Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach.

OBJECTIVES: Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining. METHODS: An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes. RESULTS: A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis. CONCLUSIONS: This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Sternoclavicular Septic Arthritis Caused by Parvimonas micra and Fusobacterium nucleatum Infection with Intra-articular Corticosteroid Administration.

Sternoclavicular septic arthritis is a rare form of septic arthritis that can lead to fatal complications, such as abscess formation and mediastinitis, in the absence of prompt diagnosis and appropriate treatment. A man in his 40s presented with pain in the right sternoclavicular joint area, and after a joint injection of steroids was administered, he was diagnosed with septic sternoclavicular arthritis caused by Parvimonas micra and Fusobacterium nucleatum. Gram staining of a specimen obtained from the abscess formation area led to early suspicion of anaerobic infection, and appropriate antibiotics were administered.

Utility of 3D reformatted images in the diagnosis of sternoclavicular joint injury.

INTRODUCTION: The purpose of this study is to evaluate the ability of musculoskeletal radiologists to diagnose sternoclavicular joint injuries in the standard CT imaging planes compared to 3D volume rendered images to define the most accurate plane to improve prospective diagnosis. MATERIALS AND METHODS: A retrospective query of our institutional database was performed. Twenty-six patients with a diagnosis of sternoclavicular joint injury, who had been evaluated with CT and treated by orthopedic surgery, and 30 control patients who did not have a sternoclavicular joint injury were included for analysis. Two blinded radiologists with specialty training in musculoskeletal radiology independently reviewed axial, coronal, sagittal, and 3D reformatted CT images and documented whether injury was present or not present. RESULTS: Accuracy was good for both radiologists on all views. It was lowest on the sagittal view for both readers. Accuracy was highest for the 3D view. When comparing the accuracy of the four views for each radiologist, there was a significant difference for Radiologist A, whose 3D images were more accurate compared to the axial and sagittal views. There was no significant difference for Radiologist B. There was good inter-reader agreement, which was highest on the 3D images. CONCLUSION: 3D volume renderings of the sternoclavicular joints have the potential to improve radiologist accuracy for detection of sternoclavicular joint injury/dislocation in the setting of chest well trauma, which could decrease instances of missed or delayed diagnosis.

Atraumatic Sternoclavicular Joint Instability: Prevalence, Etiology, and Management.

Sternoclavicular joint instability is a rare complaint in the orthopedic clinic, but patients can experience chronic pain and functional impacts. Causes of instability may be posttraumatic, infectious, autoimmune, degenerative, or secondary to generalized laxity. Conservative treatment is the initial approach to management and involves activity modification, physical therapy, oral nonsteroidal anti-inflammatory drugs, and corticosteroid injections. Surgery is indicated when conservative treatment does not manage symptoms. Figure-of-eight reconstruction techniques provide greatest biomechanical strength but are associated with risk of neurovascular injury. Other reconstruction methods have been shown to mitigate these risks with favorable short-term outcomes.

Superior Sternoclavicular Dislocation Treated with Costoclavicular Ligament Reconstruction Using Autograft: A Case Report.

CASE: We describe a case of a traumatic superior dislocation of the sternoclavicular joint (SCJ) due to an isolated rupture of the costoclavicular ligament (CCL). A magnetic resonance imaging (MRI) scan demonstrated the CCL rupture with preservation of the anterior and posterior SCJ ligaments. This was successfully treated with an isolated hamstring tendon reconstruction of the CCL, resulting in a satisfactory outcome at 1 year after the procedure. CONCLUSION: Isolated CCL reconstruction with a hamstring tendon in a patient with a superior SCJ dislocation provided a satisfactory outcome.

Traumatic posterior sternoclavicular joint dislocation - Current aspects of management.

The posterior sternoclavicular joint dislocation is a rare and potentially life-threatening injury, as massive haemorrhage can occur at the time of trauma, during reduction manoeuvres and drilling. These injuries are rare and a collective experience of managing them is of paramount importance. We present our multidisciplinary experience of managing several of these injuries in our centre, with learning points we have identified. Assessment should include Computerised Tomography Angiography (CTA) to assess the anatomy of the joint including the proximity to the underlying innominate vein and to identify any bleeding. Both closed reduction and open reconstruction have the potential for massive haemorrhage which can be controlled successfully with direct access to the underlying vessel. We recommend that all reductions should be performed in the presence of a cardiothoracic surgeon who can gain vascular control in the head, neck, and thorax. In specific high-risk cases, pre-emptive venous catheterisation can also be considered. We recommend that a discussion and rehearsal for intra-operative bleeding should be undertaken with the whole theatre team, with roles assigned pre-emptively and to allow identification of any deficiencies in staff expertise or equipment. Of the five recent cases managed in our centre one patient had a closed reduction and four had open reductions. Success of closed reductions within 48 h is high and these can be attempted up to 10 days after injury. Our patient undergoing closed reduction had a favourable outcome and returned to professional rugby at five months. Open reduction was performed in a physeal fracture as there was a delay to surgery and callus had begun to form and had the potential to adhere to the underlying vessel. In this case we performed open reduction and stabilised with tunnelled suture fixation. Our preferred method of reconstruction uses a palmaris graft with internal figure of eight bracing. One patient had a subsequent fracture of the medial clavicle around the drill holes that healed without further intervention. Despite good reduction and stability achieved following palmaris reconstructions, two patients are experiencing ongoing symptoms of globus and one with voice change without any objective underlying cause.

Is there a relation between loss of shoulder external rotation and sternoclavicular joint disorders?

BACKGROUND AND AIM: Scapulothoracic movements are essential in shoulder kinematics and can partially compensate  stiffness and loss of motion of glenohumeral joint. The scapulothoracic movement is strictly dependent on the translation and rotation of the clavicle at the sternoclavicular joint (SCJ), this being the only true joint between the axial and the upper appendicular skeleton.  Aim of the study is to define a possible correlation between loss of shoulder external rotation following surgery for anterior shoulder instability and long-term sternoclavicular joint disorders. METHODS: A group of 20 patients and a group of 20 healthy volunteers were studied.  Results: In the statistical analysis of the patient group and of the two groups jointly, the association between the reduction of shoulder external rotation and the onset of disorder of SCJ appeared statistically significant. CONCLUSIONS: Our results provide support for an association between some disorders of the SCJ and the alterations of the shoulder kinematics associated with a reduction of  ROM in external rotation. Our sample is too small to allow definitive conclusions to be drawn. These results, if confirmed by larger studies, could help us further clarify the complex kinematics of the shoulder girdle.

Current Concepts in Sternoclavicular Joint Injuries.

LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Physeal injuries of the clavicle: pediatric counterparts to adult acromioclavicular and sternoclavicular joint separations.

The epiphyses at the medial and lateral ends of the clavicle are small, ossify relatively late, and may not fuse until early adulthood. Because of this unique anatomy, pediatric and young adult injuries that involve the clavicle often differ from the patterns typically seen in older adults. Clavicular trauma that affects the acromioclavicular joint laterally or sternoclavicular joint medially often results in a physeal fracture and as such, can go unrecognized or be mistaken for a joint dislocation. Radiographic assessment is challenging, particularly when the epiphysis is not yet ossified. However, MR imaging allows for visualization of the cartilage, periosteum and perichondrium, and ligaments of the affected joints. Lateral clavicle physeal injuries can be categorized by the Dameron and Rockwood system, the pediatric correlate to the Rockwood classification of adult acromioclavicular joint injuries. Medial clavicle physeal fractures, similar to adult sternoclavicular joint dislocations, may result in anterior or posterior displacement. Because of their great ability to heal and remodel, clavicular physeal fractures respond better to conservative management than true acromioclavicular or sternoclavicular joint dislocations. Therefore, it is essential to recognize the true nature of these injuries, as there are implications for successful treatment and appropriate prognosis.

Magnetic Resonance Imaging in the Management of Significantly Displaced Adolescent Posterior Sternoclavicular Joint Injuries.

BACKGROUND: Computed tomography (CT) scans are the standard imaging modality for the diagnosis and treatment guide for adolescent posterior sternoclavicular joint (SCJ) injuries. However, the medial clavicular physis is not visualized and it is not possible to differentiate between a true SCJ dislocation and a physeal injury (PI). An magnetic resonance imaging (MRI) scan can visualize the bone and the physis. METHODS: We treated a series of patients with adolescent posterior SCJ injuries diagnosed on CT scan. Patients underwent an MRI scan to differentiate between a true SCJ dislocation and a PI and to further differentiate between a PI with or without residual medial end clavicular bone contact. Patients with a true SCJ dislocation and a PI with no contact underwent an open reduction and fixation. Patients with a PI with contact were treated nonoperatively with repeat CT scans at 1 and 3 months. At final follow-up SCJ clinical function was assessed using Quick-DASH, Rockwood, modified Constant, and single assessment numeric evaluation (SANE) scores. RESULTS: Thirteen patients (2 female and 11 male) with an average age of 14.9 years (12 to 17) were included in the study. Twelve patients were available at final follow-up (mean 50 mo, 26 to 84). One patient had a true SCJ dislocation and 3 had an off-ended PI and were treated with an open reduction and fixation. Eight patients had a PI with residual bone contact and were treated nonoperatively. For these patients serial CT scans showed that the position was maintained, with a serial increase in callus formation and bone remodeling. The average follow-up was 42.9 months (24 to 62). At final follow-up the mean Quick-disabilities of the arm, shoulder and hand (DASH) was 0.4 (0 to 2.3), Rockwood was 15, modified Constant was 98.8 (89 to 100) and SANE was 99.5% (95 to 100). CONCLUSION: In this case series of significantly displaced adolescent posterior SCJ injuries MRI scans allowed identification of true SCJ dislocations and off-ended PIs, which were successfully treated by open reduction, and PIs with residual physeal contact which were successfully treated nonoperatively. LEVEL OF EVIDENCE: Level IV-case series.

A reappraisal of pediatric thoracic surface anatomy.

Accurate knowledge of surface anatomy is essential for physical examination, invasive procedures, and anatomy education. Individual factors such as age make surface landmarks variable so accurate descriptions are needed. The aim of this study is to describe age-related surface landmarks for intrathoracic structures in children. A total of 156 thoracic computed tomography scans of children aged 0-18 years were categorized into six groups, and the associations between major intrathoracic structures and surface landmarks were analyzed. Sternal angle is an accurate surface landmark for the azygos vein-superior vena cava junction in all age groups. However, the aortic arch (except in the 0-1 year group), the bifurcation of the pulmonary trunk and the tracheal bifurcation in those aged 15-18 years were not within this plane. The left brachiocephalic vein was located behind the ipsilateral sternoclavicular joint except in the 1-3 years group, and the right was behind it in children older than 6 years. The apex of heart was at the 5th intercostal space level in the 0-1 and 12-18 years groups; however, it was higher in the other groups. The lower borders of the lungs were at the sixth costal cartilage level in the midclavicular line, eighth intercostal space level in the midaxillary line, and T12 adjacent to the vertebral column in the 15-18 years group; the lower borders were at higher levels in younger children. Defining the variations in surface anatomy by in vivo studies will increase its clinical and pedagogical value.

Increasing Incidence of Sternoclavicular Joint Infections in Intravenous Drug Users.

Sternoclavicular joint septic arthritis is rarely seen in the general population. The majority of cases are seen in intravenous drug users. Given the lack of reported cases in the literature, there is no standardized treatment algorithm for this disease. Described treatment methods range from medical management to wide local debridement. The incidence of sternoclavicular joint septic arthritis will likely continue to increase with rising usage of intravenous drugs in the United States. Within the past year, our institution treated four cases.

The German version of the Nottingham Clavicle Score is a reliable and valid patient-reported outcome measure to evaluate patients with clavicle and acromioclavicular pathologies.

PURPOSE: The Nottingham Clavicle Score (NCS) is a patient-reported outcome measure developed to evaluate treatment results of clavicle, acromioclavicular and sternoclavicular joint pathologies. Valid, reliable and user-friendly translations of outcome measure instruments are needed to allow comparisons of international results. The aim of this cross-sectional study was to translate and adapt the NCS into German and evaluate the psychometric properties of the German version. METHODS: The translation and cross-cultural adaptation of the NCS were completed using a 'translation-back translation" method and the final version was administered to 105 German-speaking patients. The psychometric properties of this version (NCS-G) were evaluated in terms of feasibility, reliability, validity and sensitivity to change. RESULTS: No major differences occurred between the NCS translations into German and back into English, and no content- or linguistic-related difficulties were reported. The Cronbach's alpha for the NCS-G was 0.885, showing optimal internal consistency. The Intraclass Correlation Coefficient for test-retest reliability was 0.907 (95% CI 0.844-0.945), with a standard error of measurement of 5.59 points and a minimal detectable change of 15.50 points. The NCS-G showed moderate to strong correlation with all other investigated scales (Spearman correlation coefficient: qDASH: ρ = - 0.751; OSS: ρ = 0.728; Imatani Score: ρ = 0.646; CMS: ρ = 0.621; VAS: ρ = - 0.709). Good sensitivity to change was confirmed by an effect size of 1.17 (95% CI 0.89-1.47) and a standardized response mean of 1.23 (95% CI 0.98-1.45). CONCLUSIONS: This study demonstrated that NCS-G is reliable, valid, reproducible and well accepted by patients, showing analogous psychometric properties to the original English version. LEVEL OF EVIDENCE: Level III.