Asian Cardiovasc Thorac Ann 2001;9:291-295
© 2001 Asia Publishing EXchange Pte Ltd
Surgical Management of Sternoclavicular Joint Infection
Lim Chong Hee, FRCS,
Jeremy Lim, MBBS,
Madhava Janardhan Naik, MS,
Thirugnanam Agasthian, FRCS
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Department of Cardiothoracic Surgery National Heart Centre Singapore, Republic of Singapore
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For reprint information contact: Lim Chong Hee, FRCS Tel: 65 436 7598 Fax: 65 224 3632 email: limch88{at}hotmail.com Department of Cardiothoracic Surgery, National Heart Centre, 17 Third Hospital Avenue, Mistri Wing, Singapore 168752, Republic of Singapore.
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ABSTRACT
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Sternoclavicular joint infection is rare and tends to present insidiously in debilitated and immunocompromised patients. Between August 1996 and July 1998, we managed 7 patients with 8 sternoclavicular joint infections. Three were women. Their age ranged from 42 to 63 years. Five of the patients had significant associated medical conditions. Six patients, including 1 with bilateral involvement, underwent surgical resection, which consisted of radical excision of the involved joint, medial third of the clavicle, first and second ribs and adjacent muscular wall, and part of the manubrium. All of them underwent delayed reconstruction with either pectoralis major or latissimus dorsi flaps. There was 1 operative mortality from continuing sepsis from another source. All the surviving patients showed no sign of local recurrent infection and no functional deficits at follow-up. We conclude that infection of the sternoclavicular joint often presents late in debilitated patients. Medical therapy often fails in these cases. Radical excision is effective in eradicating the septic focus, and functional results after reconstruction are excellent.
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INTRODUCTION
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The sternoclavicular joint (SCJ) is a synovial-fluid-filled space comprising the inferior portion of the medial end of the clavicle, a notch on the outer portion of the manubrium sternum, and the cartilage of the first rib.1 The enveloping articular space is reinforced by the anterior, posterior, and interclavicular ligaments.
SCJ infections are rare and, unless recognized, potentially life-threatening. They present with unusual clinical signs and are often misdiagnosed at initial assessment. Chronic debilitation, immunosuppression, and intravenous drug abuse are known risk factors.2 Management of this condition remains controversial. Early institution of appropriate antibiotics is effective in some cases. Delay in correct diagnosis often leads to progression of sepsis and abscess formation. Local extension into the chest wall associated with osteomyelitis and descending mediastinitis makes antibiotic delivery difficult and unlikely to succeed. Surgical intervention then becomes necessary in eradicating the septic focus.
We review the literature and our experience in the management of 7 patients who presented with this uncommon but difficult problem.
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PATIENTS AND METHODS
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Between August 1996 and July 1998, 7 patients were seen in our institution with 8 SCJ infections. There were 4 men. The mean age was 54.3 years (range, 42 to 63 years). Clinical and radiographic data were collected retrospectively from hospital records. Table 1
summarizes the clinical, microbiologic, and outcome data.
Six of the patients were operated on, including 1 with bilateral resection. We adopted a radical approach with the intention of eradicating the infective process. A curved L-shaped incision was made over the medial third of the clavicle and extended down the midline on the manubrium. Resection involved the medial third of the clavicle, the first and second ribs, and part of the manubrium. The underlying pleura is usually thick from the inflammation, so we avoid opening the pleural cavity unless there is significant effusion to be drained. The ipsilateral internal thoracic vessels were sacrificed. In patient 5 with bilateral involvement, the resection was extended to the opposite side with the entire manubrium, both medial ends of the clavicle, and the bilateral first 2 ribs excised.
A delayed pedicle muscle flap closure was performed with plastic surgeons within 24 to 48 hours. The contralateral pectoralis major or latissimus dorsi flaps were utilized. Jackson Pratt drains were placed, which were removed when drainage was less than 50 mL per day.
All the patients were monitored in the intensive care unit. They were extubated after the flap closure according to standard criteria. Pain was relieved with patient-controlled intravenous opiates. Intravenous antibiotics were con-tinued for 2 weeks after the resection. Early mobilization was encouraged. Subcutaneous heparin was used for prophylaxis against deep vein thrombosis.
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RESULTS
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There was 1 mortality. This was a 63-year-old lady (patient 1) with insulin-dependent diabetes mellitus who presented with right SCJ swelling and pain (Figure 1). Blood and tissue cultures grew Staphylococcus aureus. She never recovered from severe ongoing sepsis secondary to pneumonia and succumbed to multiple organ failure 4 months after presentation.
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Figure 1. Computed tomography of the chest of patient 1 showing a large abscess with air pockets posterior to the right sternoclavicular joint.
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The surviving patients had a median follow-up of 6 months (range, 3 to 12 months). There were no obvious functional deficits in the strength and range of motion in the shoulders. No recurrent infections were present. Significant morbidity was seen in 2 patients. Patient 5 with bilateral resection of the SCJ developed deep vein thrombosis with pulmonary embolism. She was anticoagulated with warfarin and recovered well. Except for paradoxical motion over the flap in the anterior part of the chest, she did not show any respiratory limitation. Her chest radiograph (Figure 2) illustrates the extent of surgical resection. There was minimal paradoxical motion of the chest on breathing in the other patients. Patient 4 developed cecal perforation and underwent a laparotomy with a limited right hemicolectomy. She recovered and was discharged 6 weeks after the SCJ resection. At 6-month follow-up, she was well. Patient 7, without comorbid conditions, responded well to conservative therapy of intravenous antibiotics of cloxacillin and gentamicin for 1 week. He was discharged with oral cloxacillin on complete resolution of symptoms. At 6 months, he did not show signs of recurrent infection.
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Figure 2. Postoperative chest radiograph of patient 5, who underwent bilateral sternoclavicular joint resection.
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DISCUSSION
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CLINICAL PRESENTATION AND ETIOLOGY
SCJ infection generally begins as a small focus confined initially by the joint capsule but may extend laterally into the clavicle, medially into the sternum, and posteriorly into the mediastinum. Aggressive management is warranted early in the disease process because if left untreated, up to 21% of cases may progress to abscess formation and mediastinitis.3 Progression is unrelated to the state of the immune system but perhaps related to the lack of vascularity of the joint.
Clinical onset is insidious, so delay in medical consultation and diagnosis is common. Six of our patients were not diagnosed at initial presentation. This is attributed to the rarity of the condition — hence the low index of suspicion — and the slow progression of the disease. It is pertinent to note that in 5 of our patients, pain was attributed to a musculoskeletal cause.
Reported chief symptoms are anterior chest pain and restricted unilateral shoulder movement.4 These were seen in 5 of our patients. Fever and other clinical indicators of infection, which were reported in 67%5 and 100%4 of patients by other investigators, were uncommon in our patients with only 2 being febrile.
Patients with SCJ infections often have definite pre-disposing factors, such as intravenous drug abuse,4 diabetes mellitus,6 chronic renal failure,7 endstage liver disease,8 and infection with the human immunodeficiency virus (HIV).9 However, there are reported cases of SCJ infection among patients with no detectable immuno-compromised condition. In these patients, the search for a portal of infection is all the more important as even minor infections like paronychia10 have been implicated. In our patients, diabetes mellitus (n = 4), renal failure (n = 1), and steroid therapy after renal transplantation (n = 1) were the major predisposing factors. Two of our patients were previously well. One of them (patient 7) developed SCJ infection after acupuncture, which is a common form of therapy among the Chinese for treating a variety of ailments. In the other patient (patient 2), the diagnosis was made only after histological examination of the resected tissue and consultation with the local tuberculosis control unit.
The mechanism of infection has been variously postulated to be direct injury, hematogenous seeding, and contiguous spread from adjacent structures. Subclavian venous cannulation for central line placement has been thought to be responsible for the direct introduction of skin contaminants like Staphylococcus aureus into the joint capsule.11 Blood-borne infection is also possible, though the SCJ receives only a very small proportion of the total cardiac output. The brain, kidneys, and spleen are affected the most in cases of massive septic emboli, such as in bacterial endocarditis.12 Contiguous spread from subclavian vein phlebitis13 may help explain the high incidence of SCJ infection among intravenous drug abusers. In 3 of our patients, we attributed hematogenous seeding of bacteria to the SCJ as the likely cause of the infection: during hemodialysis in patient 4, during ureteral instrumentation for calculi in patient 3, and during acupuncture in patient 7.
MICROBIOLOGY
Staphylococcus aureus was the most common pathogen cultured from our patients (n = 4). Two of the cultures were methicillin-resistant. All varieties of organisms have been cultured, including Enterococcus, Escherichia coli, Propionibacterium,14 and Bacteroides melitensis.13 More exotic microbes like Candida15 and Gonococcus9 are seen in HIV-positive patients. The diagnostic yield from articular puncture is high, and definitive microbial diagnosis is imperative in guiding the choice of antimicrobial therapy and also in determining the need for early and radical surgical intervention. A less invasive approach may be possible in cases where a less virulent bacterium, such as group B Streptococcus, is isolated as the causative agent.16
IMAGING
All our patients underwent computed tomography (CT) of the chest after plain radiographs had been taken. In only 1 case was the wrong diagnosis of chest wall sarcoma made. Plain chest films, as used by other investigators, may only demonstrate swelling of the soft tissue and only rarely will show bony destruction with osteomyelitis of the clavicle. CT scanning17 is necessary not only for diagnosis but also for defining the extent of bony and mediastinal involvement. The presence of air pockets (Figure 1
) in the fluid collection is pathognomonic of abscess formation. Nuclear scans are not normally required, but may be useful in locating the infection and other joint or bony involvement.
MANAGEMENT
Accurate delineation of the infective process is mandatory, and therapeutic decisions should be made only after the appropriate imaging studies. Microbial diagnosis is very useful in guiding antimicrobial therapy, and needle aspiration of the joint for fluid or open biopsy with tissue culture is normally required.
The spectrum of SCJ infections ranges from a periarticular inflammation and bony involvement of the clavicular head to frank abscess formation and mediastinitis. Early infection as in patient 7 may be amenable to intravenous antibiotics after a diagnostic articular puncture. More frequently, we encounter more severe infection with abscess formation and mediastinitis in critically ill patients. This requires a radical approach of resection of all infected tissue and local muscle flap reconstruction.14
The SCJ is the only connection between the shoulder and the axial skeleton, and it contributes to abduction and flexion of the shoulder by elevation and rotation of the clavicle, respectively. Despite the radical debridement required, the residual function remains excellent and excision resulted in minimal restriction of motion in our patients. Lessons learnt from the treatment of post-sternotomy infection have led us to discard the old technique of leaving the wound to heal by secondary intention. Instead, local myoplasty is preferred as the muscle flap serves not only to provide some degree of protection to the mediastinal structures exposed but also to improve the blood supply in the area, which may have low-grade infection.18 We used either pectoralis major or latissimus dorsi flaps with excellent results. Even the patient with bilateral resection showed minimal functional impairment and no evidence of respiratory compromise.
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CONCLUSION
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The diagnosis of SCJ infection is all too often missed, so a high index of suspicion is required, especially in patients with underlying risk factors. Late diagnosis is potentially disastrous as it may necessitate surgical intervention. Surgical debridement and reconstruction are indicated for more advanced infections and for cases where response to medical therapy is less than satisfactory. Despite radical resection, the residual function is only minimally compromised.
Presented at the 7th Annual Meeting of The Asian Society for Cardiovascular Surgery, Singapore, May 28–June 1, 1999.
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ABSTRACT
INTRODUCTION
