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Page 4 of 6 Schreiner et al. Plast Aesthet Res 2018;5:32 I http://dx.doi.org/10.20517/2347-9264.2018.45

Table 1. Perioperative patient characteristics
MELD- Bact. cul- NPT Bact. cul-
Pat. Age Sex Child class score tures duration tures after PMF Complications 30-day Follow
of cirrhosis mortality up
(points) Before NPT (day) NPT
1 58 M Child C 12 E. coli 22 No Yes Revision for No 43
bleeding
2 68 M Child C 7 E. coli 3 E. coli No Septic cerebral Yes
embolism
3 50 M Child B 10 Staph. aureus 24 No No No 32
4 45 M Child B 9 E. coli 32 No Yes Respiratory No 30
insufficiency and
tracheostomy
5 58 M Child B 15 Streptococcus 25 No Yes No 36
pneumoniae
6 72 M Child C 16 Staph. aureus 24 No Yes No 2
MELD: model of end stage liver disease; NPT: negative pressure therapy; PMF: pectoralis muscle flap

the extensive spread of infection to the surrounding mediastinal structures at the time of diagnosis, which
[2,5]
is usually delayed . There is no standardized treatment strategy for septic SCJ arthritis. Various surgical
options including intravenous antibiotic therapy, SCJ incision with open drainage and secondary wound
healing, radical joint resection with or without NPT combined with muscle flap transposition have been
reported. The open drainage requires prolonged wound care up to 3 months and is associated with the fail-
[6]
ure rate of up to 80% . Therefore, simple incision and drainage appears insufficient in those patients with
a severe septic arthritis, sternal and clavicular osteomyelitis with mediastinal involvement. On the other
hand, the complication rates of the radical joint resection and immediate obliteration of the chest wall defect
[7]
with pectoralis flap have been reported even as high as 50% . This aggressive surgery in the acute infection
phase can further increase the perioperative morbidity in patients with liver dysfunction associated immu-
nosuppression and coagulopathy. In our opinion, the surgery has to be adapted to the patient condition and
estimated perioperative risk, tissue quality and systemic infection control. The favoured surgical manage-
ment has to reduce the operative trauma in compliance with the traditional principles of the wound man-
[8]
agement . We recommend the NPT as an effective addition for the surgical wound debridement. The NPT
application has been widely used in acute, subacute and chronic wounds. It enables better infection control
by improving the blood flow, accelerating the tissue granulation and reducing bacterial colonization in the
[8,9]
wound . The accelerated bacterial clearance is, in our opinion, the main advantage in the acute infection
phase in patients with compromised liver function. In our patient group the chest wall resection was adapted
to the extent of bone destruction, extent of the osteomyelitis and included the hemimanubrium (n = 6), first
(n = 5) and second rib (n = 3). Our radical SCJ resections resulted in a large chest wall defect according to
[10]
classification of Joethy et al, reflecting a regularly wide infection in patients with liver insufficiency . Sub-
sequent radical joint resection has been reported adequate for the patients with extended disease [11,12] . In our
opinion, the adequate assessment of the bone viability and the osteomyelitis extent is of key relevance in the
treatment of SCJ infections. The postponed bone resection thanks to NPT allows to better assess the bone
[13]
viability and to define the resection extent, particularly in severe infections .

Chest wall defect coverage with the pedicled muscle or musculocutaneous flap has been the preferred tech-
nique. For the complete filling of the residual space, protective coverage of the exposed brachiocephalic ves-
sels and preservation of neurovascular integrity in the upper extremity the pectoral muscle has commonly
[11]
been accepted . Some authors provided the vascularized muscle flap an additional anti-inflammatory effect
[13]
due to the direct antibiotic delivery to the infection site once the flap is in place . The novel technique of
[14]
the large bone defect obliteration with engineered bone tissue is a challenge in the reconstructive surgery .
Extended SCJ infection and associated massive inflammatory process usually affect the ipsilateral chest wall
musculature precluding its application as the defect coverage. The transposition of the unimpaired contra-