Current Presentation and Optimal Surgical Management of Sternoclavicular Joint Infections

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1 Current Presentation and Optimal Surgical Management of Sternoclavicular Joint Infections Howard K. Song, MD, PhD, T. Sloane Guy, MD, Larry R. Kaiser, MD, and Joseph B. Shrager, MD Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 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. (Ann Thorac Surg 2002;73:427 31) 2002 by The Society of Thoracic Surgeons 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 Accepted for publication Oct 10, Address reprint requests to Dr Shrager, 6th Floor, Silverstein Pavilion, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104; jshrag@mail.med.upenn.edu. disease, we reviewed our recent experience with SCJ infections. Patients and Methods 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 by The Society of Thoracic Surgeons /02/$22.00 Published by Elsevier Science Inc PII S (01)

2 428 SONG ET AL Ann Thorac Surg STERNOCLAVICULAR JOINT INFECTIONS 2002;73: 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. Soft tissue coverage of the resulting space was accomplished with the use of a nonrotated, partial pectoralis major advancement flap (Fig 1B). A flap of skin and subcutaneous tissue was raised to allow mobilization of approximately the upper one third of the pectoralis major muscle laterally as far as the deltopectoral groove. This portion of the muscle was mobilized from its superior attachments to the clavicle and its medial attachments to the sternum as far caudad as approximately the third intercostal space. The medial intercostal perforators to this portion of the muscle were divided. The muscle was separated from the underlying pectoralis minor and advanced into the defect on the basis of its thoracoacromial artery vascular supply. It was then tacked to surrounding structures with interrupted absorbable sutures. Subcutaneous tissues and skin were closed over Jackson- Pratt drains, one below and one above the flap, which were removed within 7 days postoperatively. 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.) 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 Results 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 insulindependent 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. All patients in the series presented with local symptoms, including clavicular mass and joint tenderness. Bacterial (aerobic and anaerobic), fungal, and mycobacterial cultures were sent in all cases, and a variety of organisms were isolated including Staphylococcus aureus,

3 Ann Thorac Surg SONG ET AL 2002;73: STERNOCLAVICULAR JOINT INFECTIONS 429 Table 1. Patient Characteristics and Clinical Features Case Age Sex Risk Factors Symptoms Physical Findings Microorganism Isolated 1 46 M history of clavicle fracture pain chest wall mass none 2 58 F lupus, chronic steroid use pain chest wall mass none 3 45 F none none chest wall mass none 4 43 M AIDS fevers, pain chest wall mass Group G streptococcus 5 66 M history of clavicle fracture, IDDM pain chest wall mass Proteus 6 48 M pustular skin disease pain chest wall mass Proprionibacterium 7 63 M IDDM pain chest wall mass Staphylococcus AIDS acquired immunodeficiency syndrome; IDDM insulin-dependent diabetes mellitus. group G streptococcus, and Proteus and Propionibacterium species. Pathogenic organisms were not isolated from three of the patients, presumably because of sterilization of the inflammatory mass with the use of antibiotics before intraoperative culture or joint aspiration. 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. Magnetic resonance imaging of the SCJ was obtained in three cases. These findings were similar to those of computed tomography [6]. The cross-sectional images provided by magnetic resonance imaging gave excellent anatomic detail of the SCJ and surrounding structures; however, the information provided by this modality generally did not add to that provided by computed tomography scanning. Bone scans were obtained in 4 patients [7]. These studies confirmed osteomyelitis of the clavicular head and manubrium. There was a clear correlation between more aggressive 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. 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 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

4 430 SONG ET AL Ann Thorac Surg STERNOCLAVICULAR JOINT INFECTIONS 2002;73: 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. 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