Septic arthritis of the sternoclavicular joint: A unique late complication after tracheostomy

Accepted Manuscript Septic arthritis of the sternoclavicular joint: A unique late complication after tracheostomy

Kayvon F. Sharif, Fred M. Baik, Ameya A. Jategaonkar, Azita S. Khorsandi, Mark L. Urken PII: DOI: Reference:

S0196-0709(18)30383-1 doi:10.1016/j.amjoto.2018.05.005 YAJOT 2024

To appear in: Received date:

4 May 2018

Please cite this article as: Kayvon F. Sharif, Fred M. Baik, Ameya A. Jategaonkar, Azita S. Khorsandi, Mark L. Urken , Septic arthritis of the sternoclavicular joint: A unique late complication after tracheostomy. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Yajot(2017), doi:10.1016/ j.amjoto.2018.05.005

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ACCEPTED MANUSCRIPT Title: Septic arthritis of the sternoclavicular joint: a unique late complication after tracheostomy

Short running title: Sternoclavicular joint infection

Authors:

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Kayvon F. Sharif BAa,*, Fred M. Baik MDa,b, Ameya A. Jategaonkar MDb, Azita S. Khorsandi MDc, Mark L. Urken MD, FACS, FACEa,b a

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THANC (Thyroid, Head and Neck Cancer) Foundation,10 Union Square East, Suite 5B, New York, NY 10003, USA b

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Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel Medical Center, 10 Union Square East, Suite 5B, New York, NY 10003, USA c

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*Corresponding Author Kayvon Sharif Research Associate THANC Foundation 10 Union Square East, Suite 5B New York, NY 10003 [email protected] 212-844-6491 (tel.) 212-844-8465 (fax)

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Department of Radiology, New York Eye & Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY 10003, USA

Declarations of Interest:

Dr. Urken is the Medical Advisor of the THANC Foundation

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ACCEPTED MANUSCRIPT Abstract Background: Septic arthritis of the sternoclavicular joint is a rare infection associated with significant morbidity and mortality. Several risk factors for septic arthritis have been reported in the literature ranging from immunodeficiency to intravenous drug use. Case Presentation: A 63-year-old male previously treated for synchronous squamous cell carcinomas of

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the epiglottis and floor of mouth presented with tenderness and swelling of the sternoclavicular joint two months after tracheostomy decannulation. Computed tomography and bone scans confirmed the

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diagnosis of septic arthritis of the sternoclavicular joint. The patient’s clinical course, surgical treatment,

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and management considerations are discussed here.

Conclusion: Septic arthritis of the SCJ is a rare but serious infection. Once diagnosed, septic arthritis of

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the SCJ should be promptly treated to prevent further morbidity and mortality.

Keywords

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sternoclavicular joint; septic arthritis; tracheostomy complications

1. Introduction

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Septic arthritis of the sternoclavicular joint (SCJ) is an extremely rare entity, observed in less

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than one percent of all bone infections [1-3]. This condition poses risks for serious complications such as chest wall abscess, osteomyelitis, mediastinitis, myositis, bacteremia, and premature death [2]. While several risk factors have been identified, including intravenous drug use, immunodeficiency, trauma, distant infection, and diabetes mellitus, up to 23% of cases are not attributable to any predisposing factor [1]. Here, we present a case of septic arthritis of the SCJ as a late complication from tracheostomy.

2. Case Description 2

ACCEPTED MANUSCRIPT A 63-year-old male with a past medical history of alcohol abuse and an 80 pack-year smoking history presented with a right neck mass. Additional comorbidities included cirrhosis with a Model for End-Stage Liver Disease (MELD) score of 14 (range 6-40, where scores above 19 represent candidacy for organ transplantation) [4]. Examination of the head and neck demonstrated two suspicious lesions, one in the floor of mouth and a second on the laryngeal surface of the epiglottis. Computed tomography

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(CT) scan of the neck revealed multiple enlarged right level 3 nodes, with asymmetric prominence of the right infrahyoid epiglottis and aryepiglottic fold. Fine needle aspiration of the neck node confirmed the

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diagnosis of squamous cell carcinoma (SCC), and direct laryngoscopy with biopsy confirmed the

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presence of synchronous primary SCCs of the floor of mouth (T2) and the epiglottis (T1N2bM0). The consensus from tumor board discussion was to proceed with surgery for the floor of mouth

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cancer and then follow with definitive chemoradiation to treat the larynx. The patient underwent a wide

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local excision of the floor of mouth lesion with a split thickness skin graft reconstruction, and a right level 1-4 selective neck dissection. An uneventful tracheostomy with a Bjork flap was performed at this

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time. He was decannulated one week after surgery. Four weeks after surgery, he received concurrent

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chemoradiation. He received 70 Gy of radiation to the larynx and bilateral necks over 7 weeks, along with cisplatin at a lower dose of 30 mg/m2 due to his cirrhosis. Due to the anticipated swallow

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dysfunction, a gastric tube was inserted.

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Six months later, the patient presented with recurrent nodal disease in the contralateral neck and underwent a left selective neck dissection. A tracheostomy was performed at this time due to radiation changes in the larynx and to avoid airway obstruction post-operatively. His course was complicated by an abscess involving the left neck, requiring surgical washout and a two-week course of ampicillin/sulbactam. Blood cultures were negative at this time. He was decannulated after appropriate downsizing and capping, but his stoma remained slow to heal. A 2mm tracheocutaneous fistula was still present on discharge. One week later, he presented to an outside hospital with fever and was found to 3

ACCEPTED MANUSCRIPT have polymicrobial bacteremia, but a clear source of infection was not identified. He was treated with intravenous antibiotics. Blood cultures were negative following that therapy. However, during follow-up in clinic two weeks later, he was noted to have swelling, erythema and tenderness of the right sternoclavicular joint, leading to a readmission. Of note, the patient continued to smoke and consume an oral diet during this time, despite recommendations to adhere to gastric tube feeding due to clinical

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evidence of aspiration.

On admission, the patient had a temperature of 98.2F, heart rate of 103, and blood pressure of

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97/57 mmHg. His white blood cell count was 6.9, but blood cultures were positive for methicillin

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sensitive Staphylococcus aureus (MSSA) bacteremia. CT scans demonstrated erosive changes of the clavicular head and the adjacent portion of the sternum. In addition, a chest wall collection demonstrated

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an extensive air and fluid level and adjacent soft tissue swelling, extending into the right pectoralis

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major muscle (Fig. 1). A bone scan was also performed, which demonstrated increased metabolic activity in the right SCJ (Fig. 2).

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Drainage of the chest wall abscess was performed and in subsequent days, he underwent

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resection of the sternoclavicular joint. Intraoperatively, the joint space was seen to be extensively eroded and replaced with necrotic debris (Fig. 3). The sternal head and superior aspect of the manubrium were

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resected and a right pectoralis major flap was rotated into the joint space for tissue coverage (Fig. 3).

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Final pathology ruled out the presence of malignancy. The prior tracheostomy site was noted to be incompletely healed. The decision was made to formalize the tracheostomy to prevent communication between the sternoclavicular wound and the trachea. Negative pressure wound therapy was initiated to promote healing. Post-operatively, the surgical site demonstrated progressive healing, with gradual resolution of erythema and healthy granulation tissue. However, his course was complicated by worsening hepatic encephalopathy and

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ACCEPTED MANUSCRIPT cirrhosis. After several weeks of intensive treatment, he was placed on comfort care and ultimately succumbed.

3. Discussion To our knowledge, this is the first report of SCJ septic arthritis as a late-stage tracheostomy

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complication. Our patient did not have any other identifiable source of his sepsis nor other localized infection to explain the cause of his SCJ infection. Given the findings on CT of an air-filled tract leading

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from the prior tracheostomy to the infected joint, we presume this to be the underlying etiology of

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infection. Serious infection due to tracheostomy is extremely rare. A multi-institutional review of over 1000 tracheostomies reported infection, defined as tracheitis or wound infection, to be less than 1% of

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early and late-stage complications [5]. Another possible explanation is that the SCJ was seeded during

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his episodes of bacteremia in the month prior to clinical presentation. The patient’s prior history of radiation to the neck, malnutrition, continued oral diet despite clinical aspiration, and continued cigarette

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smoking may have been contributing factors to infection.

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SCJ infections typically present in an indolent or subacute fashion [6]. Symptomatic presentations of SCJ septic arthritis include chest pain localized to the joint, shoulder pain, reduced

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range of motion, redness and swelling of the local skin, and fever [1,3]. Leukocytosis is seen in a

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minority of all reported cases [7]. Given the tight, thick ligamentous encapsulation of the joint, joint distention due to an effusion is often seen late in the progression of the joint infection [1]. This may delay the presentation and diagnosis of SCJ septic arthritis. The most common associated factors of SCJ infection include intravenous drug use, diabetes, immunosuppression and distant infections [8,9]. Up to 67% of SCJ infections are due to Staphylococcus aureus while other responsible pathogens include Pseudomonas aeruginosa (10%), Brucella melitensis (9%), Escherichia coli (5%), and Mycobacterium tuberculosis (<5%) [1,3]. 5

ACCEPTED MANUSCRIPT CT or magnetic resonance imaging (MRI) should be performed to determine the extent of infection, inflammation, and bone destruction [10]. In addition, a bone scan can be helpful in distinguishing infection from degenerative joint changes. This requires a three-phase study in which the first two phases show hyperemia in cases of infection [11]; in our case, only a one-phase bone scan was performed. Further, the finding of joint space involvement on imaging can help to rule out bony

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metastasis, as this is rarely seen and is more indicative of infectious or degenerative changes [12,13]. Surgical management is indicated for septic arthritis of the SCJ. This involves en bloc joint

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resection and debridement followed by a pectoralis major transposition flap for coverage of the resultant

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defect [1,8,14,15]. While primary closure is feasible, open wound management with negative pressure wound therapy has shown to be a beneficial adjunct for continued egress of necrotic and infected

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material [9]. In their case series of 40 infected SCJ resections, Kachala et al. reported no difference in

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wound healing between primary closure or negative pressure wound therapy, and concluded open wound management to be preferable in patients with extensive comorbidities [16]. Ultimately, SCJ

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infection portends a poor prognosis. The infection is associated with a variety of complications ranging

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from chest wall abscesses and mediastinitis to bacteremia [3]. Reported mortality rates range between 4

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4. Conclusion

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and 23%, despite aggressive surgical treatment [1,8].

Septic arthritis of the SCJ is a rare but serious infection. This report outlines a unique case of SCJ infection as a late-stage complication of tracheostomy. Exam findings of sternoclavicular tenderness, erythema and fluctuance should initiate an expedited workup. Once diagnosed, septic arthritis of the SCJ should be promptly treated to prevent further morbidity and mortality.

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Acknowledgments We would like to acknowledge the Mount Sinai Health System and the THANC Foundation for their generous support of this research.

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ACCEPTED MANUSCRIPT References [1] Ross JJ, Shamsuddin H. Sternoclavicular septic arthritis: review of 180 cases. Medicine (Baltimore).

2004;83(3):139-148. [2] Tanaka Y, Kato H, Shirai K, et al. Sternoclavicular joint septic arthritis with chest wall abscess in a healthy adult: a case report. J Med Case Reports. 2016;10:69.

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[3] Murga A, Copeland H, Hargrove R, Wallen JM, Zaheer S. Treatment for sternoclavicular joint infections: a multi-institutional study. J Thorac Dis. 2017;9(6):1503-1508.

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[4] Kamath PS, Kim WR, Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD). Hepatol Baltim Md. 2007;45(3):797-805.

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[5] Halum SL, Ting JY, Plowman EK, et al. A multi-institutional analysis of tracheotomy complications. The Laryngoscope. 2012;122(1):38-45.

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[6] Yood RA, Goldenberg DL. Sternoclavicular joint arthritis. Arthritis Rheum. 1980;23(2):232-239.

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[7] Nusselt T, Klinger H-M, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch Orthop Trauma Surg. 2011;131(3):319-323.

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[8] Song HK, Guy TS, Kaiser LR, Shrager JB. Current presentation and optimal surgical management of sternoclavicular joint infections. Ann Thorac Surg. 2002;73(2):427-431.

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[9] Nguyen M, Moffatt-Bruce SD, Merritt RE, D’Souza DM. Clinical Effectiveness of Negative Pressure Wound Therapy Following Surgical Resection of Sternoclavicular Joint Infection: A Case Report. Cureus. 2016;8(10).

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[10] Carlos GN, Kesler KA, Coleman JJ, Broderick L, Turrentine MW, Brown JW. Aggressive surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg. 1997;113(2):242-247.

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[11] Kim EE, Haynie TP, Podoloff DA, Lowry PA, Harle TS. Radionuclide imaging in the evaluation of osteomyelitis and septic arthritis. Crit Rev Diagn Imaging. 1989;29(3):257-305.

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[12] Balestreri L, Canzonieri V, Innocente R, Cattelan A, Perin T. Temporomandibular joint metastasis from rectal carcinoma: CT findings before and after radiotherapy. A case report. Tumori. 1997;83(3):718-720. [13] Feki J, Bouzguenda R, Ayedi L, et al. Bone metastases from gastrointestinal stromal tumor: a case report. Case Rep Oncol Med. 2012;2012:509845. [14] Schipper P, Tieu BH. Acute Chest Wall Infections: Surgical Site Infections, Necrotizing Soft Tissue Infections, and Sternoclavicular Joint Infection. Thorac Surg Clin. 2017;27(2):73-86. [15] Burkhart HM, Deschamps C, Allen MS, Nichols FC, Miller DL, Pairolero PC. Surgical management of sternoclavicular joint infections. J Thorac Cardiovasc Surg. 2003;125(4):945-949. [16] Kachala SS, D’Souza DM, Teixeira-Johnson L, et al. Surgical Management of Sternoclavicular Joint Infections. Ann Thorac Surg. 2016;101(6):2155-2160. 8

ACCEPTED MANUSCRIPT Figure Captions

Figure 1. (A) Computed tomography (CT) scan demonstrating midline linear air (noted by arrows) tracking with surrounding soft tissue prominence at the level of the first tracheal ring and the prior tracheostomy tube, which was in communication with the right sternoclavicular joint. (B) CT scan

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demonstrating osteolysis of right clavicular head (thin arrow), in conjunction with diffuse surrounding

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soft tissue swelling with air pockets, extending to the right pectoralis major muscle (thick arrow).

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Figure 2. One-phase bone scan identifying uptake in the right sternoclavicular joint (arrow).

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Figure 3. Intraoperative photos demonstrating (A) necrosis of the right sternoclavicular joint, with erosion of the clavicular head (thick arrow) and of the manubrium (thin arrow). The instrument is placed

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beneath the clavicle with circumferential dissection prior to debridement. (B) The right pectoralis major

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pedicled flap was raised and used to provide coverage of the joint space following debridement.

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Figure 1

Figure 2

Figure 3