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Page 2 of 6 Schreiner et al. Plast Aesthet Res 2018;5:32 I http://dx.doi.org/10.20517/2347-9264.2018.45

INTRODUCTION
Sternoclavicular joint (SCJ) infections represent 1% of all septic joints in the general population and less than
[1]
4% of them occur in patients with liver cirrhosis . The surgical treatment ranges from simple joint incision
and drainage to radical joint resection. However, there are no clearly defined surgical principles of the SCJ
infections management. The liver cirrhosis has been identified as a risk factor for severe SCJ infections that
[2]
significantly increases perioperative mortality . Therefore, in patients with liver insufficiency, the choice of
the surgery must be adjusted to the reduced patient condition, expected higher perioperative morbidity and
advanced stage of the disease. However, it should consequently follow the principles of the septic surgery.
We present our multidisciplinary experience with the staged surgical management of severe SCJ in high-risk
patients, performed by the thoracic and plastic-reconstructive surgeons.

METHODS
From February 2008 to May 2018 six patients with liver insufficiency were admitted to our hospital due to
SCJ infections manifested by erythema and swelling over the SCJ area as well as shoulder pain aggravated by
movement. Initial diagnostics included the joint aspiration, chest and neck computed tomography (CT) and
standard blood tests. The first stage surgery included a J-shaped incision from the medial supraclavicular re-
gion, through the SCJ, to the median sternal line at the level of the second intercostal space. After extended
debridement and necrectomy the negative pressure therapy (NPT) was started with 75 mmHg and gradually
increased to 125 mmHg. During subsequent operations, the bone viability and the extent of osteomyelitis
were assessed and tissue biopsies for microbiological analysis were taken regularly until definitive wound
closure. The intravenous antibiotic therapy was commenced due to the general anaesthesiology after taking
the blood culture probes, modified according to the antibiogram and continued for 4 weeks after the hospital
discharge.

Thanks to thoracic surgeons, “en bloc” resection of the SCJ including the hemi-manubrium, the middle 1/3 of
the clavicle as well as affected first and/or second rib was performed. Thereafter the NPT was continued for
2-3 weeks and the vacuum system exchanged every 3-5 days until wound granulation of tissue was formed.
Afterwards, the chest wall defects were covered due to the plastic surgeons with the pedicled muscle or mus-
culocutaneous flap involving chest wall musculature from the contralateral side [Figure 1].

RESULTS
The patient characteristics and clinical features are summarized in Table 1. All 6 patients were male at the
age of 58 ± 10 years [range 45-72] suffering from alcohol related Child B or Child C liver cirrhosis with the
[3]
median model of end stage liver disease score of 11.5 [range 9-16] . The chest-CT showed the destruction of
the SCJ and the neighbouring ribs with the soft tissue gangrene in 5 patients, and the chest wall abscess in
all patients. Inflammatory mediastinal mass and chest wall phlegmon was noted in 4 and 3 patients, respec-
tively. Osteomyelitis was histologically proven in all patients [Figure 2]. According to the SCJI classification
[4]
of Abu Arab et al. , grade IV and V extent was noted in 2 and 4 patients, respectively. One patient died on
the 5th postoperative day due to cerebral septic embolism and aortic endocarditis. Four patients underwent
successful chest wall defect coverage with the contralateral PMF [Figure 3], in 1 patient delayed wound clo-
sure was possible without PMF transposition. The surgical revision was necessary in 1 patient due to severe
bleeding and 1 patient required tracheotomy for prolonged ventilation case. The intraoperative blood loss at
the initial operation was 350 ± 180 mL. During the postoperative course 18 ± 14.8 erythrocyte concentrates,
16.3 ± 18.1 fresh frozen plasma concentrates and 1.5 ± 0.7 thrombocyte concentrates were transfused. The
average NPT duration was 22 ± 9 days and the average length of hospital stay was 35 ± 21 days. The average
follow-up time and disease-free interval were in 5 survivors 24 ± 18 months.