Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience

Abstract

Background Adequate treatment of deep sternal wound infections (DSWIs) after open thoracic surgery still presents a major challenge. This study retrospectively analyzes the results of a single center's 12-year experience in treating DSWI, with special emphasis on free flap reconstruction.

Methods In this single-center, retrospective study, all patients admitted with the diagnosis of DSWI after open thoracic surgery between 2009 and 2020 were included. A comparative analysis was performed between: (1) pedicled versus free flaps, (2) the center's two workhorse flaps—the pedicled latissimus dorsi (pLD) versus free anterolateral thigh (fALT) flaps, as well as (3) myocutaneous (MC) versus fasciocutaneous (FC) flaps. Primary endpoints were length of hospital stay (LOS) after reconstruction and in-hospital mortality.

Results Of a total of 165 patients included, 152 underwent DSWI defect reconstruction with a total of 12 different reconstruction methods. Although the defect size was larger in patients who underwent free flap coverage, and the risk profile in the fALT and FC flap groups was higher, the LOS after reconstruction (in days) did not differ significantly between the groups (pedicled vs. free flaps: 23 vs. 28, p > 0.05; pLD vs. fALT: 24.5 vs. 26, p > 0.05; MC vs. FC flaps: 23 vs. 26, p > 0.05). Also, no significant differences were found in terms of in-hospital mortality when comparing the groups (pedicled vs. free flaps: 11.2 vs. 17.4%, p > 0.05; pLD vs. fALT: 11.5 vs. 12.5%, p > 0.05; MC vs. FC flaps: 12.9 vs. 12.5%, p > 0.05).

Conclusion With proper patient selection, free tissue transfer is a valuable alternative in the treatment of sternal dehiscence after a DSWI. Furthermore, our data demonstrate that MC flaps are not necessarily superior to FC flaps in the reconstruction of sternal osteomyelitis defects.

Keywords

deep sternal wound infection - sternal osteomyelitis - sternal dehiscence - free flap reconstruction - chest wall reconstruction - wound infection

Publikationsverlauf

Eingereicht: 26. Juni 2022

Angenommen: 30. November 2022

Artikel online veröffentlicht:
24. Januar 2023

• References

• 1 Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996; 111 (06) 1200-1207
• 2 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999; 27 (02) 97-132 , quiz 133–134, discussion 96
• 3 Breyer RH, Mills SA, Hudspeth AS, Johnston FR, Cordell AR. A prospective study of sternal wound complications. Ann Thorac Surg 1984; 37 (05) 412-416
• 4 Bryant LR, Spencer FC, Trinkle JK. Treatment of median sternotomy infection by mediastinal irrigation with an antibiotic solution. Ann Surg 1969; 169 (06) 914-920
• 5 Scully HE, Leclerc Y, Martin RD. et al. Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J Thorac Cardiovasc Surg 1985; 90 (04) 523-531
• 6 Luckraz H, Murphy F, Bryant S, Charman SC, Ritchie AJ. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg 2003; 125 (02) 301-305
• 7 Domkowski PW, Smith ML, Gonyon Jr DL. et al. Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis. J Thorac Cardiovasc Surg 2003; 126 (02) 386-390
• 8 Jurkiewicz MJ, Bostwick III J, Hester TR, Bishop JB, Craver J. Infected median sternotomy wound. Successful treatment by muscle flaps. Ann Surg 1980; 191 (06) 738-744
• 9 Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg 1984; 88 (03) 357-364
• 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 Jones G, Jurkiewicz MJ, Bostwick J. et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997; 225 (06) 766-776 , discussion 776–778
• 12 Landes G, Harris PG, Sampalis JS. et al. Outcomes in the management of sternal dehiscence by plastic surgery: a ten-year review in one university center. Ann Plast Surg 2007; 59 (06) 659-666
• 13 Lemaignen A, Birgand G, Ghodhbane W. et al. Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation. Clin Microbiol Infect 2015; 21 (07) 674.e11-674.e18
• 14 Li Y-H, Zheng Z, Yang J. et al. Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: a retrospective case series. Medicine (Baltimore) 2017; 96 (16) e6391-e6395
• 15 Spindler N, Kade S, Spiegl U. et al. Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall. BMC Surg 2019; 19 (01) 173
• 16 Weinzweig N, Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg 1995; 34 (05) 471-477
• 17 Kolbenschlag J, Hörner C, Sogorski A. et al. Sternal reconstruction with the omental flap-acute and late complications, predictors of mortality, and quality of life. J Reconstr Microsurg 2018; 34 (05) 376-382
• 18 Levy AS, Ascherman JA. Sternal wound reconstruction made simple. Plast Reconstr Surg Glob Open 2019; 7 (11) e2488-e6
• 19 Dornseifer U, Kleeberger C, Ehrl D, Herter F, Ninkovic M, Iesalnieks I. Arteriovenous loop-independent free flap reconstruction of sternal defects after cardiac surgery. J Reconstr Microsurg 2016; 32 (07) 506-512
• 20 Banic A, Ris HB, Erni D, Striffeler H. Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum. Ann Thorac Surg 1995; 60 (04) 1028-1032
• 21 Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis. J Thorac Cardiovasc Surg 2002; 123 (06) 1185-1190
• 22 Engel H, Pelzer M, Sauerbier M, Germann G, Heitmann C. An innovative treatment concept for free flap reconstruction of complex central chest wall defects–the cephalic-thoraco-acromial (CTA) loop. Microsurgery 2007; 27 (05) 481-486
• 23 Reichenberger MA, Harenberg PS, Pelzer M. et al. Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects. J Thorac Cardiovasc Surg 2010; 140 (06) 1283-1287
• 24 Taeger CD, Horch RE, Arkudas A. et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery 2016; 36 (02) 121-127
• 25 Brown RE, McCall TE, Neumeister MW. Use of free-tissue transfer in the treatment of median sternotomy wound infections: retrospective review. J Reconstr Microsurg 1999; 15 (03) 171-175
• 26 Cabbabe EB, Cabbabe SW. Immediate versus delayed one-stage sternal débridement and pectoralis muscle flap reconstruction of deep sternal wound infections. Plast Reconstr Surg 2009; 123 (05) 1490-1494
• 27 Kamel GN, Jacobson J, Rizzo AM. et al. Analysis of immediate versus delayed sternal reconstruction with pectoralis major advancement versus turnover muscle flaps. J Reconstr Microsurg 2019; 35 (08) 602-608
• 28 Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open 2021; 28: 77-89
• 29 Nickl S, Steindl J, Langthaler D. et al. First experiences with incisional negative pressure wound therapy in a high-risk poststernotomy patient population treated with pectoralis major muscle flap for deep sternal wound infection. J Reconstr Microsurg 2018; 34 (01) 1-7
• 30 Shih Y-J, Chang S-C, Wang C-H. et al. A simple protocol for the management of deep sternal surgical site infection: a retrospective study of twenty-five cases. Surg Infect (Larchmt) 2014; 15 (06) 815-820
• 31 Kannan RY. The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds. J Thorac Cardiovasc Surg 2016; 152 (01) 264-268
• 32 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37 (02) 149-159
• 33 Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap; variations in its vascular pedicle. Br J Plast Surg 1989; 42 (03) 260-262
• 34 Di Candia M, Lie K, Kumiponjera D, Simcock J, Cormack GC, Malata CM. Versatility of the anterolateral thigh free flap: the four seasons flap. Eplasty 2012; 12: e21
• 35 Kerby DS. The simple difference formula: an approach to teaching nonparametric correlation. Compr Psychol 2014; 3: 11.IT.3.1
• 36 Kozlow JH, Patel SP, Jejurikar S, Pannucci CJ, Cederna PS, Brown DL. Complications after sternal reconstruction: a 16-y experience. J Surg Res 2015; 194 (01) 154-160
• 37 Wong MS, Kim J, Yeung C, Williams SH. Breast necrosis following left internal mammary artery harvest: a case series and a comprehensive review of the literature. Ann Plast Surg 2008; 61 (04) 368-374
• 38 Beier JP, Arkudas A, Lang W, Weyand M, Horch RE. Sternumosteomyelitis - chirurgische Behandlungskonzepte. Chirurg 2016; 87 (06) 537-550
• 39 Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982; 69 (05) 815-829
• 40 Ghods M, Grabs R, Kersten C, Chatzopoulos PP, Geomelas M. A modified free muscle transfer technique to effectively treat chronic and persistent calcaneal osteomyelitis. Ann Plast Surg 2012; 68 (06) 599-605
• 41 Salgado CJ, Mardini S, Jamali AA, Ortiz J, Gonzales R, Chen H-C. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg 2006; 118 (06) 1401-1411
• 42 Yazar S, Lin C-H, Lin Y-T, Ulusal AE, Wei F-C. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117 (07) 2468-2475 , discussion 2476–2477
• 43 Cotogni P, Barbero C, Rinaldi M. Deep sternal wound infection after cardiac surgery: evidences and controversies. World J Crit Care Med 2015; 4 (04) 265-273
• 44 El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996; 61 (03) 1030-1036
• 45 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
• 46 Ennker IC, Bär AK, Florath I, Ennker J, Vogt PM. In search of a standardized treatment for poststernotomy mediastinitis. Thorac Cardiovasc Surg 2011; 59 (01) 15-20
• 47 Cauley RP, Barron S, Slatnick B. et al. An algorithmic approach to the surgical management of sternal dehiscence: a single-center experience. J Reconstr Microsurg 2022; 38 (08) 671-682
• 48 Hauser J, Steinau HU, Ring A, Lehnhardt M, Tilkorn DJ. Sternal osteomyelitis. Etiology, diagnostics and operative therapy concepts [in German]. Chirurg 2014; 85 (04) 357-365 , quiz 366–367
• 49 Pairolero PC, Arnold PG, Harris JB. Long-term results of pectoralis major muscle transposition for infected sternotomy wounds. Ann Surg 1991; 213 (06) 583-589 , discussion 589–590
• 50 Lin C-H, Lin C-H, Tsai F-C, Lin P-J. Unilateral pedicled pectoralis major harvested by endoscopic-assisted method achieves adequate management of sternal infection and mediastinitis. J Reconstr Microsurg 2019; 35 (09) 705-712
• 51 Ehrl D, Broer PN, Ninkovic M, Giunta RE, Moellhoff N. Extending the indication of the superior thyroid artery as a recipient vessel for complex upper body defects. Ann Plast Surg 2021; 86 (05) 551-556
• 52 Chiang IH, Chen SG, Wang CH. Treatment of sternal wound infection using a free myocutaneous flap. Ann Thorac Surg 2015; 100 (05) 1907-1910
• 53 Knudsen FW, Andersen M, Niebuhr U, Nielsen PL, Krag C. The role of the internal thoracic artery in the sternal blood supply. Scand J Thorac Cardiovasc Surg 1993; 27 (01) 3-8
• 54 Dell'Amore A, Congiu S, Campisi A, Mazzarra S, Zanoni S, Giunta D. Sternal reconstruction after post-sternotomy dehiscence and mediastinitis. Indian J Thorac Cardiovasc Surg 2020; 36 (04) 388-396