overlying the presternal abscess pocket was made. The abscess was drained and the wound was thoroughly irrigated with a povidone/saline solution. It was treated with frequent povidone-soaked packing.
Despite appropriate antibiotics and local wound care, the infectious process did not improve. Further workup proceeded with lateral sternal roentgenograms, which showed erosion of the anterior cortex and increased soft-tissue density overlying the sternum (Fig 1
). Technetium-99m bone scan showed increased activity involving the upper sternum that was consistent with osteomyelitis.
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Fig 1. . Lateral sternal roentgenogram: Note the erosion of the anterior sternal table (arrow), and the increased overlying soft-tissue density.
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The anterior sternal periosteum and infected sternum were aggressively debrided in the operating room. The posterior sternal periosteum was left intact, and bilateral pectoralis flaps were used to provide a well-vascularized and conforming soft tissue coverage.
Surgical pathologic examination confirmed acute and chronic sternal osteomyelitis with findings of acute and chronic inflammation and fibrosis in the presternal soft tissue specimens. Final bacterial cultures grew Staphylococcus aureus. Appropriate antibiotic administration was continued postoperatively (10 days of intravenous vancomycin, then 5 weeks of oral ciprofloxicin). The patient made an uneventful recovery with good wound healing and no recurrence to date (3 years).
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Comment
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Primary sternal osteomyelitis is a rare entity, comprising 0.3% of all cases of osteomyelitis in the literature [1]. Upon review of the English-language literature in 1989, Gill and Stevens [2] found 57 reported cases.
Primary sternal osteomyelitis has no contiguous focus of infection, whereas secondary sternal osteomyelitis is usually a complication of sternotomy [3]. In the preantibiotic era, sternal osteomyelitis was often associated with staphylococcal bacteremia and sepsis, with a high associated mortality. Mortality associated with sternal osteomyelitis has decreased dramatically with the advent of antibiotics. In more recent decades, there has been an increased incidence of primary sternal osteomyelitis in intravenous drug abusers, with a predilection for Pseudomonas osteomyelitis. In addition, there is often an antecedent history of blunt trauma [4].
Primary sternal osteomyelitis presents with anterior sternal pain, tenderness, redness, and swelling. Due to the rarity of the condition, the diagnosis and appropriate treatment are often delayed. The differential diagnosis is broad and should include cellulitis, soft-tissue abscess, benign and malignant soft-tissue tumors, and bony tumors. Diagnosis of sternal osteomyelitis requires a high index of suspicion and a needle or open bone biopsy. Plain roentgenograms and computed tomography are the central radiographic components in the workup, whereas conventional tomography and magnetic resonance imaging offer little additional information. Nuclear isotope scans including technetium 99m and gallium 67 are useful but are nonspecific.
Coagulase-positive Staphylococcus aureus is the predominant species responsible for both primary and secondary sternal osteomyelitis, although Pseudomonas aeruginosa is predominant among intravenous drug abusers [4]. Hematogenously disseminated osteomyelitis in intravenous drug abusers has a high propensity for spinal involvement and septic arthritis of the sternoclavicular joint [5]. Salmonella, Klebsiella, Aspergillus, and Mycobacterium tuberculosis have also been reported as causal organisms of sternal osteomyelitis [6].
Primary sternal osteomyelitis is often clinically subacute, unlike the clinically virulent secondary osteomyelitis of the sternum. Primary sternal osteomyelitis can be treated with a limited but complete resection of the anterior periosteum and infected bone, rather than radical sternal resection as in cases of secondary sternal osteomyelitis [7]. If not grossly infected, the posterior sternal periosteum should be left intact to maintain the integrity of the mediastinum [7]. If a large sternal resection is warranted, a staged resection has been advocated by some to maintain chest wall stability. As an adjunct to thorough debridement of infected bone, immediate muscle flap reconstruction provides well-vascularized soft tissue coverage and bulk that conforms to fill dead space. This approach decreases recurrence of infection and time to complete healing [8].
Although successful treatment of primary osteomyelitis has been reported with antibiotics alone [9], early surgical treatment provides definitive treatment resulting in decreased morbidity and more cost-effective treatment. Medical management incurs the morbidity of a prolonged course of medication, interference with work and other daily activities, and the possibility of treatment failure necessitating surgical debridement. Our survey of Orange County hospital estimates that the cost for a surgically treated patient is one-third to one-half that of treating the same patient with a 6-week intravenous antibiotic course (with a 1-week hospital stay, home visiting nurse, and placement of a Broviac catheter). The cost is even more dramatic with the unreliable patient (history of intravenous drug abuse) who cannot be discharged home with a central line and home intravenous therapy, thus necessitating a prolonged hospital stay.
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Footnotes
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Address reprint requests to Dr Gazzaniga, Division of Cardiothoracic Surgery, Department of Surgery, UC Irvine Medical Center, 101 The City Dr, Orange, CA 92668.
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References
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- Maier HC. Infection of the costal cartilidge and sternum. Surg Gynecol Obstet 1947;84:1038–44.
- Gill EA, Stevens DL. Primary sternal osteomyelitis. West J Med 1989;151:199–203.[Medline]
- Culliford AT, Cunningham JN Jr, Zeff RH, et al. Sternal and costochondral infections following open-heart surgery-a review of 2594 cases. J Thorac Cardiovasc Surg 1976;72:714–26.[Abstract]
- Boll KL, Jurik AG. Sternal osteomyelitis in drug addicts. J Bone Joint Surg Am 1990;72-B:328–9.[Abstract/Free Full Text]
- Jara FM, Yap A, Toledo-Pereyra LH, Magilligan GJ Jr. The role of surgery in primary osteomyelitis of the chest wall. J Thorac Cardiovasc Surg 1979;77:147–50.[Abstract]
- Brown RB, Trenton J. Chronic abscesses and sinuses of the chest wall-the treatment of costal chondritis and sternal osteomyelitis. Ann Surg 1952;135:44–51.[Medline]
- Mir-Sepasi MH, Gazzaniga AB, Bartlett RH. Surgical treatment of primary sternal osteomyelitis. Ann Thorac Surg 1975;19:698–703.[Abstract]
- Jeevanandan V, Smith CR, Rose EA, Malm JR, Hugo NE. Single stage management of sternal wound infection. J Thorac Cardiovasc Surg 1990;99:256–62.[Abstract]
- Sant GR. Primary sternal osteomyelitis. J R Coll Surg Edinb 1979;24:368–9.[Medline]
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Abstract
Introduction
