It is better to know what you don’t know

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Sternoclavicular septic arthritis caused by Staphylococcus aureus: excellent results from medical treatment and limited surgery

Sternoclavicular joint infection (SCJI) is a rare disease that, not surprisingly, has been difficult to study. The literature is dominated by retrospective reviews of small patient series, usually numbering in the 5 to 20 patient range. The trend in general has been to pursue aggressive surgical management including joint resection largely due to concerns regarding failure of more conservative measures. This stems from publications such as the series by Song et al. in 2002 that documented a higher failure rate (83%) in a series of seven patients [1]. This high number, in hindsight, was likely due to a referral bias. Additionally, in a meta-analysis of 170 cases of sternoclavicular joint infection spanning 20 years and 62 publications [2], 58% of patients were treated surgically and, of those, 53% underwent the more radical en bloc resection of the sternoclavicular joint. Furthermore, 24% of the patients who underwent the more radical surgery had failed prior attempts at less aggressive surgery such as simple incision and debridement. No mention is made in this series of the outcomes of medical management overall.

Jang et al. present an institutional series over a seven-year period including 22 patients with SCJI due to Staphylococcus aureus which challenges convention [3]. In this series, half of the patients are managed medically and half are managed with limited surgical debridement. Surgical debridement was generally utilized when an abscess was identified and none of the patients underwent joint resection. The authors report a 100% success rate with this approach during a lengthy follow-up period, median 53 weeks. Moreover, they note no deterioration in joint function during the follow-up period.

So how can this be? I suspect it is multifactorial. One factor is the patient population. Jang et al. [3] reports an obesity rate of 14% in their study as compared to a 35% rate in the series from Kachala et al. [4] out of the Cleveland Clinic. Furthermore, they have no IV drug users whereas the Kachala et al.’s [4] study reports a rate of 10%. Notably, both studies have a similar rates of end-stage renal failure and MRSA infection. Jang et al. [3] importantly limits their study to S. aureus patients whereas most other series include other organisms which may follow a more fulminant course. Furthermore, as mentioned above, there is clearly a component of selection bias in many of the myriad of small surgical series which report only the patients that the surgeons evaluated. Clearly these series miss the medically managed patients that Jang et al. [3] have included.

Jang et al. [3] demonstrate that SCJI, like any other disease, exists on a spectrum. As a result, a graded approach to treatment is warranted. This can include medical management for appropriately selected patients based on imaging and comorbidities. Limited surgical intervention may be appropriate for diagnostic purposes as well as for patients with focal collections and minimal joint damage. Radical resection may be reserved for those patients with extensive joint destruction, osteomyelitis, extensive surrounding tissue involvement or those at risk for recurrence due to immunosuppression, significant comorbidities or access to healthcare. Much remains unknown at present and thus further research opportunities abound. For instance, what are the implications for long-term joint dysfunction with limited surgical intervention versus radical approaches? Kachala et al. [4] demonstrated minimal functional impairment based on patients who had undergone radical surgery utilizing the QuickDASH score over a five-year period. Is limited surgical intervention superior? Joint destruction with limited surgery could lead to symptomatic joint destabilization over long-term follow-up requiring arthroplasty. How does primary closure, pectoralis muscle flap coverage, wound vac closure effect long-term function? Clearly, at present, we must be aware of what we do not know. As a result, surgeons should not immediately jump to radical surgery as the only option for the treatment of SCJI but rather consider all available options based on the severity of the presentation.

Disclosure statement

No potential conflict of interest was reported by the authors.