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Ann Thorac Surg 2002;74:1225-1227
© 2002 The Society of Thoracic Surgeons

Case report

Spontaneous sternoclavicular joint infections

Michel Haddad, MDa, Donna E. Maziak, MDCM*a, Farid M. Shamji, MDb

a Department of Surgery, Division of Cardiac, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada
b Division of Thoracic Surgery, University of Ottawa, Ottawa Hospital, Ottawa, Ontario, Canada

Accepted for publication May 19, 2002.

* Address reprint requests to Dr Maziak, Ottawa Hospital, General Campus, 501 Smyth Road 6NW-6354, Ottawa, ONT, Canada K1H-8L6
e-mail: dmaziak{at}ottawahospital.on.ca


   Abstract
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 Abstract
Introduction
 Case reports
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 References
 
Spontaneous sternoclavicular (SC) joint infections are uncommon. Most cases of contained SC joint infections respond well to conservative treatment measures such as intravenous antibiotics and local drainage. However, some cases are more extensive, extending beyond the boundaries of the joint capsule, occasionally involving the anterior chest wall and mediastinum. We report our experience with 3 patients with spontaneous advanced SC joint infections. Radical surgical treatment seemed to provide the best control of this infection.


   Introduction
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 Abstract
 Introduction
Case reports
 Comment
 References
 
Spontaneous infection of the sternoclavicular (SC) joint is an uncommon clinical entity. Various risk factors are found to be associated with this type of infection. These include diminished host immunity, the presence of indwelling central venous catheters, intravenous drug abuse, and chronic diseases such as diabetes mellitus, renal failure, and hepatic dysfunction [1, 2]. In most cases, the infection responds well to conservative treatment with intravenous antibiotics and local drainage. However, certain SC joint infections prove to be refractory to these treatment measures. These infections tend to be extensive and, unlike minor infections, spread beyond the boundaries of the joint itself, sometimes invading mediastinal structures.

Three patients were referred to our service with SC joint infections after failing conservative treatment measures. Two patients were men in their eighth decade of life, and one was a 30-year-old woman. They possessed some of the known risk factors associated with SC joint infections (see Table 1). None of the patients, however, had indwelling venous line catheters or a history of intravenous drug abuse. In addition, none of them had undergone recent surgical procedures.


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  		Table 1. Sternoclavicular Joint Infection Risk Factors in Our 3 Patients

 

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Patient 1
The first patient presented with a 2-month history of a progressively enlarging left sternoclavicular subcutaneous tender mass with overlying erythema. The patient also complained of hoarseness. This infection was initially treated with oral cloxacillin with no success. On initial presentation to us, the patient was afebrile with a normal white blood cell count. His chest roentgenogram was reported as normal. Computed tomography (CT) of his chest showed destruction of the medial end of the left clavicle and bone destruction of the left part of the manubrium (Fig 1). There was marked tissue swelling around the clavicle, anteriorly and medially, with some posterior soft tissue swelling. No mediastinal collections were found. As a result, the abscess was drained and the wound packed under general anesthesia. Cultures of the abscess grew Staphylococcus aureus. The bone scan showed no osteomyelitis. The patient was later sent home with a 6-weeks course of intravenous antibiotics (Cefazolin).



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  		Fig 1. Computed tomographic scan of the chest of a patient with a left sternoclavicular joint abscess (arrow) eroding into the manubrium and clavicle.

 
The patient was readmitted 10 weeks after discharge due to the development of a large draining sinus over the left SC joint. He had no fever or pain. As a result, he underwent en bloc excision of his left SC joint, with the left half of the manubrium, medial end of the clavicle, and first rib. The wound was left open and packed. The cultures continued to grow Staphylococcus aureus. The patient was started on intravenous vancomycin and rifampin. Two weeks later, the wound was closed with a pectoralis major muscle flap. This flap was developed by mobilizing and advancing the pectoralis major muscle medially in order to cover the defect created by the resection of the SC joint. The patient was later discharged home on intravenous antibiotics (4 weeks of vancomycin). The final pathology of the surgical specimen showed acute osteomyelitis. The patient continued to do well 14 months postoperatively.

Patient 2
The second patient was initially admitted to the medical service with a cough, shortness of breath on exertion, left chest pain which was exacerbated by movement, and right foot pain and erythema. He also had a tender, swollen, erythematous mass over his left SC joint. This patient was febrile on presentation, with an elevated white blood cell count, hypoxemia, and renal failure. He was diagnosed with a right foot cellulitis, left SC joint infection, and pneumonia. CT of the chest revealed a right lower lobe pneumonia and a small fluid collection of the left SC joint. Blood cultures were negative. Ultrasound of the SC joint did not reveal any fluid collection, but there was inflammation. There was no osteomyelitis on bone scan. The patient was treated with intravenous cefuroxime. Subsequently, the left SC joint was explored and packed open. Tissue cultures were negative. In addition, bronchoscopy washings were also obtained and grew candida. The patient was later discharged home on the oral antibiotics erythromycin, ciprofloxacin, and fluconazole for 3 weeks. The SC joint infection seemed to have healed well on discharge.

Three months later, the patient presented to the hospital with an 8 x 10-cm indurated, erythematous mass over his left SC joint. The joint was reexplored and debrided. Necrotic granulation tissue was found at the site with no purulent material. The cultures grew coagulase negative Staphylococcus and Coryneform sp bacteria. A postoperative CT scan showed soft tissue defect at the left SC joint with soft tissue swelling and a defect of the medial end of the clavicle and lateral manubrium. Despite intravenous Cefazolin and metronidazole for a month, the cellulitis increased further. As a result, the patient required extensive left chest-wall debridement with resection of the medial end of the left clavicle, left half of the head of the manubrium, and medial end of the first rib. Cultures grew pseudomonas, which was believed to be a super-infection at the site. The patient was started on intravenous ceftazidime and ciprofloxacin. A month later, the wound was covered with a pectoralis major muscle flap in a similar fashion to the first patient. The final pathology showed chronic osteomyelitis and septic arthritis with subacute inflammation of the SC joint. No malignancy was found. The patient was still doing well at his last follow-up 16 months postoperatively.

Patient 3
The third patient was a 30-year-old woman who was admitted to the intensive care unit for uncontrolled diabetic ketoacidosis. The patient did not have any other medical conditions. Three days after admission, the patient developed a 6-cm tender fluctuant mass over the right SC joint. Needle aspiration revealed streptococcus infection. Intravenous antibiotics and local drainage of the right SC joint failed to control the sepsis. The infection soon spread rapidly into the right chest wall and retrosternum despite large doses of intravenous antibiotics and multiple debridements. The patient died of uncontrolled sepsis 5 days later.


   Comment
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 Abstract
 Introduction
 Case reports
 Comment
References
 
Various factors have been identified as predisposing to the development of spontaneous SC joint infections. These include a history of chronic disease such as chronic renal failure, diabetes mellitus, or any factor which renders patients immunocompromised such as the prolonged use of corticosteroids. In addition, SC joint infections have also been observed in some patients who have indwelling subclavian venous catheters, a history of intravenous drug abuse, or recent surgical procedures which could potentially be a source of bacteremia [1, 2]. This type of infection is fortunately uncommon. However, with the increasing prevalence of immunocompromised individuals and the increasing utilization of indwelling subclavian venous catheters, this type of infection is seen in increasing numbers [1–7].

All of our patients had compromised host defenses, such as diabetes or steroid use. The infections seemed to be spontaneous in origin. None of them had an indwelling central line access, history of intravenous drug abuse, or recent surgical procedures.

For mild SC joint infections, where the infection is contained within the confines of the joint capsule, initial conservative treatment with intravenous antibiotics seems to be the treatment of choice [1]. However, with any sign of joint swelling, diagnostic and therapeutic aspiration of the joint in addition to intravenous antibiotics has been advocated [1]. Certain SC joint infections, however, present at more advanced stages. This occurs when the infection spreads beyond the boundaries of the joint itself, sometimes invading mediastinal structures. Conservative measures tend to fail in these instances as we have seen in our patients and other reported cases [1, 8].

Based on our experience, and support from review of the literature [1, 3, 8], early radical debridement seems to be the best treatment option for advanced SC joint infections. Conservative treatment modalities in these cases resulted in a failure of treatment and increased morbidity. Our patients eventually required radical enbloc SC joint resection. This occurred despite optimum initial intravenous antibiotics and local debridment. It is a treatment option that, although radical, allows irradication of this infection with acceptable morbidity to these patients.

In order to cover the defect created by the SC joint resection, a staged pectoralis major muscle flap was advanced into the defect. We believe that a staged approach would be safer in case any residual infection was overlooked at the time of joint resection and debridement. Therefore, if no infection appeared in the wound about 2 weeks after joint resection, then it would be safe to cover the defect. This is different from the single-stage approach advocated by some surgeons [8].

The SC joints are the only connection between the upper limbs and the axial skeleton. However, removal of this joint is reported to have minimal functional effect on upper limb and shoulder mobility [4]. This has also been shown by a recent article published by Song and colleagues [8]. Fortunately, this has also been our experience with our 2 surviving patients.


   References
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 Abstract
 Introduction
 Case reports
 Comment
 References
 

  1. Carlos G.N., Kesler K.A., Coleman J.J., Broderick L., Turrentine M.W., Brown J.W. Aggressive surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg 1996;113:242-247.[Abstract/Free Full Text]
  2. Lindsey R.W., Leach J.A. Sternoclavicular osteomylitis and pyarthrosis as a complication of subclavian vein catheterization: a case report and review of the literature. Orthopaedics 1984;7:1017-1021.
  3. Van Linthoudt D. Abscess formation in sternoclavicular joint septic arthritis. J Rheumatol 1989;16:413-414.[Medline]
  4. Yasuda T., Amura K., Fugiwara M. Tuberculous arthritis of the sternoclavicular joint. Phys Ther Rev 1961;41:421-432.[Medline]
  5. Culham E., Peat M. Functional anatomy of the shoulder complex. J Orthop Sports Phys Ther 1993;18:342-350.[Medline]
  6. Friedman R.S., Perez H.D., Goldstein I.M. Septic arthritis of the sternoclavicular joint due to gram-positive microorganisms. Am J Med Sci 1981;282:91-93.[Medline]
  7. Wohlgethan J.R., Newberg A.H., Reed J.I. The risk of abscess from sternoclavicular septic arthritis. J Rheumatol 1988;15:1302-1306.[Medline]
  8. Song H.K., Guy T.S., Kaiser L.R., Shrager J.B. Current presentation and optimal surgical management of SC joint infections. Ann Thorac Surg 2002;73:427-431.[Abstract/Free Full Text]



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