Infected median sternotomy wound. Successful treatment by muscle flaps

The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds

OBJECTIVE

To determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns.

METHODS

This was a retrospective case review of 9 patients with sternal wound dehiscence over an 18-month period between 2013 and 2015. Seven of the 9 patients received a single IMAP flap to cover full-length sternal wounds, including 4 with a fasciocutaneous flap and 3 with a musculocutaneous flap.

RESULTS

All of the patients were male, with a mean age of 68 years. The mean number of perforators was 1.3, with a mean perforator diameter of 1.5 mm. In all cases, the torsion angle was 80 degrees, with a translational pedicle movement of 1 to 2 cm. There were no instances of total flap failure and only 2 cases of partial flap necrosis, which were managed conservatively. One flap, performed when both internal mammary arteries had been harvested previously, showed complete survival.

CONCLUSIONS

The IMAP flap has an advantage in its the ability to reconstruct the entire length of a sternotomy wound from the suprasternal notch to the xiphisternum with relatively minimal dissection and morbidity compared with more conventional flaps such as pectoralis major, rectus, and omental flaps. Nevertheless, caveats for its use remain, such as in patients with vasopressor therapy and the resulting subclavicular scar, which is unaesthetic in women. Overall, the IMAP flap is an attractive reconstructive tool specifically in stable male patients with noninfected sternotomy wound dehiscence with a defect width of up to 7 cm. In this patient subset, it is the ideal first-line reconstructive tool.

Staphylococcus aureus-Associated Musculoskeletal Infections

Musculoskeletal infections caused by Staphylococcus aureus are among the most difficult-to-treat infections. S. aureus osteomyelitis is associated with a tremendous disease burden through potential for long-term relapses and functional deficits. Although considerable advances have been achieved in diagnosis and treatment of osteomyelitis, the management remains challenging and impact on quality of life is still enormous. S. aureus acute arthritis is relatively seldom in general population, but the incidence is considerably higher in patients with predisposing conditions, particularly those with rheumatoid arthritis. Rapidly destructive course with high mortality and disability rates makes urgent diagnosis and treatment of acute arthritis essential. S. aureus pyomyositis is a common disease in tropical countries, but it is very seldom in temperate regions. Nevertheless, the cases have been increasingly reported also in non-tropical countries, and the physicians should be able to timely recognize this uncommon condition and initiate appropriate treatment. The optimal management of S. aureus-associated musculoskeletal infections requires a strong interdisciplinary collaboration between all involved specialists.

Rigid sternal fixation in the management of pediatric postmedian sternotomy mediastinitis: A 20-year study

BACKGROUND AND AIM

Pediatric patients are at a risk of mediastinitis, a life-threatening complication of median sternotomy, following cardiac surgery for congenital conditions. Our experience with rigid internal sternal fixation in pediatric patients with postmedian sternotomy mediastinitis is presented.

METHODS AND MATERIALS

A retrospective chart review was performed of patients <18 years of age diagnosed with postoperative mediastinitis between January 1, 1990 and December 31, 2009. Charts were reviewed for demographic data, cardiac history, causative microorganism, and infectious risk factors. The methods of surgical intervention including flap coverage and use and type of sternal plating (resorbable and/or titanium) were also recorded. The primary end point of interest was overall survival.

RESULTS

Twenty-five pediatric patients were diagnosed with postoperative mediastinitis. Rigid fixation of the sternum following debridement was performed in 20 patients (age range: 1 month-18 years), all of whom successfully tolerated the procedure. Resorbable plates were used in 13 patients. Five patients did not undergo rigid fixation due to either serious ill-health or lack of adequate sternal bone stock. No patient experienced recurrent sternal wound infection. A total of 20 patients (80%) survived to discharge. Three patients succumbed to their heart condition prior to rigid fixation, one died following sternal closure from unrelated causes, and one patient was lost to follow-up.

CONCLUSIONS

Post-sternotomy mediastinitis in pediatric patients may be addressed using wide debridement, rigid sternal fixation, and flap coverage. In our series of 25 patients with pediatric mediastinitis, none died from mediastinitis. Placement of hardware did not adversely affect patient survival. This study demonstrates the feasibility of rigid sternal fixation.

Changes in the management of deep sternal wound infections: a 12-year review

BACKGROUND

Deep sternal wound infection (DSWI) is a rare but life-threatening complication following cardiac surgery associated with increased morbidity and mortality. Management of these patients has evolved over the years and can include sternal rewiring, mediastinal irrigation, negative-pressure wound therapy (NPWT) dressing or repair with flaps. We reviewed changes in our management of DSWI and outcomes.

METHODS

Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, 5472 underwent cardiac surgery at St Vincent's Hospital, Melbourne, and 42 were identified as developing DSWI requiring re-operation between June 2002 and September 2014. Data were collected pertaining to risk factors for DSWI, management strategies and outcomes. Patients were compared from a period prior to NPWT dressing use (June 2002-February 2006, n = 14) and since the NPWT has been used regularly in the management of DSWI (from March 2006, n = 28). Patients were also compared based on the requirement for flap closure of their sternal wound.

RESULTS

Because of the widespread use of NPWT dressings, there is a trend towards fewer sternal infections requiring flap closure (25 versus 42.8%) and less post-operative complications after definitive closure (7.1 versus 28.6%). Before and after widespread NPWT use, patients require similar number of re-operations before closure and have no significant differences in time to definitive closure or length of hospital stay.

CONCLUSION

The use of NPWT dressings as a bridge to definitive closure may reduce the need for more burdensome flap reconstruction, does not delay definitive reconstruction or prolong hospital stay and may reduce post-reconstruction complications requiring re-operation.

Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis

Background

This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures.

Methods

Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated.

Results

Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism.

Conclusion

Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.

Management of sternal wounds by limited debridement and partial bilateral pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach

PURPOSE

Because sternal wound complications after sternotomy can be life threatening and often occur in very sick patients, optimal management of these complications remains an important topic. To decrease postoperative morbidity and shorten the recovery period, the senior author (J.A.A.) sought a less invasive approach to sternal debridement and flap closure in carefully selected patients. The purpose of this study was to evaluate the effectiveness of this approach by obtaining specific outcomes data from a series of patients treated with this less invasive method.

MATERIALS AND METHODS

Of the most recent 174 sternal wounds treated by the senior author, 25 underwent limited debridement and partial bilateral pectoralis major advancement flaps. The charts of these 25 patients were reviewed and analyzed.

RESULTS

In the 25 patients who underwent limited debridement, there were no mortalities intraoperatively or during the 30-day postoperative period. Six patients (24%) experienced complications after debridement, including 1 recurrent sternal wound infection, 1 partial wound dehiscence, 1 seroma, 1 hematoma, and 1 wound edge necrosis requiring revision. Mean length of hospitalization after the procedure was 10 days, compared with 30 days (P = 0.0001) as previously reported with full debridement (Plast Reconstr Surg 2004; 114:676). Mean estimated intraoperative blood loss was reduced from 331 mL during full debridement to 93 mL (P < 0.0001) with limited debridement (Plast Reconstr Surg 2004; 114:676). There was no increase in postoperative morbidity (24 % vs 13 %, P = 0.2117).

CONCLUSIONS

The authors advocate limited sternal debridement and partial bilateral pectoralis major myocutaneous advancement flaps in patients with limited wounds and partially or fully healed sternums. We demonstrate that the procedure is effective but less invasive than complete debridement, reduces operative time and blood loss, and shortens length of hospitalization.

Use of the pectoralis major fasciocutaneous flap in the treatment of post sternotomy dehiscence: a new approach

OBJECTIVE

To describe a new surgical technique for the treatment dehiscence after median thoracotomy transsternal using fasciocutaneous flap composed of the pectoralis major fascia.

METHODS

Between January 2009 and December 2010, from 1,573 patients submitted to coronary artery bypass graft, 21 developed wound dehiscence after sternotomy and were treated with bilateral pectoralis major muscle fasciocutaneous flap, including partial portion of the rectus abdominis fascia. Patients were followed for a minimum of 90 days postoperatively.

RESULTS

All patients had favorable outcome following 90 days, not having any partial or total dehiscence. There were no cases of postoperative infection.

CONCLUSION

The procedure was rapid and effective. Compared with techniques using muscle, myocutaneous or greater omentum flaps, this surgery was less aggressive and maintained the integrity of tissue region. The authors considered that this technique should be used as the first option, leaving the flaps to more complex cases of relapse.

Profuse mediastinal hemorrhage due to mediastinitis after a sternal infection

A 79-year-old female patient was admitted because of profuse bleeding from a skin defect in the anterior chest due to a deep sternal wound infection. Eighteen years earlier, she had undergone irradiation to treat a sternal metastasis from breast cancer. Computed tomography (CT) showed the extravasation of iodinated contrast material from the ascending aorta. The patient underwent an immediate thoracotomy and recovered. This report presents a very rare case of massive bleeding from the thoracic aorta due to a mediastinal infection after irradiation for sternal metastasis from breast cancer.

Open reduction internal fixation poststernotomy mediastinitis

Introduction. Mediastinitis has been reported to complicate 5% of sternotomy surgery. We have adopted an open reduction and rigid internal fixation (ORIF) approach during the conventional rescue surgery in the treatment of mediastinitis. Methods. A retrospective review was performed to compare the outcomes of patients that had an ORIF to correct postoperative mediastinitis following median sternotomy. These were compared with the outcome of the patients that did not undergo ORIF. Results. In the 5-year study period, we reviewed 35 mediastinitis patient charts. Postoperatively, the ORIF patient group remained in the Intensive Care Unit (ICU) and on a ventilator for a mean of 1.5 and 0.75 days, respectively. Patients treated without ORIF spent significantly more days in the ICU (mean of 7.5 days, P < 0.05) and on a ventilator (mean of 2.15 days, P = 0.1). Furthermore, it was found that none of the patients (0%) who underwent ORIF complained of any postoperative sternal instability or pain. Preoperatively, however, these rates were as high as 72%. Conclusions. In the select patient, ORIF can be a safe option in the management of mediastinitis, which we have shown to significantly decrease morbidity and mortality by providing anatomic reduction as well as physiologic stabilization. We have shown that ORIF will improve the quality of life of the patient by minimizing abnormal sternal mobility and pain and will also decrease inpatient costs by decreasing days spent in the ICU and ventilator dependence.

Failure of secondary wound closure after sternal wound infection following failed initial operative treatment: causes and treatment

BACKGROUND

Patients transferred to Plastic Surgery Departments for sternum osteomyelitis have a high morbidity of about 3%. Despite several known options for sternal wound coverage and salvage operations, wound dehiscence or wound necrosis can occur, increasing patient morbidity.

PATIENTS AND METHODS

One hundred thirty-five patients admitted between January 2007 and December 2010 were evaluated in a retrospective study for wound dehiscence after salvage wound coverage at our institution. Various flaps were applied, such as pectoralis major myocutaneous pedicled flaps, pectoralis major muscle pedicled flaps, latissimus dorsi pedicled flaps, greater omental flaps, and vertical rectus abdominis muscle and transverse rectus abdominis muscle flaps. Inclusion criteria were sternal wound infection, bacterial wound infection, previous wound debridement outside our institution, vacuum-assisted closure device wound treatment at our institution, and secondary flap closure of the sternal defect at our institution. A multivariate regression analysis was performed.

RESULTS

One hundred thirty patients met the inclusion criteria. In all patients, bacterial wound colonization was shown. Forty patients showed wound dehiscence after closure at our institution. Reasons for wound dehiscence were attributed to wound size, >4 different species of bacteria colonizing the wound, gram-negative bacteria, Candida albicans, intensive care unit stay, and female gender. Interestingly, wound dehiscence was not significant correlated to obesity, smoking, atherosclerosis, renal insufficiency or type of closure influenced significantly, or necrosis.

CONCLUSIONS

Female patients after CABG, with large sternal wounds infected with gram-negative bacteria and candida, have an 85% risk of wound dehiscence after flap coverage for sternal wound infection.

Optimizing reconstruction of oncologic sternectomy defects based on surgical outcomes

BACKGROUND

The optimal strategy for oncologic sternectomy reconstruction has not been well characterized. We hypothesized that the major factors driving the reconstructive strategy for oncologic sternectomy include the need for skin replacement, extent of the bony sternectomy defect, and status of the internal mammary vessels.

STUDY DESIGN

We reviewed consecutive oncologic sternectomy reconstructions performed at The University of Texas MD Anderson Cancer Center during a 10-year period. Regression models analyzed associations between patient, defect, and treatment factors and outcomes to identify patient and treatment selection criteria. We developed a generalized management algorithm based on these data.

RESULTS

Forty-nine consecutive patients underwent oncologic sternectomy reconstruction (mean follow-up 18 ± 23 months). More sternectomies were partial (74%) rather than total/subtotal (26%). Most defects (n = 40 [82%]) required skeletal reconstruction. Pectoralis muscle flaps were most commonly used for sternectomies with intact overlying skin (64%) and infrequently used when a presternal skin defect was present (36%; p = 0.06). Free flaps were more often used for total/subtotal vs partial sternectomy defects (75% vs 25%, respectively; p = 0.02). Complication rates for total/subtotal sternectomy and partial sternectomy were equivalent (46% vs 44%, respectively; p = 0.92).

CONCLUSIONS

Despite more extensive sternal resections, total/subtotal sternectomies resulted in equivalent postoperative complications when combined with the appropriate soft-tissue reconstruction. Good surgical and oncologic outcomes can be achieved with defect-characteristic-matched reconstructive strategies for these complex oncologic sternectomy resections.

An alternative technique for surgical management of poststernotomy osteomyelitis and reconstruction of the sternal defect

Introduction. Sternal osteomyelitis with or without mediastinal infection is a severe and rare complication of median sternotomy. In this paper, an alternative technique for the reconstruction of sternal defects with the use of bilateral pectoralis major pedicled muscle flaps is presented. Case presentation. A 70-year-old man with the diagnosis of poststernotomy osteomyelitis underwent reconstruction of his sternal defect with the use of bilateral pectoralis major muscle flaps. The patient had an uneventful recovery, and the physical examination revealed a normal range of motion for both upper limbs and sternal stability. Conclusion. The proposed technique incorporates a simple mobilization of the two pectoralis major muscles to be used as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. Using this technique, a muscular implant is made that seals the dead space, which has no tension due to the presence of a second layer. Postoperative results are excellent, not only regarding infection and functionality but also from an aesthetic point of view.

Significant predictors of complications after sternal wound reconstruction: a 21-year experience

BACKGROUND

We sought to identify patient comorbidities that predict complications after tissue flap sternal reconstruction.

METHODS

A retrospective study, December 1989 to December 2010, analyzed numerous comorbidities, including diabetes mellitus (DM), hypertension (HTN), coronary artery disease, congestive heart failure (CHF), and renal insufficiency, as independent risk factors for postoperative complications. Pearson χ2 test, Fisher exact test, 2-sample t test, and median-unbiased estimation were used for data analysis. Significance was P≤0.05.

RESULTS

In all, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required reoperation because of complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Our analysis found DM, HTN, and CHF as significant predictors of complications after sternal reconstruction (P=0.014, 0.012, and 0.006).

CONCLUSIONS

Results suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.

Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases

BACKGROUND

Sternal wound infections are a life-threatening complication of cardiovascular surgery, and management can present a great challenge for the plastic surgeon. Successful treatment involves a multidisciplinary approach, immediate detection, meticulous debridement, and delivery of vascularized tissue to the infected wound bed.

METHODS

Twenty-nine years experience of a single surgeon in 415 sternal wound reconstructions is retrospectively analyzed. Flap choice was based on the amount of vascularized tissue required. Low-risk, early infections were treated with debridement and a single flap. Large, high-risk wounds were treated with multiple debridements and covered with a combination of flaps to reduce infection and eliminate dead space.

RESULTS

Immediate wound closure with aggressive debridement and flap coverage in a single-stage early in the series (first 12 patients, 1980-1981) led to a mortality rate of 25% due to sepsis and cardiovascular instability. Thereafter, treatment was altered, and patient stability and wound preparation were emphasized, often requiring multiple debridements (91% of all patients). Nine percent of patients, with early low-risk infections, underwent single-stage rewiring and coverage with pectoralis or omental flaps. Coverage of multiple debrided purulent wounds was performed using pectoralis major flap (37% of total number of patients), omentum (18%), a pectoralis/omentum combination (34%), or rectus abdominis flap (2%). A multistage approach and use of 2 flaps for coverage resulted in a 1.5% mortality due to sepsis, 2.5% infection rate, 1.5% skin necrosis rate, and 1.5% hematoma/seroma rate. The use of multiple flaps in large, complex wounds resulted in a complication rate similar to smaller wounds covered with a single flap. In all, 3.5% of the patients required a salvage operation with alternate flaps.

CONCLUSION

This large series demonstrates the importance of early detection of infection, meticulous staged debridement of nonviable tissue, and elimination of dead space with multiple vascularized flaps.

Chest wall reconstruction for sternal dehiscence after open heart surgery

BACKGROUND

Sternal dehiscence is a grave complication after open heart surgery. Sternal debridement and flap coverage are the mainstays of therapy, but no consensus exists regarding the appropriate level of debridement. More recently, the use of vacuum-assisted closure devices has been advocated as a bridge to definitive closure, but indications for use remain incompletely defined.

MATERIALS AND METHODS

A retrospective review of all chest wall reconstructions performed from January 2000 to December 2010 was conducted. The type of operative management was evaluated to assess morbidity, mortality, and length of hospital stay.

RESULTS

Fifty-four patients underwent chest wall reconstruction for poststernotomy mediastinitis. Of these patients, 24 underwent conservative sternal debridement with flap closure, 24 underwent radical sternectomy including resection of the costal cartilages followed by flap closure, and 6 underwent radical sternectomy with vacuum-assisted closure therapy followed by flap closure in a delayed fashion. There were 15 patients in the conservative group and 8 patients in the radical sternectomy group who developed postoperative complications (62.5% vs 33.3%, P < 0.05). The conservative sternectomy group had more serious complications requiring reoperation compared to the radical sternectomy group (86.7% vs 25.0%, P < 0.05). The most common complication in the former group was flap dehiscence (8/15, 53.3%), whereas that in the latter group was a superficial wound infection (6/8, 75.0%). There was no significant difference in mortality (25.0% vs 25.0%, P > 0.05%) or length of hospital stay.

CONCLUSIONS

Radical sternectomy including the costal cartilages is associated with lower rates of surgical morbidity and reoperation, but not mortality.

Infraareolar pectoralis major myocutaneous island flap as treatment of first choice for deep sternal wound infection

Deep sternal wound infection (DSWI) is a grave complication of median sternotomy, associated with high morbidity, mortality and escalating treatment costs. There is general consensus that optimal treatment comprises radical debridement followed by coverage with a vascularised flap. However, there is ongoing debate regarding the ideal operative procedure. We present our experience with the infraareolar pectoralis major island myocutaneous flap (PEC-MI flap) as treatment of first choice in DSWI. Following a retrospective chart review, data pertaining to patient demographics, type of cardiac surgery performed, prevalence of known DSWI risk factors, identified pathogens, duration of surgery, flap-related complications, duration of hospital stay and antibiotic therapy, as well as mortality were noted. Additionally, we describe the operative technique and review the relevant literature. Twenty-five patients underwent coverage with the PEC-MI flap in our department. The average age was 69.2 years. Nineteen patients underwent coronary artery bypass surgery, 10 valve replacement, two aortic replacement surgery and one pericardiectomy. In six cases, no internal mammary artery was used in cardiac surgery, in 11 cases one and in seven cases both internal mammary arteries were used. The average duration of surgery was 154.2 min and the average hospital stay was 28.4 days. Complications which required revision surgery were haematoma in three cases, one wound dehiscence and one recurrent infection. Two cases required coverage with an additional regional flap. The PEC-MI flap has been used as flap of first choice in our clinic for treatment of DSWI. It is sufficient to raise the flap unilaterally, and it does not require skin grafting. The combination of immunocompetent bulky muscle tissue used to obliterate the sternal cavity and the large skin paddle enabling a low-tension skin closure allows reliable and efficient treatment of this severe complication.

Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction

The chest wall functions as a protective cage around the vital organs of the body, and significant disruption of its structure can have dire respiratory and circulatory consequences. The past several decades have seen a marked improvement in the management and reconstruction of complex chest wall defects. Widespread acceptance of muscle and musculocutaneous flaps such as the latissimus dorsi, pectoralis major, serratus anterior, and rectus abdominis has led to a sharp decrease in infections and mortality. Successful reconstructions are dependent upon a detailed knowledge of the functional anatomy and blood supply of the chest and the underlying pathophysiology of a particular disease process. This article will provide an overview of key principles and evidence-based approaches to chest wall reconstruction.

Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps

Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Treatment outcomes of postoperative mediastinitis in cardiac surgery; negative pressure wound therapy versus conventional treatment

Background

The aim of the present study is to compare negative pressure wound therapy versus conventional treatment outcomes at postoperative mediastinitis after cardiac surgery.

Methods

Between January 2000 and December 2011, after 9972 sternotomies, postoperative mediastinitis was diagnosed in 90 patients. The treatment modalities divided the patients into two groups: group 1 patients (n = 47) were initially treated with the negative pressure wound therapy and group 2 patients (n = 43) were underwent conventional treatment protocols. The outcomes were investigated with Kaplan-Meier method, log-rank test, Student’s test and Fisher’s exact test.

Results

The 90-days mortality was found significantly lower in the negative pressure wound group than in the conventionally treated group. Overall survival was significantly better in the negative pressure wound group than in the conventionally treated group.

Conclusion

Negative pressure wound therapy is safe and reliable option in mediastinitis after cardiac surgery, with excellent survival and low failure rate when compared with conventional treatments.

The treatment of an unusual complication associated with a HeartMate II LVAD in an adolescent

The HeartMate II LVAD has provided a bridge to heart transplantation or a permanent fixture for destination therapy for patients with heart failure. LVAD infections are associated with significant morbidity even when treated with explantation, device exchange, or a salvage procedure. We present an unusual complication following the placement of the HeartMate II device in an adolescent, whereby a pocket infection resulted in a large soft tissue defect overlying and surrounding the device. The novel use of a VRAM flap was successfully used to repair the defect and salvage the device.

The V-Y latissimus dorsi musculocutaneous flap in the reconstruction of large posterior chest wall defects

Posterior chest wall defects are frequently encountered after excision of tumors as a result of trauma or in the setting of wound dehiscence after spine surgery. Various pedicled fasciocutaneous and musculocutaneous flaps have been described for the coverage of these wounds. The advent of perforator flaps has allowed the preservation of muscle function but their bulk is limited. Musculocutaneous flaps remain widely employed. The trapezius and the latissimus dorsi (LD) flaps have been used extensively for upper and middle posterior chest wounds, respectively. Their bulk allows for obliteration of the dead space in deep wounds. The average width of the LD skin paddle is limited to 10-12 cm if closure of the donor site is expected without skin grafting. In 2001 a modification of the skin paddle design was introduced in order to allow large flaps to be raised without requiring grafts or flaps for donor site closure. This V-Y pattern allows coverage of large anterior chest defects after mastectomy. We have modified this flap to allow its use for posterior chest wall defects. We describe the flap design, its indications, and its limitations with three clinical cases.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Sternal reconstruction after cardiac transplantation: a case of an oversized donor heart

BACKGROUND

We present a unique case of a cardiac transplant recipient who received an oversized heart.

METHODS

To allow the chest to accommodate the organ, extensive resection of the bony chest wall was performed. As both pectoralis major myocutaneous flaps and omental transposition were insufficient to cover the wound, a chest rotational flap was chosen.

RESULTS

The large size of the flap allowed us to cover the entire protuberant heart, and the excess soft tissue absorbed the pulsations from the heart without placing tension on the suture line.

CONCLUSION

While the closure of complex sternal wounds can pose great challenges, the plastic surgeon possesses a variety of options including pectoralis, omental, rectus abdominus, latissimus dorsi as well as skin and subcutaneous flap closures to choose from.

Immediate debridement and reconstruction with a pectoralis major muscle flap for poststernotomy mediastinitis

Background

Poststernotomy mediastinitis is a rare, but life-threatening complication, thus early diagnosis and proper management is essential for poststernotomy mediastinitis. The main treatment for mediastinitis is aggressive debridement. Several options exist for reconstruction of defects after debridement. The efficacy of immediate debridement and reconstruction with a pectoralis major muscle flap designed for the defect immediately after the diagnosis of poststernotomy mediastinitis is demonstrated.

Methods

Between September 2009 and June 2011, 6 patients were referred to the Department of Plastic and Reconstructive Surgery and the Department of Thoracic and Cardiovascular Surgery of Ajou University Hospital for poststernotomy mediastinitis. All of the patients underwent extensive debridement and reconstruction with pectoralis major muscle flaps, advanced based on the pedicle of the thoracoacromial artery as soon as possible following diagnosis. A retrospective review of the 6 cases was performed to evaluate infection control, postoperative morbidity, and mortality.

Results

All patients had complete wound closures and reduced severity of infections based on the erythrocyte sedimentation rate and C-reactive protein levels and a reduction in poststernal fluid collection on computed tomography an average of 6 days postoperatively. A lack of growth of organisms in the wound culture was demonstrated after 3 weeks. There were no major wound morbidities, such as hematomas, but one minor complication required a skin graft caused by skin flap necrosis. No patient expired after definitive surgery.

Conclusions

Immediate debridement and reconstruction using a pectoralis major muscle flap is a safe technique for managing infections associated with poststernotomy mediastinitis, and is associated with minimal morbidity and mortality.

Management of sterno-mediastinitis

With an incidence rate of 1-4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%. Risk factors for sternal instability are insulin-dependent diabetes mellitus, obesity, immunosuppressed state, chronic obstructive pulmonary disease, osteoporosis, history of radiation, renal failure, body height, smoking and nutritional state. The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically. As a result of interdisciplinary cooperation, a therapy concept has developed which is adapted to the patient individually. Therapy begins with the simplest measures and, if deemed necessary, this is then escalated step by step. The aim of the treatment is to bring the infection under control, which requires radical surgical debridement, removal of infected and necrotic tissue, removal of all foreign bodies (including wires and osteosynthesis material) and the removal of all infected, necrotic osseous material if necessary followed by vacuum-assisted closure therapy. The reconstruction of defects of the anterior chest wall is achievable using different muscle flaps. Mostly the muscle pectoralis major is used unilaterally or bilaterally with or without disinsertion of the tendon. Other options are the omental flap, the muscle latissimus dorsi flap or the muscle rectus abdominis flap. A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved successful and can be carried out with a high standard of safety.

Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy

Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4-12 mo). Late local follow-up results, both functional and aesthetic, were good.We conclude that negative-pressure wound therapy-in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps-is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.

Application of the Titanium Plate Fixation System in Sternum Transverse Incisions

The purpose of this study was to review the application of the titanium plate fixation system in sternum transverse incisions and assess its advantages over the conventional methods of steel wire fixation. Sternal healing of 249 patients who underwent a thymectomy and/or excision of the thymoma with a transverse sternal incision was compared between patients who underwent titanium plate fixation or steel wire fixation. Short-term results: The stability of the sternum was significantly superior in the titanium plate group compared with the steel wire group ( P < 0.01). Out-of-bed activities started earlier for patients in the titanium plate group compared with the steel wire group ( P < 0.01). Long-term results: The sternal healing rate in the titanium plate group was significantly higher than the steel wire group ( P < 0.05). Titanium plate fixation improves the postoperative sternal stability in patients with transverse sternal incisions for thymectomy and/or excision of a thymoma. Titanium plate fixation also reduces postoperative pain, enhances the patient's physical activity, and decreases the long-term nonunion rate of the sternum.

Surgical treatment for epidural abscess in the posterior cranial fossa using trapezius muscle or musculocutaneous flap

Two patients developed an epidural abscess in the posterior cranial fossa following tumor dissection from the occipital region of the head and underwent surgical treatment. After debridement of necrotic and infectious tissues inside the abscess was performed, the empty cavity was filled and the tissue defect was reconstructed by using a trapezius muscle flap or a trapezius musculocutaneous flap. Both patients had good clinical results, and their abscesses were healed. The trapezius muscle flap and trapezius musculocutaneous flap were quite useful in the treatment for epidural abscess in the posterior cranial fossa.

Sternal plate fixation for sternal wound reconstruction: initial experience (retrospective study)

Background

Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4 - 5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.

Methods

A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System^®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean ± SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).

Results

There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.

Conclusion

Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

Secondary omental and pectoralis major double flap reconstruction following aggressive sternectomy for deep sternal wound infections after cardiac surgery

Background

Deep sternal wound infection after cardiac surgery carries high morbidity and mortality. Our strategy for deep sternal wound infection is aggressive strenal debridement followed by vacuum-assisted closure (VAC) therapy and omental-muscle flap reconstrucion. We describe this strategy and examine the outcome and long-term quality of life (QOL) it achieves.

Methods

We retrospectively examined 16 patients treated for deep sternal wound infection between 2001 and 2007. The most recent nine patients were treated with total sternal resection followed by VAC therapy and secondary closure with omental-muscle flap reconstruction (recent group); whereas the former seven patients were treated with sternal preservation if possible, without VAC therapy, and four of these patients underwent primary closure (former group). We assessed long-term quality of life after DSWI by using the Short Form 36-Item Health Survey, Version 2 (SF36v2).

Results

One patient died and four required further surgery for recurrence of deep sternal wound infection in the former group. The duration of treatment for deep sternal wound infection in the recent group was significantly shorter than that in previous group (63.4 ± 54.1 days vs. 120.0 ± 31.8 days, respectively; p = 0.039). Despite aggressive sternal resection, the QOL of patients treated for DSWI was only minimally compromised compared with age-, sex-, surgical procedures-matched patients without deep sternal wound infection.

Conclusions

Aggressive sternal debridement followed by VAC therapy and secondary closure with an omental-muscle flap is effective for deep sternal wound infection. In this series, it resulted in a lower incidence of recurrent infection, shorter hospitalization, and it did not compromise long-term QOL greatly.

Cardiac reoperation in a patient who previously underwent omentoplasty for postoperative mediastinitis: a case report

Sternal infection has become a rare but challenging problem with significant mortality and morbidity rates since the introduction of sternotomy. Reported rates of mediastinal and sternal infection range from 0.4% to 5%. The ideal reconstruction after sternal debridement is still controversial. Different methods, such as debridement and open packing with continuous antibiotic irrigation, or sternectomy with omental or muscle transposition have been proposed. In this study, we present the cardiac reoperation of a 52 year old man with corrected transposition of great arteries (c-TGA) who had undergone a previous omentoplasty for postoperative mediastinitis.

Functional impairment after treatment with pectoral muscle flaps because of deep sternal wound infection

OBJECTIVE

Pectoral muscle flaps (PMF) are effective in terminating protracted sternal wound infections (SWI) but long-term outcome remains uncertain. Therefore, the aim of this study was to evaluate long-term outcome in patients treated with PMF.

DESIGN

Thirty-four of 263 patients revised because of deep SWI from 1991--2005 were treated with PMF. Of the 21 patients alive, 11 had left-sided, two right-sided and eight bilateral procedures. Sternal debridement without closure of the sternum was done in 17 patients. Nineteen of 21 patients responded to a questionnaire.

RESULTS

At follow-up on average 5.9 years (range 1.9--14.8 years) after surgery 63% (12/19) experienced unstable chest. Two thirds (12/18) reported problems carrying a grocery bag and 37% (7/19) had problems putting on a coat. Reduction of power and mobility was more common in the right arm and shoulder even in patients with left-sided PMF. Thirty-two percent (6/19) would have preferred alternative treatment if possible to avoid sternal instability even if healing had been substantially delayed.

CONCLUSIONS

Surgery with PMF and sternal debridement was associated with long-term disability, which appeared to be significant in one third of the patients. The function of the right arm and shoulder was affected more often despite the majority of procedures being left-sided suggesting that loss of skeletal continuity of the chest wall is more disabling than loss of pectoral muscle function.