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Ann Thorac Surg 2002;73:427-431
© 2002 The Society of Thoracic Surgeons

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Original article: general thoracic

Current presentation and optimal surgical management of sternoclavicular joint infections

^a Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

Accepted for publication October 10, 2001.

* Address reprint requests to Dr Shrager, 6th Floor, Silverstein Pavilion, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
e-mail: jshrag{at}mail.med.upenn.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Infection of the sternoclavicular 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 sternoclavicular 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 sternoclavicular 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.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Bone and joint infections are challenging clinical problems that frequently affect patients with underlying systemic disorders. Host factors and infection with resistant organisms often complicate the management of these problems. Consequently, the treatment of bone and joint infections requires intensive and specialized therapy, often including operative debridement in addition to long-term intravenous antibiotics.

Of interest to thoracic surgeons, such infections have a predilection for several unusual anatomic sites including the sternoclavicular joint (SCJ) [1–3]. Suppurative infections involving the SCJ are particularly challenging to treat because of their proximity to major vascular structures and the lack of substantial overlying soft tissues. Because of these factors and the relatively low incidence of SCJ infection, the treatment of this entity has not been standardized. It had been our anecdotal clinical impression that simple incision and drainage of these infections generally fails, and that perhaps a more aggressive initial approach to these lesions is warranted. To determine whether this is in fact the case, and to fully characterize the current presentation and optimal management of this disease, we reviewed our recent experience with SCJ infections.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
We retrospectively reviewed the medical records of patients undergoing surgical management of suppurative infections of the SCJ at this institution during the past 8 years. Each patient was examined and treated by one of the authors. Treatment outcome was determined by review of the medical record; long-term functional outcome was assessed by follow-up telephone interviews with patients. Patients were asked to rate the functional capacity of their affected upper extremity as "normal," "fair," or "poor."

Surgical techniques
Simple incision, drainage, and debridement of infected SCJs was performed in most cases at outside institutions but in two cases at our institution. These procedures varied in details, but they generally involved incising the skin directly overlying the affected joint and widely opening the joint capsule. Necrotic tissue and involved bone were then debrided, the cavity was irrigated, and the wound was either packed and allowed to heal by secondary intention or closed over drains.

For patients treated with formal resection of the SCJ (Fig 1A), a skin incision was made over the manubrium as far caudad as the level of the third costal cartilage in the midline and carried a variable distance into the supraclavicular region, depending on the exposure required. The muscular attachments to the affected side of the manubrium and the medial clavicle were first divided, and the bony structures were then separated from the underlying soft tissues, using periosteal elevators, at the anticipated sites of bony division. The clavicle was then divided lateral to the inflammatory mass (generally at its neck) with a Gigli saw. An inverted L-shaped division of the manubrium was then performed with a standard sternal saw or Lebski knife. This manubrial division maintained a minimum of 50% of the manubrium intact, preserving the stability of the contralateral upper thoracic cage. The manubrial resection was most often taken to include only the manubrium directly adjacent to the SCJ and a small portion of the anterior first rib (4 patients). Less commonly (2 patients), it was taken slightly more inferiorly to involve a diseased portion of the anterior second rib as well. The SCJ was then dissected completely away from the underlying inflammatory mass and anatomic structures and removed. Further debridement of the clavicle or manubrium could be performed at this time if the margins of debridement did not yet appear healthy. The residual phlegmon was carefully debrided to healthy tissue and irrigated. In no case was resection of great vessels required, and great vessel injury did not occur.

View larger version (37K): [in this window] [in a new window]   Fig 1. Technique of sternoclavicular joint resection (SCJ) and pectoralis flap closure. The SCJ is resected with up to 50% of the manubrium and up to one third of the medial clavicle (A). The resulting chest wall defect is obliterated with a partial pectoralis major advancement flap based on the thoracoacromial artery (B). (SCM = sternocleidomastoid muscle.)

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Our chart review identified 7 patients treated surgically for suppurative infections of the SCJ at this institution during the past 8 years. Table 1 summarizes the patient characteristics and clinical features. The patients’ ages ranged from 43 to 66 years, and 5 of the 7 patients were male. Risk factors predisposing patients to infectious complications were common. These included insulin-dependent diabetes mellitus (n = 2), human immunodeficiency virus infection (n = 1), and long-term immunosuppression (n = 1). The history of 1 patient was significant for an ipsilateral clavicle fracture in the distant past, and another had a chronic, pustular skin condition from which he was thought to suffer frequent septic episodes. All of the cases appeared to result from hematogenous seeding of the SCJ rather than direct inoculation.

Cross-sectional imaging by computed tomography was used to evaluate the SCJ of all patients presenting with suspected infection. Characterization of an inflammatory condition was greatly facilitated by these studies, which were diagnostic of SCJ infection in all cases [4, 5]. Figure 2 depicts bone windows from a computed tomography scan with findings typical for SCJ infection. Note the manubrial and clavicular erosion and involvement of the joint space as well as the surrounding soft tissue phlegmon.

View larger version (113K): [in this window] [in a new window]   Fig 2. Computed tomographic image (bone windows) of a patient with sternoclavicular joint infection. The study demonstrates manubrial and clavicular erosion and involvement of the joint space as well as significant surrounding soft tissue involvement.

There was a clear correlation between more aggressive surgical treatment and successful outcome. Six patients were treated with simple incision, drainage, and debridement in conjunction with antibiotic therapy. This procedure was generally ineffective, leading to recurrence of infection in 5 of 6 patients, and 3 patients were left with a nonhealing sinus tract.

Conversely, 6 patients were treated with formal resection of the SCJ with or without resection of a portion of the anterior second rib, with soft tissue coverage by advancement flaps from ipsilateral pectoralis major muscle. Response to this therapy was excellent. All patients were cured by the operation followed by a minimum of 2 and a maximum of 6 weeks of postoperative antibiotics (the longer courses were in patients with positive cultures or more impressive operative findings). There were no wound complications, and all patients reported "normal" upper extremity function at long-term follow-up (mean, 28 months). Of note, 5 of the patients undergoing this more extensive procedure had previously failed to resolve their infection with simple incision and drainage and prolonged antibiotic therapy.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Suppurative SCJ infections remain an unusual clinical problem, but a general thoracic surgeon is likely to encounter several cases in the course of a career. As a result of its rarity, the description of this condition in the literature is primarily in the form of case reports and small series [8–11], and optimal therapy has not been defined. Interestingly, in previous reports SCJ infection has most frequently been associated with intravenous drug abuse [4, 12–16] or indwelling central venous catheters [9, 17], although a variety of other predisposing factors have been described. In our series, the most common risk factor identified was long-term immunosuppression related to diabetes mellitus, steroid use, or human immunodeficiency virus infection. This difference in presentation may reflect the growing prevalence of patients with immunosuppression related to chronic disease or prior organ transplantation and may also signal an increasing incidence of SCJ infection outside of drug abusers.

The surgical management of SCJ infection is complicated by the joint’s anatomic location superficially beneath the skin and its relationship to nearby major vascular and neural structures. Simple incision and drainage of the joint was almost always ineffective in our series, failing to resolve the infection in 5 of 6 patients in whom it was performed. This was likely because of the poor capacity of the bone to clear established infection, even in nonimmunocompromised hosts, as well as to the usual presence of widespread infectious involvement of the surrounding tissues owing to the chronic nature of the process.

Conversely, formal resection of the SCJ, including partial resection of the manubrium, medial clavicle, anterior first rib, and in some cases an involved portion of the anterior second rib, yielded excellent results. This approach allowed achievement of margins of healthy bone and complete debridement of the mediastinum. A partial pectoralis major advancement flap was used to fill the resulting space with well-vascularized soft tissue and also served to provide coverage of deeper structures, including the major vessels. This more aggressive surgical treatment cured all 6 patients in whom it was applied, with no recurrent infections.

One important detail of the SCJ resection is that it included partial resection of at most the ipsilateral one half of the manubrium. One might be concerned that such an incomplete manubrial resection would increase the susceptibility of patients treated in this fashion to recurrent infection because of the small size of this structure and the potential for infectious spread through the continuous marrow space. However, in our judgment, complete manubrial resection would have left patients with the potential for bilateral shoulder instability, which would be likely to be associated with significant upper extremity disability. The approach taken in this series, including only partial resection of the ipsilateral manubrium, was effective in clearing the infectious process while largely maintaining the integrity of the upper bony thorax and specifically the contralateral SCJ. This procedure was well tolerated from a functional viewpoint, with all patients treated with SCJ resection and pectoralis flap closure describing "normal" upper extremity function at long-term follow-up.

As an additional technical note, it is important to differentiate our method of pectoralis flap coverage from that recently described by Zehr and colleagues [18]. These authors described the use of a rotated, split pectoralis major flap based on the medial intercostal perforators in 2 patients. Our flap also uses only part of the pectoralis muscle, thus maintaining humeral flexion, but we believe that it likely has a more reliable blood supply than the rotated flap inasmuch as it is based on the muscle’s primary thoracoacromial vascular pedicle. We have found that simple advancement after the mobilization described, without the need to divide the origin of the muscle on the humerus, provides sufficient bulk for excellent soft tissue coverage. An additional important technical note is that the patients are maintained in an ipsilateral upper extremity sling for 10 days after the procedure, with progressively increasing range of motion of the arm after that point, to prevent retraction of the flap resulting from pectoralis muscle contraction.

In evaluating the significance of our findings, it is important to remain mindful of the selection bias inherent in any surgical series. If there were patients with SCJ infections at this institution who were successfully treated with long-term antibiotics, they would not likely have been referred to the thoracic surgical service and therefore would not have been included in this series. The rate of failure of medical treatment alone is therefore unknown, and as a result we cannot recommend formal SCJ resection as the initial treatment for all patients presenting with this problem. Our poor results with simple incision and drainage of the SCJ, however, offer compelling evidence that formal SCJ resection should be undertaken certainly in patients who fail medical therapy and probably as first-line therapy in patients with evidence of extensive osteomyelitis on computed tomography or magnetic resonance imaging scanning.

The results of the only prior series reporting an aggressive surgical approach to SCJ infection similar to ours [17] yielded similar, but not identical, recommendations. In that series, in contrast to ours, a selected group of 4 patients with limited disease treated with simple joint exploration and debridement were "successfully" treated by this lesser operation, although 1 died of endocarditis 1 month postoperatively. All of the 4 patients in that series treated by wide surgical excision similar to the approach we advocate were cured of infection without limitation of limb function. These results certainly support our conclusion that wide resection and flap coverage is the most effective treatment, but the fact that some patients who underwent limited debridement were managed successfully in this manner clouds the issue of whether it is appropriate to attempt such limited procedures as an initial step.

In summary, our findings indicate that aggressive surgical management with formal resection of the SCJ and partial pectoralis advancement flap closure is preferred for the treatment of extensive infections in this region. We demonstrate that this procedure is highly effective and can be performed safely and with excellent preservation of upper extremity function.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Blankstein A., Nerubay J., Lin E., et al. Septic arthritis of the sternoclavicular joint. Orthop Rev 1986;15:440-442.[Medline]
2. George S., Wagner M. Septic arthritis of the sternoclavicular joint. Clin Infect Dis 1995;21:1525-1526.[Medline]
3. Dauwe D.M., Van Oyen J.J., Samson I.R., Hoogmartens M.J. Septic arthritis of a lumbar facet joint and a sternoclavicular joint. Spine 1995;20:1304-1306.[Medline]
4. Alexander P.W., Shin M.S. CT manifestation of sternoclavicular pyarthrosis in patients with intravenous drug abuse. J Comp Assist Tomogr 1990;14:104-106.[Medline]
5. Tecce P.M., Fishman E.K. Spiral CT with multiplanar reconstruction in the diagnosis of sternoclavicular osteomyelitis. Skel Radiol 1995;24:275-281.[Medline]
6. Nicastro N., Finazzo M., Gallo C., et al. Su un raro caso di artrite sterno-clavicolare nell‘AIDS: aspetti con ecografia, Tomografia Computerizzata e Risonanza Magnetica. [Unusual case of sterno-clavicular septic arthritis in AIDS: ultrasonography, computerized tomography, and magnetic resonance findings]Radiol Med 1999;97:86-88.[Medline]
7. Imanishi Y., Mitogawa Y., Takizawa M., et al. Relapsing polychondritis diagnosed by Tc-99m MDP bone scintigraphy. Clin Nucl Med 1999;24:511-513.[Medline]
8. Chen W.S., Wan Y.L., Lui C.C., et al. Extrapleural abscess secondary to infection of the sternoclavicular joint. Report of two cases. J Bone Joint Surg Am 1993;75:1835-1839.[Free Full Text]
9. Aglas F., Gretler J., Rainer F., Krejs G.J. Sternoclavicular septic arthritis: a rare but serious complication of subclavian venous catheterization. Clin Rheum 1994;13:507-512.[Medline]
10. Gillis S., Friedman B., Caraco Y., et al. Septic arthritis of the sternoclavicular joint in healthy adults. J Intern Med 1990;228:275-278.[Medline]
11. Taylor L.J., Belham G.J. Monarticular septic arthritis of the sternoclavicular joint. Arch Emerg Med 1985;2:177-178.[Medline]
12. Nair V. Sternoclavicular arthritis: an unusual complication of drug abuse. J Med Soc NJ 1975;72:519-520.[Medline]
13. Bayer A.S., Chow A.W., Louie J.S., Guze L.B. Sternoarticular pyoarthrosis due to gram-negative bacilli. Report of eight cases. Arch Intern Med 1977;137:1036-1040.[Abstract/Free Full Text]
14. Covelli M., Lapadula G., Pipitone N., et al. Isolated sternoclavicular joint arthritis in heroin addicts and/or HIV positive patients: three cases. Clin Rheum 1993;12:422-425.[Medline]
15. Gifford D.B., Patzakis M., Ivler D., Swezey R.L. Septic arthritis due to pseudomonas in heroin addicts. J Bone Joint Surg Am 1975;57:631-635.[Abstract/Free Full Text]
16. Goldin R.H., Chow A.W., Edwards J.E., Jr, et al. Sternoarticular septic arthritis in heroin users. N Engl J Med 1973;289:616-618.
17. Carlos G.N., Kesler K.A., Coleman J.J., Broderick L., Terrentine M.W., Brown J.W. Aggressive surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg 1997;113:242-247.[Abstract/Free Full Text]
18. Zehr K.J., Heitmiller R.F., Yang S.C. Split pectoralis major muscle flap reconstruction after clavicular-manubrial resection. Ann Thorac Surg 1999;67:1507-1508.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): T. Sloane Guy Larry R. Kaiser Joseph B. Shrager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Song, H. K. Articles by Shrager, J. B. Search for Related Content PubMed PubMed Citation Articles by Song, H. K. Articles by Shrager, J. B. Related Collections Chest wall