Ann Thorac Surg 2011;91:257-261. doi:10.1016/j.athoracsur.2010.07.112
© 2011 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Sternoclavicular Joint Infection: A Comparison of Two Surgical Approaches
Varun Puri, MDa,*,
Bryan F. Meyers, MDa,
Daniel Kreisel, MD, PhDa,
G. Alexander Patterson, MDa,
Traves D. Crabtree, MDa,
Richard J. Battafarano, MD, PhD,a,
Alexander S. Krupnick, MDa
a Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri
Accepted for publication July 21, 2010.
* Address correspondence to Dr Puri, Cardiothoracic Surgery, 3108 Queeny Tower, Barnes Jewish Hospital, One Barnes Jewish Hospital Plaza, St. Louis, MO 63110 (Email: puriv{at}wudosis.wustl.edu).
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Abstract
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Background: This study compares conventional open debridement with the recently proposed flap closure technique for sternoclavicular joint infection.
Methods: This is a retrospective review of patients undergoing surgery for sternoclavicular joint infection during the last 7 years.
Results: 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.
Conclusions: 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.
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Introduction
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Septic arthritis of the sternoclavicular joint (SCJ) is an unusual problem with a low worldwide incidence [1]. Therapeutic options range from antibiotic therapy with or without joint aspiration to radical resection of the joint with flap reconstruction. Thoracic surgeons are often involved in the care of patients referred for surgical therapy because of the proximity of major vessels to the joint and the relatively frequent involvement of the first or even the second ribs in the process. During the last decade there have been several publications describing the successful use of joint resection and primary or early flap closure for SCJ infection (SCJI) [2–4]. Our group has used both the more conservative approach of wide debridement and open wound care as well as the more recently adopted approach of joint resection and primary flap closure. To determine whether clinical outcomes from the two approaches were comparable, we reviewed our recent experience with SCJIs.
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Patients and Methods
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Data Acquisition
We queried a prospectively maintained institutional cardiothoracic surgical database with the following key phrases: sternoclavicular infection, sternoclavicular septic arthritis, clavicular infection/osteomyelitis. All the cases were from a single institution. The study was reviewed by the institutional review board and exempted. Patient records from 2002 through 2009 were reviewed. Case records were individually reviewed, and only patients with SCJ septic arthritis were included. Patients who had SCJI as a result of an infected median sternotomy were excluded. Operative mortality included those patients who died within the first 30 days after the operation and those who died later but during the same hospitalization. Follow-up was obtained through outpatient clinic visits and correspondence with local physicians. Active wound care for more than 2 weeks was defined as prolonged wound care.
Statistical Analysis
Data were analyzed using Stata software (StataCorp, College Station, TX). Comparison analyses were performed using Student's t test with unequal variances for mean values, Mann-Whitney test for median values, and 
2 test with Fisher's exact test for proportions. A probability value of 0.05 or less was considered significant.
Surgical Technique
For patients undergoing the open wound procedure, a hockey-stick incision was made directly over the involved SCJ. The sternal and clavicular heads of the sternocleidomastoid were sectioned. The head of the clavicle and the lateral part of the manubrium sterni were resected en bloc or separately. The medial end of the first rib was generally débrided with rongeurs. The subclavian vein was protected and pleural entry avoided if possible. The surrounding infected soft tissues were sharply débrided to healthy margins. If at the end of the initial operation, it was believed that more debridement would be necessary, patients were brought back to the operating room for planned second-look procedures. The resulting defects (Fig 1) were managed with saline-soaked gauze packing initially and generally converted to negative-pressure wound therapy (NPWT) within a few days. Most patients required prolonged wound care (>2 weeks).
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Fig 1. The resulting defect after resection of the right sternoclavicular joint. The medial end of the first rib has been débrided.
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For patients undergoing the flap procedure a similar hockey-stick incision was used. The clavicle was divided lateral to the phlegmon with a Gigli saw. A segment of manubrium adjacent to the SCJ was divided with a sternal saw. This maintained a minimum of 50% of the manubrium intact, preserving the stability of the contralateral upper thoracic cage. The medial end of the first rib was also divided and removed en bloc with the SCJ specimen. The SCJ was then dissected 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. A partial pectoralis major advancement flap was next mobilized and inset to cover the soft tissue defect (Fig 2). One drain was placed under the flap, and another was placed superficial to the muscle. The drains were removed when the cumulative output of the two drains was less than 60 mL/day and the drainage appeared nonpurulent. Antibiotic use was individualized on the basis of culture results.
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Fig 2. A partial pectoralis major advancement flap has been used to provide coverage for the wound after joint resection.
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Results
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Twenty patients (10 women, 10 men) with a mean age of 56.5 years underwent a total of 35 operations for SCJI from 2002 to 2009. Pain (17 of 20 patients; 85%) and swelling (19 of 20 patients; 95%) were the main presenting symptoms. A minority of patients (7 of 20 patients; 35%) had documented fever before admission. Two of twenty (10%) patients were taking immunosuppressive medications, and another 7 of 20 patients (35%) were diabetic. Thirteen of twenty patients (65%) had a discernible focus of infection away from the SCJ: urinary tract infection, 3 of 20 patients (15%); intravenous drug abuse–related bacteremia, 3 of 20 patients (15%); line sepsis, 2 of 20 patients (10%); others, 5 of 20 patients (25%). The patients had been symptomatic for a median of 2 weeks before presentation.
All patients underwent computed tomography or magnetic resonance imaging scans to document the presence and extent of infection. Representative images are shown (Figs 3,4).
Intraoperative microbiologic cultures yielded growth in samples obtained from the majority of patients (16 of 20 patients; 80%). The organisms identified were oxacillin-sensitive Staphylococcus aureus, 7 of 20 patients (35%); methicillin-resistant S aureus, 6 of 20 patients (30%); and streptococcus, 3 of 20 patients (15%).
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Fig 3. Computed tomography scan showing left sternoclavicular joint infection. The changes are of predominant inflammation with early bone erosion.
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Fig 4. Computed tomography scan showing left sternoclavicular joint infection. The image shows predominant bone lysis with little soft tissue phlegmon. A contralateral pneumonia and effusion are also seen.
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The debridement and open wound procedure was performed in 10 of 20 patients (50%), and the joint resection and flap closure procedure in 10 of 20 patients (50%). The two groups were comparable in comorbidities, duration of symptoms, computed tomography and magnetic resonance imaging findings, and microbiologic results (Table 1).
Despite an approach of planned reoperation for wound care, the open group had fewer procedures performed per patient as a result of fewer unplanned procedures per patient (Table 2). The open group also had a trend toward a shorter hospital stay (Table 2).
The incidence of wound complications (hematoma, seroma) was lower in open patients, but all open patients (10 of 10 patients; 100%) required prolonged wound care compared with 2 of 10 patients (20%) in the flap group. There were five significant wound complications in the flap group (hematoma, 2 patients; flap dehiscence with infection, 2 patients; seroma, 1 patient) All these patients required wound reexploration. The 2 patients in the flap group who required prolonged wound care had their wounds opened at unplanned repeat procedures. The only hospital mortality occurred in the flap group but was attributable to unrelated causes. Eventual wound healing was satisfactory in all survivors. The patients in the open group required wound care for a median of 12 weeks.
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Comment
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The true incidence of SCJI is not known, but it is likely to be low, as reported in a review published in 2004 summarizing a total of 180 cases in the literature [1]. Similarly, the fraction of patients requiring an operation for SCJI is unclear. In the review by Ross and Shamsuddin [1], 102 of 174 patients (58%) underwent an operation, but this is likely to be an overestimate when applied to the general population as it is more likely that patients undergoing an operation are reported in the literature. Others have recommended that drainage using needle aspiration combined with antibiotics could be sufficient treatment in early disease [5].
Pain, swelling, and fever are the most common presenting complaints [1–4, 6]. In the review by Ross and Shamsuddin [1], the most common risk factor was intravenous drug use (21%), followed by infection at a distant site (15%), diabetes mellitus (13%), trauma (12%), and infected central venous access (9%). Similarly, a variety of predisposing conditions were present in our patients.
Patients with an SCJ swelling may not have clear-cut systemic evidence of infection. Imaging with computed tomography or magnetic resonance imaging scans is generally warranted. Johnson and colleagues [7] noted that although there was overlap with both SCJI and degeneration, the imaging findings that were significantly associated with infection included joint distension of 10 mm or greater, joint capsule distension extending more than 5 mm over the clavicle and sternum, and adjacent bone marrow edema. Imaging findings of erosions, cortical irregularity, hyperemia, and enhancement were seen in both groups, although they were more common with infection [7].
Fifteen percent of our patients had an infection related to intravenous drug abuse. The SCJ is more frequently and disproportionately involved in septic processes in this population. It is postulated that seeding occurs from propagation of infection through the wall of the subclavian vein into the overlying SCJ, after injection of contaminated narcotics into an upper extremity [8]. Also, intravenous drug users might accidentally inject the SCJ, while attempting to access the vessels of the head and neck for drug abuse [9]. The possibility of retained needle fragments and resultant risk of a needlestick injury is quite real, and the surgeon must not bluntly dissect an abscess in an intravenous drug user with a gloved finger [10, 11].
When faced with surgical management of SCJI, our approach is to resect the joint. A similar strategy has been advocated in recent surgical literature [2–4]. When the diagnosis is indeterminate, an initial approach of incision and drainage with biopsy is justified. Once joint resection and debridement have been performed, the choice is between immediate or early wound closure with a muscle flap versus managing an open wound and allowing tertiary closure. Burkhart and associates [4] managed 6 of their 20 patients with open wound care. Ten of our twenty patients were managed with open wounds and required an average of 1.6 procedures per patient, including planned reoperations for debridement. The obvious disadvantage of this approach is the need for prolonged wound care. The use NPWT has mitigated the nuisance value of the same to some degree. Also, if additional procedures are required for debridement, the patients already expect them as they have been appropriately counseled about wound management. Exposed subclavian vessels in the bed of the wound are more of a theoretic concern as thick inflamed surrounding tissue invariably covers them. In general, our patients did well with the open wound approach.
The use of NPWT has simplified the care of open wounds in thoracic surgical patients. Through tissue mechanical deformation, NPWT increases arteriolar dilatation, blood flow, and tissue oxygenation in surgical wounds. It also reduces edema and the bacterial bioburden and allows better tissue granulation and healing [12]. We generally use NPWT within a few days after the initial debridement when no further operative debridement is planned, and the sponges are changed three times a week. The subclavian vessels are generally not exposed in the bed of the wound. Patients typically tolerate this therapy well with support from home health services.
The use of flap closure of the defect has been successfully used in the literature [2–4]. We used this approach primarily at the time of joint resection in 10 of our 20 patients but encountered a higher incidence of local problems, including bleeding requiring reexploration in 1 patient, transfusion in 2 patients, and wound infection or flap skin dehiscence in 2 patients. It is possible that the small number of patients in our series is a confounding factor or that technical issues with the operation may have led to some of these complications. Our goal has been to perform an equivalent debridement in both the open and flap groups as inadequate debridement is bound to require repeat procedures in either group. Song and coworkers [2] performed primary flap closure in 6 patients, of which 5 had been previously treated with incision and drainage. This may lead to a lower load of infected tissue at the time of their joint resection and flap closure. Similarly, Burkhart and colleagues [4] performed delayed closure in the majority of their patients (12 of 20 patients) and thus likely had a lower load of infection in the tissues at the time of flap closure. A strategy of delayed closure with a flap may thus lead to better results than primary flap closure.
One of the obvious advantages of early or primary flap closure is that no wound care is needed and patients may proceed to discharge. This, however, may not be a significant issue in a patient with numerous other problems that necessitate continued hospitalization. With our review of our own data we are now more likely to perform joint resection and open wound care than primary flap closure in patients with SCJI. This is especially true in patients with other critical problems and when there is any doubt about complete eradication of infection after our initial debridement. We are also more likely to consider delayed flap closure of wounds after an initial period of open wound care.
In conclusion, for SCJI, a single-stage resection and muscle advancement flap leads to a higher incidence of complications in our hands. Debridement with open wound care provides satisfactory outcomes with minimal perioperative complications but requires prolonged wound care.
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References
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- Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases Medicine (Baltimore) 2004;83:139-148.[Medline]
- Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternoclavicular joint infections Ann Thorac Surg 2002;73:427-431.[Abstract/Free Full Text]
- Carlos GN, Kesler KA, Coleman JJ, Broderick L, Turrentine MW, Brown JW. Aggressive surgical management of sternoclavicular joint infections J Thorac Cardiovasc Surg 1997;113:242-247.[Abstract/Free Full Text]
- Burkhart HM, Deschamps C, Allen MS, Nichols 3rd FC, Miller DL, Pairolero PC. Surgical management of sternoclavicular joint infections J Thorac Cardiovasc Surg 2003;125:945-949.[Abstract/Free Full Text]
- El Ibrahimi A, Daoudi A, Boujraf S, Elmrini A, Boutayeb F. Sternoclavicular septic arthritis in a previously healthy patient: a case report and review of the literature Int J Infect Dis 2009;13:e119-e121.[Medline]
- Mikroulis DA, Verettas DA, Xarchas KC, Lawal LA, Kazakos KJ, Bougioukas GJ. Sternoclavicular joint septic arthritis and mediastinitis. A case report and review of the literature. Arch Orthop Trauma Surg 2008;128:185-187.[Medline]
- Johnson MC, Jacobson JA, Fessell DP, Kim SM, Brandon C, Caoili E. The sternoclavicular joint: can imaging differentiate infection from degenerative change? Skeletal Radiol 2010;39:551-558.[Medline]
- George S, Wagner M. Septic arthritis of the sternoclavicular joint Clin Infect Dis 1995;21:1525-1526.[Free Full Text]
- Kay DJ, Mirza N. Diagnosis and management of complications of self-injection injuries of the neck Ear Nose Throat J 1996;75:670-676.[Medline]
- Blumstein H, Roberts JR. Retained needle fragments and digital dissection N Engl J Med 1993;328:1426.[Medline]
- Hutchins KD, Williams W, Natarajan GA. Neck needle foreign bodies: an added risk for autopsy pathologists Arch Pathol Lab Med 2001;125:790-792.[Medline]
- Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies Eur J Cardiothorac Surg 2010;37:880-887.[Abstract/Free Full Text]
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Abstract
Introduction
