Ann Thorac Surg 2011;91:261-262. doi:10.1016/j.athoracsur.2010.08.059
© 2011 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Rodney J. Landreneau, MD
The Heart, Lung & Esophageal Surgery Institution, University of Pittsburgh, UPMC Shadyside Medical Center, 5200 Centre Ave, Ste 715, Pittsburgh, PA 15232
(Email: landreneaurj{at}upmc.edu).
Puri and associates [1] provide a thorough review of the risk factors, cause, and pathologic consequences of the uncommon but challenging problem of sternoclavicular joint infection [1]. Resection of the joint and necrotic tissue is the most effective treatment when boney destruction and significant local phlegmon is present. Pairolero and colleagues [2] appropriately stated in his important contribution to the management of sternal infections to "follow the same time-honored principles of wound healing elsewhere: the wound must be drained adequately; all necrotic tissue, devascularized tissue, and foreign material must be removed; and all residual space must be obliterated" [2].
The primary message of Puri and colleagues' [1] work is that resection of the sternoclavicular joint and debridement of the wound followed by negative pressure wound therapy is associated with equivalent long-term success and fewer complications compared with resection and debridement, and immediate pectoralis muscle flap coverage of the wound. Although the limited number of patients in this series does not allow us to definitively accept their contention that immediate pectoralis muscle flap coverage is inferior to open management with healing by "secondary intention." the results do enlighten us to the use of the "alternative" open approach with negative pressure wound therapy.
Other issues regarding the use of the partial pectoralis muscle flap advancement are important to this topic. Support for primary muscle flap use to cover the brachiocephalic vasculature after resection is not commonly warranted. Although such coverage is an important consideration after manubrial clavicular resection for primary malignant lesions or when mediastinal tracheostomy is required after laryngopharyngectomy, it does not apply to this situation in which a deep inflammatory phlegmon separates the vasculature from the necrotic joint tissues. Second, the potential advantages and shortcomings of the various technique of pectoralis muscle flap rotation use must be understood. Accordingly, careful attention to the neurovascular integrity of the pectoralis muscle flap and of the pectoralis muscle remaining in situ must be respected to insure flap viability and optimal upper extremity functionality [3].
I believe that this work by Puri and colleagues [1] is an important contribution to our clinical decision making for this difficult problem of sternoclavicular joint infection. Further investigation into the relative usefulness of resection with open management compared with resection with delayed muscle flap rotation is warranted. As we look more closely into this area of inquiry, I believe it is important for thoracic surgeons to understanding the anatomic and physiologic limitations of the various approaches to muscle flap rotation for this and other thoracic space problems.
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References
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- Puri V, Meyers BF, Kreisel D, et al. Sternoclavicular joint infection: a comparison of two surgical approaches Ann Thorac Surg 2011;91:257-262.[Abstract/Free Full Text]
- Pairolero PC, Arnold PG, Harris JB. Long-term results of pectoralis major muscle tranposition for infected sternotomy wounds Ann Surg 1991;213:583-589.[Medline]
- Corten EML, Schellekens PPA, Bleys RLAW, Kon M. The nerve supply of the clavicular part of the pectoralis major muscle: An anatomic study and clinical application of the function-preserving pectoralis major island flap Plastic and Reconstruct Surg 2003;112:969-975.
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Sternoclavicular Joint Infection: A Comparison of Two Surgical Approaches
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Ann. Thorac. Surg. 2011 91: 257-261.
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