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DOI: 10.1055/s-0042-1743167
An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience
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Abstract
Background Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.
Methods A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.
Results One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5–15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).
Conclusion Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.
Authors' Contribution
All authors contributed to the conception of the project, data collection, data analysis, and manuscript preparation.
Publikationsverlauf
Eingereicht: 21. September 2021
Angenommen: 27. Dezember 2021
Artikel online veröffentlicht:
04. März 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
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References
- 1 Milton H. Mediastinal surgery. Lancet 1897; 1: 872-875
- 2 Salehi Omran A, Karimi A, Ahmadi SH. et al. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality. BMC Infect Dis 2007; 7: 112
- 3 Floros P, Sawhney R, Vrtik M. et al. Risk factors and management approach for deep sternal wound infection after cardiac surgery at a tertiary medical centre. Heart Lung Circ 2011; 20 (11) 712-717
- 4 Sears ED, Wu L, Waljee JF, Momoh AO, Zhong L, Chung KC. The impact of deep sternal wound infection on mortality and resource utilization: a population-based study. World J Surg 2016; 40 (11) 2673-2680
- 5 Kubota H, Miyata H, Motomura N. et al. Deep sternal wound infection after cardiac surgery. J Cardiothorac Surg 2013; 8: 132
- 6 Biancari F, Gatti G, Rosato S. et al. Preoperative risk stratification of deep sternal wound infection after coronary surgery. Infect Control Hosp Epidemiol 2020; 41 (04) 444-451
- 7 Gummert JF, Barten MJ, Hans C. et al. Mediastinitis and cardiac surgery–an updated risk factor analysis in 10,373 consecutive adult patients. Thorac Cardiovasc Surg 2002; 50 (02) 87-91
- 8 Ohira S, Miyata H, Yamazaki S. et al. Deep sternal wound infection after bilateral internal thoracic artery grafting: insights from a Japanese national database. J Thorac Cardiovasc Surg 2019; 157 (01) 166-173.e1
- 9 Loop FD, Lytle BW, Cosgrove DM. et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990; 49 (02) 179-186 , discussion 186–187
- 10 Nahai F, Rand RP, Hester TR, Bostwick III J, Jurkiewicz MJ. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg 1989; 84 (03) 434-441
- 11 Spiess AM, Balakrishnan C, Gursel E. Fascial release of the pectoralis major: a technique used in pectoralis major muscle closure of the mediastinum in cases of mediastinitis. Plast Reconstr Surg 2007; 119 (02) 573-577
- 12 Nazerali RS, Hinchcliff K, Wong MS. Rigid fixation for the prevention and treatment of sternal complications. Ann Plast Surg 2014; 72 (Suppl. 01) S27-S30
- 13 Fawzy H, Alhodaib N, Mazer CD. et al. Sternal plating for primary and secondary sternal closure; can it improve sternal stability?. J Cardiothorac Surg 2009; 4 (01) 19
- 14 Golosow LM, Wagner JD, Feeley M. et al. Risk factors for predicting surgical salvage of sternal wound-healing complications. Ann Plast Surg 1999; 43 (01) 30-35
- 15 Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis. Eur J Cardiothorac Surg 2004; 26 (02) 367-372
- 16 Park JS, Kuo JH, Young JN, Wong MS. Rigid sternal fixation versus modified wire technique for poststernotomy closures: a retrospective cost analysis. Ann Plast Surg 2017; 78 (05) 537-542
- 17 Thorsteinsson K, Fonager K, Mérie C. et al. Age-dependent trends in postoperative mortality and preoperative comorbidity in isolated coronary artery bypass surgery: a nationwide study. Eur J Cardiothorac Surg 2016; 49 (02) 391-397
- 18 Bakri K, Mardini S, Evans KK, Carlsen BT, Arnold PG. Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps. Semin Plast Surg 2011; 25 (01) 43-54
- 19 Piwnica-Worms W, Azoury SC, Kozak G. et al. Flap reconstruction for deep sternal wound infections: factors influencing morbidity and mortality. Ann Thorac Surg 2020; 109 (05) 1584-1590
- 20 Greig AV, Geh JL, Khanduja V, Shibu M. Choice of flap for the management of deep sternal wound infection–an anatomical classification. J Plast Reconstr Aesthet Surg 2007; 60 (04) 372-378
- 21 Weinand C, Xu W, Perbix W, Theodorou P, Lefering R, Spilker G. Deep sternal osteomyelitis: an algorithm for reconstruction based on wound width. J Plast Surg Hand Surg 2013; 47 (05) 355-362
- 22 Schulman NH, Subramanian V. Sternal wound reconstruction: 252 consecutive cases. The Lenox Hill experience. Plast Reconstr Surg 2004; 114 (01) 44-48
- 23 Kaye AE, Kaye AJ, Pahk B, McKenna ML, Low DW. Sternal wound reconstruction: management in different cardiac populations. Ann Plast Surg 2010; 64 (05) 658-666
- 24 Levy AS, Ascherman JA. Sternal wound reconstruction made simple. Plast Reconstr Surg Glob Open 2019; 7 (11) e2488
- 25 Schimmer C, Reents W, Berneder S. et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial. Ann Thorac Surg 2008; 86 (06) 1897-1904
- 26 Goh SSC. Post-sternotomy mediastinitis in the modern era. J Card Surg 2017; 32 (09) 556-566
- 27 Schiraldi L, Jabbour G, Centofanti P. et al. Deep sternal wound infections: evidence for prevention, treatment, and reconstructive surgery. Arch Plast Surg 2019; 46 (04) 291-302
- 28 Wu LC, Renucci JD, Song DH. Sternal nonunion: a review of current treatments and a new method of rigid fixation. Ann Plast Surg 2005; 54 (01) 55-58
- 29 Vos RJ, Jongbloed L, Sonker U, Kloppenburg GTL. Titanium plate fixation versus conventional closure for sternal dehiscence after cardiac surgery. Thorac Cardiovasc Surg 2017; 65 (04) 338-342
- 30 Voss B, Bauernschmitt R, Will A. et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence. Eur J Cardiothorac Surg 2008; 34 (01) 139-145
- 31 Huh J, Bakaeen F, Chu D, Wall Jr MJ. Transverse sternal plating in secondary sternal reconstruction. J Thorac Cardiovasc Surg 2008; 136 (06) 1476-1480
- 32 Cicilioni Jr OJ, Stieg III FH, Papanicolaou G. Sternal wound reconstruction with transverse plate fixation. Plast Reconstr Surg 2005; 115 (05) 1297-1303