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Address reprint requests to M. Blair Marshall, MD, Associate Professor of Surgery, Chief, Division of Thoracic Surgery, 4 PHC MedStar Georgetown University Hospital, 3800 Reservoir Road, NW, Washington, DC 20007
Pathologic abnormality of the sternoclavicular joint (SCJ) is rare. The ideal management of patients presenting with complaints of this region frequently requires a tailored approach. As well, the SCJ may be managed by thoracic or orthopedic surgeons, further diluting general surgeons' exposure to this pathologic abnormality. Differentiating between SCJ osteoarthritis vs osteomyelitis may at times be challenging; however, as the process continues, the cause will usually declare itself.
Those with osteoarthritis may benefit from local steroid injection to ameliorate the inflammation and subsequent pain associated with this process (Fig. 1). For those who fail conservative treatment, surgical excision of the joint is curative in this noninfectious process.
SCJ septic arthritis is a rare clinical entity, accounting for only 1% of cases of septic arthritis in the general population
(Fig. 2). It can, however, result in life-threatening complications if not treated adequately. Although mild cases may respond to antibiotics and surgical debridement, more serious cases require SCJ joint resection. Other pathologic abnormalities of the SCJ, including refractory arthritis, may require this approach as well.
Clinical Features and Diagnosis
SCJ septic arthritis most commonly affects adults, although cases have been reported in children. The diagnosis may be challenging due to vague presenting symptoms or lack of clinical signs. Symptoms on presentation include swelling, pain, and/or erythema over the SCJ, with a variable presence of fever. Source of the seeding organism includes central venous catheters, trauma, distant infection, skin excoriations, and intravenous drug use. Associated comorbidities include diabetes and immunosuppression. A minority of cases have no predisposing factors. Cases may be complicated by the development of clavicular osteomyelitis, rib osteomyelitis, mediastinitis, mediastinal or lung abscess, or systemic sepsis.
The diagnosis of SCJ septic arthritis is confirmed by computed tomography (CT) scan or magnetic resonance imaging. Culture isolates are typically monoclonal with Staphylococcus aureus predominating; other causative organisms include Pseudomonas, group G streptococcus, Proteus, and Propionibacterium.
In addition to appropriate antibiotics, most patients with SCJ septic arthritis require operative management. For patients with infection confined to the SCJ capsule, incision and drainage with debridement may suffice.
Resection of the SCJ, including the anterior costal cartilages of rib 1 and sometimes rib 2, with debridement, irrigation, and muscle flap reconstruction is often indicated for patients with more extensive infection and tissue destruction.
Closed suction drains should remain in place until drainage is <30 mL per day. Adequate pain control is essential and consists of oral and intravenous narcotics and nonsteroidal anti-inflammatory drugs. Physical therapy should begin on postoperative day 1 and should focus on shoulder range-of-motion exercises.
Local outcomes are excellent in most case series, with most patients experiencing control of infection and excellent functional outcomes. There is minimal functional disability in relation to the pectoralis advancement flap. We prefer single-staged procedures when possible to limit the number of interventions and to hasten recovery. Adverse events include persistent infection requiring further operative management and sequelae of systemic sepsis, although this is extremely unusual.
Sternoclavicular septic arthritis: Review of 180 cases.