Septic Arthritis of an Atlantoaxial Facet Joint with Normal Inflammatory Markers: Case Report and Literature Review.

BACKGROUND: Septic arthritis of the atlantoaxial facet joint is extremely rare. Contiguous spread to the median atlantoaxial joints with subsequent dens erosion can lead to atlantoaxial instability. Misleading normal inflammatory markers can result in delayed diagnosis and catastrophic consequences. CASE DESCRIPTION: A 56-year-old man presented with right-sided neck pain that had lasted for 2 days. He did not have fever or chills, and his serum C-reactive protein and erythrocyte sedimentation rate were normal. The patient was diagnosed with acute neck strain and treated conservatively. The pain continued for the next 3 weeks; cervical spine radiographs demonstrated normal findings with the exception of degenerative changes. The patient was treated with physical rehabilitation for the presumed neck strain and degenerative changes of the cervical vertebrae. Worsening neck pain and stiffness prompted a magnetic resonance imaging study obtained 5 weeks after the initial presentation, which showed an epidural collection with septic arthritis of the right facet and median atlantoaxial joints. Computed tomography demonstrated severe dens erosion. Surgical evacuation of the abscess and occipitocervical fusion were performed. Pathologic evaluation of tissue obtained during surgery demonstrated the presence of an infection, and Streptococcus anginosus grew from cultures. CONCLUSIONS: Infection must be considered in the differential diagnosis for neck pain when imaging findings are suggestive of an infectious process, even in an afebrile patient with normal C-reactive protein and erythrocyte sedimentation rate levels. Magnetic resonance imaging and computed tomography can play a critical role in such cases, potentially leading to a more timely diagnosis.

Surgical Management of Sternoclavicular Joint Infections.

BACKGROUND: Infections of the sternoclavicular joint (SCJ) respond poorly to nonoperative management and typically require resection. We examined presenting characteristics and outcomes after surgical management of SCJ infections, reviewing a 20-year single-institution experience. METHODS: From January 1992 to December 2012, 40 patients (age, 57 ± 12 years; 70% male) underwent resection of an infected SCJ. Sternal infections after cardiac surgery were excluded. Clinical features, microbiology, recurrence, survival, and functional impairment were assessed. Infection was documented by the surgeon, and supported by tissue culture. Clinical presentation and treatment course were obtained by review of medical records. The functional assessment was determined by phone interviews using the validated QuickDASH outcome measure. Mortality data were gathered from the medical record. RESULTS: Pain was the presenting symptom in 93% of patients. Staphylococcal species were isolated in 73% of tissue specimens. Fifteen patients (37%) underwent primary closure and 25 patients (63%) underwent closure by secondary intention with application of negative-pressure wound therapy. There were four recurrences (10%), one after primary closure and three in the secondary intention group. No deaths occurred within 30 days of operation, and 5-year survival was 67%. Functional assessment using the QuickDASH outcome measure revealed minimal loss in upper extremity function after the procedure (preoperative score, 10 ± 3; postoperative score, 19 ± 6.8; n = 11). There was no difference in functional outcome comparing primary closure versus secondary intention (19 ± 4.4 versus 20 ± 8.2; p = 0.64). CONCLUSIONS: Septic arthritis of the SCJ is routinely managed surgically at many centers. We report that primary closure with a muscle flap can achieve similar outcomes to secondary intention in selected patients. Furthermore, patients experienced minimal functional impairment at long-term follow-up.