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PubMed1995

Bronchial rupture caused by blunt chest injury.

We have surgically treated six patients with bronchial rupture caused by blunt chest injury in the past 5 years. All injuries resulted from traffic accidents, except in one patient who was hit by a crane. Clinical manifestations included chest pain (n = 6), subcutaneous emphysema (n = 4), and dyspnea (n = 6). Roentgenographic findings were tension (n = 3) or nontension (n = 3) pneumothorax, subcutaneous emphysema (n = 4), pneumomediastinum (n = 3), deep cervical emphysema (n = 5), and delayed collapse of the affected lung (n = 3). Three patients had associated injuries: right clavicle and rib fractures in the first; right humeral, scapular, and multiple rib fractures and left sternoclavicular joint dislocation in the second; and left clavicle fracture in the third. These six patients all underwent immediate tube thoracostomy and then bronchoplasty. Bronchoplasty was performed within 3 days in four patients and on days 16 and 30, respectively, in the other two patients. The affected lung demonstrated full expansion in all patients immediately after bronchoplasty. Follow-up bronchoscopy showed good patency of all bronchi.

Accidents, Traffic↗
PubMed1998

A new surgical approach to the innominate and subclavian vein.

A new technique extending the incision used for thoracic outlet decompression with a subclavicular approach to the first rib is presented. After the first rib and scalenotomy are removed, the subclavicular incision is continued into the sternum medially and superiorly to the sternal notch. This gives easy access to the innominate-subclavian-axillary vein segment. Eight patients with extensive chronic fibrotic obstruction of the subclavian-innominate vein segment underwent operation with this technique. It allows placement of either long patches of saphenous vein to reestablish normal caliber or replacement, as is our choice, with a small-sized cryopreserved descending thoracic aortic homograft. The operation is carried out in an extrapleural plane preserving the sternoclavicular joint, avoiding the deformity caused by transclavicular techniques. Repair of the sternotomy creates a stable incision. Follow-up to 14 months shows patency of the venous channel with no complications. This surgical approach is recommended to solve the problem of satisfactory exposure of the subclavian-innominate venous channel after decompression of the thoracic outlet.

Adolescent↗
PubMedDate not supplied

A safe zone for resection of the medial end of the clavicle.

Medial clavicle resection is indicated when symptoms of sternoclavicular instability or degeneration remain disabling despite nonoperative management. Preservation or reconstruction of the costoclavicular ligament (rhomboid ligament) is essential to prevent subsequent instability of the remainder of the medial clavicle. Eighty-six cadaveric sternoclavicular joints were dissected to determine the distance (safe resection length [SRL]) from the inferior articular surface of the medial end of the clavicle to the most medial insertion of the costoclavicular ligament (rhomboid ligament). The mean SRL was 1.2 +/- 0.3 cm in men and 1.0 +/- 0.2 cm in women. Resection of 1.0 cm of the medial clavicle would result in no or minimal disruption of the costoclavicular ligament in 84% of men, and resection of 0.9 cm of the medial clavicle would result in no or minimal disruption of the costoclavicular ligament in 89% of women. We recommend that these amounts be used as a guide to safe resection of the medial clavicle but that the costoclavicular ligament be exposed to allow certainty of preservation.

Aged↗
PubMed2003

Effect of carotid bifurcation location on the length of internal carotid disease.

BACKGROUND: A relationship between the height of the carotid bifurcation and the extent of disease in the internal carotid artery has not been reported. The aim of the present study was to determine if such a correlation exists. METHODS: Fifty-one patients undergoing carotid endarterectomy had measurements made of the height of the carotid bifurcation from the sternoclavicular joint. The length of disease removed distal to the bifurcation after carotid endarterectomy was also measured. Correlation analysis was performed. RESULTS: There is a statistically significant negative correlation between the extent of disease in the internal carotid artery and the height of the bifurcation. CONCLUSIONS: A low carotid bifurcation correlates with a longer extent of disease in the internal carotid artery.

Body Weights and Measures↗
PubMed1999

Histological characteristics of sternoclavicular beta 2-microglobulin amyloidosis and clues for its histogenesis.

BACKGROUND: The pathogenesis of beta 2-microglobulin amyloidosis (A beta 2m) has yet to be fully elucidated. METHODS: We describe the distribution and extent of A beta 2m deposition and macrophagic infiltration in cartilage, capsule, and synovium of sternoclavicular joints obtained postmortem from 54 patients after 3 to 244 (median 46) months of dialysis. Twenty-four nonuremic patients served as a control group. The diagnosis of amyloidosis (A) rested on a positive Congo Red staining (typical birefringence) and that of A beta 2m on positive immunostaining of the A deposits with a monoclonal anti-beta 2m antibody. The size of A deposits was measured. RESULTS: A beta 2m was detected in 32 (59%), and non-beta 2m amyloid (Anon beta 2m) was detected in an additional 8 (15%) of the 54 dialyzed patients. A beta 2m deposits were present in the cartilage of all A beta 2m (+) patients (100%). They were localized solely in the cartilage in 27% of the cases, either as a thin patchy layer or as a continuous thicker layer (identified as stage I). A beta 2m was additionally present in the capsule and/or synovium without macrophages in 27% of the cases (identified as stage II). The correlation between the size of cartilaginous deposits and dialysis duration (P = 0.02) as well as with the prevalence (P = 0.03) and size of capsular deposits (P = 0.02) suggests that stage II is a later stage of A deposition. Clusters of macrophages were detected around capsular and synovial amyloid deposits in 46% of the cases (identified as stage III). The longer duration of dialysis in those with stage III as well as the relationship between the size of the A beta 2m deposits and the prevalence of macrophagic infiltration suggests that stage III is the last stage of A beta 2m deposition. Marginal bone erosions were observed in 9 out of 12 patients with stage III deposits. Their size was correlated with that of cartilaginous deposits (P = 0.01). Among the 24 control patients, Anon beta 2m was detected in 12 patients (cartilage 100%, capsule 8%, synovium 30%). CONCLUSIONS: The earliest stage of A beta 2m deposition occurs in the cartilage. A beta 2m subsequently extends to capsule and synovium. These two first stages do not require macrophage infiltration. Macrophages are eventually recruited around larger synovial or capsular deposits in the final stage. Marginal bone erosions develop in this late stage.

Adolescent↗
PubMed2001

Acne with chronic recurrent multifocal osteomyelitis involving the mandible as part of the SAPHO syndrome: case report.

For 12 years, a 26-year-old man had acne conglobata and a non-suppurative diffuse sclerosing osteomyelitis of the mandible as part of a chronic recurrent multifocal osteomyelitis of the sternum, the pelvic bones, and the femoral head, and aseptic arthritis of the knee, the fibulotalar, and the sternoclavicular joints. This fulfills the formal criteria of the SAPHO syndrome. Repeated surgical and antibiotic treatment combined with hyperbaric oxygen caused partial improvement. Complete relief and partial disappearance of the scintigraphic lesions was achieved with long-term corticosteroids, non-steroidal anti-inflammatory drugs, minocycline, and isotretinoin.

Acne Vulgaris↗
PubMed1999

[Vertebral destruction with sever pain in the SAPHO syndrome].

HISTORY AND ADMISSION FINDINGS: A 57-year-old man had for the past 18 months complained of recurrent, recently worsening, belt-like backache radiating ventrally. On admission a skin rash consisting of blister and pustules was noted on the palms of both hands. He had pain on pressure over the right upper abdomen, an enlarged prostate and definite pain on percussing the vertebral column with restricted movement of the thoracic vertebral column, but no other physical signs. INVESTIGATIONS: Radiology revealed clearly increased sclerosis of several thoracic vertebrae with osteolytic destruction and a paravertebral soft tissue tumor. Search for a primary tumor was unsuccessful. Bone scintigraphy demonstrated nuclide enrichment of the thoracic vertebrae and of the sternoclavicular joints without increase in the LeukoScan. These findings indicated the diagnosis of SAPHO syndrome (synovitis-acne-pustulosis-hyperostosis-osteomyelitis). TREATMENT AND COURSE: Rapid subjective and objective improvement followed the administration of clindamycin and ibuprofen. CONCLUSION: In case of bone pain of uncertain aetiology, especially when associated with skin rash, the rare SAPHO syndrome should be considered in the differential diagnosis, avoiding lengthy diagnostic steps and allowing early treatment.

Acquired Hyperostosis Syndrome↗
PubMed2002

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis.

OBJECTIVE: Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. METHODS: Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). RESULTS: Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. CONCLUSION: We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

Aged↗
PubMed1998

Arthralgias following dilation and curettage.

A 36-year-old woman presented to the emergency department with right hip pain of one week's duration. An x-ray of the hip was unremarkable. She was diagnosed with trochanteric bursitis, given ibuprofen (800 mg tid) and crutches, and sent home. The next day, continual pain and progressive functional impairment prompted her to see an orthopedist. He concurred with the initial diagnosis and administered a corticosteroid injection into the right trochanteric bursa. Propoxyphene (65 mg q4h prn) was added to her medical regimen, and she was again sent home. Pain developed in the right sacroiliac area the next day. Within 24 hours, the right shoulder and right sternoclavicular joint were also involved, and the patient began having subjective fever and chilliness. She returned to the orthopedist and was immediately referred to a rheumatologist who ordered blood cultures and admitted her to the hospital.

Adult↗
PubMed1992

Streptobacillus moniliformis endocarditis: case report and review.

A 46-year-old man with rat-bite fever due to Streptobacillus moniliformis that was complicated by endocarditis is reported. Other unusual features of this case include septic arthritis with prominent involvement of the sternoclavicular joint and the absence of a rash. Sixteen cases of streptobacillary endocarditis have previously been described. This condition occurs most often in the setting of previously damaged heart valves, usually as a result of rheumatic heart disease. Echocardiography demonstrated valvular vegetations in two of the four cases in which it was performed. Embolic phenomena are rare, and therapy with adequate doses of penicillin is usually curative.

Animals↗
PubMed1999

SAPHO syndrome or psoriatic arthritis? A familial case study.

OBJECTIVE: To discuss the relationships between SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) syndrome and the group of spondylarthropathies. METHODS: Few reports of familial SAPHO have been published. We describe three children, two sisters and one brother, whose clinical and radiological presentation was in accordance with SAPHO syndrome. RESULTS: Two children developed psoriasis, and one child palmoplantar pustulosis. Both sacroiliac and sternoclavicular joints were involved in these three cases. Some features in our observations are also common to psoriatic arthritis. No association was found with HLA antigens, but a history of trauma preceding the onset of symptoms was present in all three children. CONCLUSIONS: We can consider that SAPHO is nosologically related to spondylarthropathies. Psoriatic arthritis could be the missing link between SAPHO and spondylarthropathies. It is likely that both genetic and environmental factors are involved.

Acquired Hyperostosis Syndrome↗
PubMed2004

SAPHO syndrome treated with pamidronate: an open-label study of 10 patients.

BACKGROUND: In recent years the SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) has been encountered more frequently. However, clinical evidence indicating superiority of a specific therapeutic modality is still absent. Pamidronate, a second-generation bisphosphonate, has a pronounced effect on bone metabolism by suppressing bone resorption. We report our clinical experience with intravenous pamidronate in SAPHO syndrome. METHODS: Between the years 1999 and 2003 we treated 10 patients with the SAPHO syndrome who did not respond to NSAIDs, oral corticosteroids, colchicine, methotrexate, sulphasalazine or infliximab. All patients were treated with 60 mg pamidronate, given intravenously within an hour. In cases of no response a subsequent dose was given within a month and if there was a partial response an additional infusion was given after 4 months. The primary endpoint was the disappearance of recurrent bouts of bone pain, osteitis or hyperostosis, or recurrent synovitis. Reduction of the frequency of attacks by 50% was regarded as a partial response. RESULTS: Seven of the patients were females and three were males. The age at diagnosis ranged from 26 to 68 yr. All patients had axial or peripheral arthritis and cutaneous involvement; three had severe acne, eight had pustulosis and two had concomitant psoriasis vulgaris. Hyperostosis of the anterior chest wall involving either sternocostal or sternoclavicular joints, as seen on technetium 99 bone scintigraphy, was detected in all patients. Complete remission was observed following therapy in six patients, three others partially responded and only one patient had no response. Two patients needed four cycles of pamidronate infusion, one patient needed three, six needed two infusions and one patient remitted following a single pamidronate infusion. In all but one patient pamidronate was effective in preventing recurrent bouts of pustulosis. CONCLUSION: Pamidronate seems to be a very effective mode of therapy for patients with the SAPHO syndrome, by promoting remission in all components of the disorder, such as bone, joint and skin involvement, and ceases the bouts that characterize this disorder.

Acquired Hyperostosis Syndrome↗
PubMed1978

Is the anterior bone scan necessary in the diagnosis of osseous metastases?

Bone imaging studies of 1650 patients with known or strongly suspected extraosseous malignancies were reviewed to determine whether a completely negative posterior view was sufficient to exclude metastatic disease. Of 708 negative posterior images, 27 (3.4%) were positive for metastasis on anterior views. All of the anterior lesions were in the sternium, sternoclavicular joints and first four ribs. When the posterior view is positive, further views may be unnecessary. Negative or equivocal posterior images necessitate anterior views of the thoracic cage.

Bone Neoplasms↗
PubMedDate not supplied

Tuberculosis of the chest wall: CT findings.

To assess the CT features of tuberculosis of the chest wall, the CT findings in four patients with documented tuberculous chest wall infection were reviewed. Two patients were Caucasian and two were of Chinese origin. All had normal immune status. In two cases tuberculosis involved the ribs, in one the costal cartilage, and in one the sternoclavicular joint. Computed tomography demonstrated osseous and cartilaginous destruction (in four), soft tissue masses with calcification (in two), and rim enhancement following intravenous contrast medium administration (in two). Underlying pleuroparenchymal tuberculosis was present in two cases. Tuberculosis of the chest wall is characterized by bone or costal cartilage destruction and soft tissue masses that may demonstrate calcification or rim enhancement with or without evidence of underlying lung or pleural disease.

Adult↗
PubMed1979

Traumatic forequarter amputation: case report.

Traumatic forequarter amputation is rare and extremely mutilating. A 21-year-old male factory worker who sustained a traumatic shoulder girdle amputation is described. The injury mechanism was traction from the machine's force combined with the compressive force on the sternoclavicular joint. The factors leading to survival from this injury include rapid transportation, prompt and effective resuscitation, including treatment of shock, and adequate surgical management. Recognition of the complications associated with retrosternoclavicular dislocation is emphasized.

Accidents, Occupational↗
PubMed2003

Radical excision in the management of thoracic and cervicothoracic tumors involving the spine: results in a series of 36 cases.

STUDY DESIGN: A new surgical technique for en bloc resection of posterior mediastinum tumors invading the spine is described. OBJECTIVE: To demonstrate that major soft tissue tumors of the thoracic apex (Pancoast Tobias syndrome) or posterior mediastinum tumors can be removed en bloc even though the vertebral body or the foramina are invaded. SUMMARY OF BACKGROUND DATA: En bloc surgery of tumor is accepted today as being the goal of carcinologic surgery with the best results for survival. Until now, no surgical technique has been described for radical excision of soft tissue tumors invading the thoracic spine adjacent to the ribs and lung. We reviewed our 8 years' experience of 36 such cases and report outcome and survival rates. METHOD: The authors have joined their abilities and technique to enable complete en bloc extratumoral resections of lung tumors or posterior mediastinum tumors invading the adjacent soft tissue and spine. The surgical technique recommended by the authors is different at the cervicothoracic and medium thoracic level. At the cervicothoracic level, the authors first perform an anterior approach with dislocation of the sternoclavicular joint and dissection of the subclavian vessels with exposure of the brachial plexus. Dissection of the tumor from the anterior soft tissues is then performed but is kept attached to the adjacent spine. Dissection of lung hilum and its division are done through the same approach. At the thoracic level, the authors perform a posterior lateral thoracotomy for dissection of lung hilum and division of its elements. The lung and the adjacent tumoral ribs are not removed but are carefully kept undissected against the spine. Thoracoscopy can replace the open thoracotomy in small and medium-sized tumors. En bloc extratumoral resection is the second step performed through a median posterior cervicothoracic or thoracic approach. Vertebrectomy is complete or partial depending on the type of extension against or inside the vertebrae. RESULTS: Thirty-six cases have been operated on with this technique. Vertebrectomy was complete in seven cases and partial in 29. Follow-up ranges from 6 days to 7.2 years (average, 23.3 months). One patient died 1 year postoperatively from an unrelated cause. Only 35 patients are available for follow-up analysis. Twenty-one patients (60%) are dead, with an average survival of 16.7 months 8 days to 44 months. The 14 others (40%) are alive (average, 38.26 months; range, 8-87 months). CONCLUSIONS: Even though a learning curve is necessary to achieve this extreme type of surgery, selective preoperative screening of patients is mandatory. Interesting results today confirm the feasibility of possible treatment of tumors still considered unresectable.

Adolescent↗