What is the management and treatment approach for sternal crepitus?

Management and Treatment of Sternal Crepitus

The management of sternal crepitus requires prompt surgical debridement and appropriate antibiotic therapy, with the specific approach determined by the underlying cause, most commonly osteomyelitis or soft tissue infection. 1

Diagnostic Approach

• Initial radiographs are the first-line imaging study for suspected sternal crepitus to detect soft tissue gas and bony abnormalities 1
• CT scan without contrast is recommended if radiographs show soft tissue gas, as it offers higher sensitivity for detecting the extent and compartmental location of gas 1
• MRI with contrast is the preferred imaging modality for suspected osteomyelitis to determine the extent of bone and soft tissue involvement 1
• Blood cultures and tissue/abscess cultures should be obtained to identify causative pathogens 1, 2

Treatment Based on Etiology

For Sternal Osteomyelitis

1. Surgical Management:

   • Surgical debridement of all necrotic tissue is strongly recommended 1, 2
   • For post-sternotomy infections, removal of infected steel wires is necessary 2, 3
   • In severe cases, partial or complete sternal resection may be required 3, 4
   • Vacuum-assisted closure (VAC) therapy may be beneficial for widespread infected subcutaneous tissue, though it may not be useful for treating the underlying osteomyelitis itself 2, 3

2. Antimicrobial Therapy:

   • For Candida sternal osteomyelitis:

     • Fluconazole 400 mg daily for at least 6 months OR an echinocandin (caspofungin 50-70 mg daily, micafungin 100 mg daily, or anidulafungin 100 mg daily) for 2 weeks followed by fluconazole for at least 4 months 1
     • Lipid formulation amphotericin B (3-5 mg/kg daily) for 2 weeks followed by fluconazole is an alternative option 1

   • For bacterial sternal osteomyelitis:

     • Empiric therapy should cover Staphylococcus aureus (including MRSA) with vancomycin until culture results are available 1, 5
     • For confirmed pathogens, targeted antibiotics should be administered for a minimum of 6 weeks, and up to 18 months for resistant organisms like coagulase-negative Staphylococcus or Corynebacterium species 2, 5

3. Reconstructive Options:

   • For extensive debridement, muscle flap reconstruction may be necessary 3, 4
   • Bilateral pectoralis major muscle flaps have shown effectiveness in managing sternal defects 3, 4
   • Omental flaps may be used alone or in combination with pectoralis flaps for larger defects 4

For Soft Tissue Infection with Crepitus

1. Surgical Management:

   • Prompt and aggressive surgical debridement of all necrotic tissue is essential 1
   • Incision and drainage of any abscess or collection 1, 5

2. Antimicrobial Therapy:

   • For necrotizing soft tissue infections:
     • Broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic organisms 1
     • Vancomycin plus an agent active against gram-negative bacilli is recommended for initial empirical therapy 1
     • Adjust antibiotics based on culture results 1

Special Considerations

• Patients with diabetes or immunocompromised status may require more aggressive surgical debridement and longer courses of antimicrobial therapy 1, 5
• Chronic sternal osteomyelitis may be treated successfully with prolonged antimicrobial therapy without mandatory surgical resection in select cases, provided that accurate microbiological and radiological studies are performed 2
• Post-sternotomy infections require careful evaluation of sternal stability; rigid sternal fixation may be beneficial in some cases to improve healing and reduce complications 1

Follow-up and Monitoring

• Regular clinical assessment for signs of persistent infection (pain, erythema, drainage) 2, 3
• Serial imaging (CT or MRI) may be necessary to evaluate treatment response in cases of osteomyelitis 1, 2
• For patients with implanted hardware, long-term suppressive antibiotics may be required if complete removal is not possible 1

Common Pitfalls to Avoid

• Inadequate debridement is a common cause of treatment failure; ensure all necrotic tissue is removed 3, 4
• Premature discontinuation of antibiotics can lead to relapse, especially with resistant organisms 2
• Failure to identify and address underlying risk factors (diabetes, malnutrition, immunosuppression) may lead to poor outcomes 1, 5
• Overlooking the possibility of polymicrobial infection; cultures should be taken before starting antibiotics 1, 2