Vacuum-Assisted Closure for Sternal Wounds: A First-Line Therapeutic Management Approach

Vacuum-assisted closure of a large palmar defect after debriding a midpalmar tuberculous abscess

A rare case of tuberculous deep palmar abscess of the hand was treated with radical excisional debridement, resulting in a large palmar skin and soft tissue defect that was successfully closed with a vacuum dressing followed by split skin grafting. Vacuum dressings are useful adjuncts to treat large soft tissue defects in patients who are unsuitable for complex reconstruction. The moist wound environment prevents desiccation of exposed vital structures and decreases pain, allowing early mobilisation in the hand. The wound granulates and contracts rapidly, allowing earlier skin grafting or faster healing by secondary intention. The closed system vacuum dressing is particularly useful in managing debrided tuberculous soft tissue infections. The dressing is perfectly sealed and requires less frequent changing, decreasing contamination and transmission of tuberculosis to other patients and health care staff, while minimising the risk of secondary nosocomial bacterial infection of the wound.

The pectoralis major muscle extended island flap for complete obliteration of the median sternotomy wound

The sequence of adverse events initiated by a sternal wound infection today can typically be ameliorated by interposing a vascularized flap. The pectoralis major muscle due to its propinquity has universally been the workhorse flap for minimizing this dilemma, with our experience over the past 25 years being no exception as 123 of 156 patients so inflicted required this donor site in some format. However, a rectus abdominis muscle had to be used in combination in 22 patients, particularly for coverage of the xiphoid region, and this can add significant morbidity in an already compromised patient population. This conundrum provided the impetus starting in 2003 for the development of a pectoralis major muscle extended island flap, whereby skeletonizing its vascular pedicle back to near the origin of the thoracoacromial axis, the desired extended reach can be obtained. Since that time, 18 pectoralis major muscle extended island flaps have been successfully used, with only a single wound complication still requiring use of a rectus abdominis muscle flap. This has proven to be a reliable option that alone allows complete closure of the median sternotomy wound while avoiding the need for combined flaps with preservation of the rectus abdominis muscle.

Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment

OBJECTIVE

Sternal wound infections are a serious complication after cardiac surgery. Although a variety of treatment algorithms has been published, the ideal operative treatment of complicated median sternotomy wounds is the subject of ongoing controversy.

METHODS

In a retrospective review, 3016 consecutive open-heart surgery patients between January 2003 and June 2006 were evaluated: 65.6% underwent coronary artery bypass surgery (CABG), 16.3% cardiac valve replacement, 13.5% combined CABG and valve replacement, 2.8% aortic reconstruction or replacement, 0.6% artificial heart implantation, and 1.2% cardiac transplantation.

RESULTS

Sixty-three patients (2.1%) developed sternal wound infections. Fifty-six wounds were treated with débridement, irrigation, and re-wiring. Thirty-four patients were treated using vacuum-assisted closure therapy. Nineteen of these patients eventually required plastic surgical coverage with either rectus abdominis or pectoralis major flaps. Diabetes mellitus, rethoracotomy, duration of operation and, interestingly, the time of operation (morning versus afternoon) presented significant risk factors for development of sternal wound infections (P <.05). Three patients developed partial flap necrosis and required a second flap. Eventually, all defects were successfully reconstructed and there was no recurrent ostemyelitis noticed over the entire observation period (follow-up, 23 +/- 13 months).

DISCUSSION

Patients at risk for development of sternal wound infections may be preferably operated in the morning at first position. Vaccuum-assisted closure therapy acts as a link between radical débridement and definitive plastic coverage. The type of flap is individually chosen based on location of the defect and availability of certain vascular axis. The presented interdisciplinary approach with radical surgical débridement, application of subatmospheric pressure dressings, and early involvement of the plastic surgical team allows efficient treatment of infected median sternotomy wounds.

Sternotomy wounds: rectus flap versus modified pectoral reconstruction

BACKGROUND

Infected sternotomy wounds occur in 0.5 to 8.4 percent of open heart operations. They are complex problems, with a mortality rate of 8.1 to 14.8 percent despite flap closure. For closure, the pectoralis major flap has had considerable success. However, in providing coverage to the lower third of the sternum, it may be deficient. Modifications to improve closure have included a rectus flap or an anterior rectus fascia extension to the pectoralis flap.

METHODS

This retrospective study of 130 consecutive sternotomy wounds compares 41 bilateral pectoralis major muscle flaps with a modified anterior rectus fascia extension against 56 rectus abdominis muscle flaps alone in addressing the lower third of the sternum following dehiscence.

RESULTS

Pectoralis flaps with rectus fascia extension and rectus flaps have similar success, postoperative course, and morbidity and mortality rates. The pectoralis flaps with rectus fascia extensions prevented superior dehiscence, but this modification does not eliminate dehiscence of the distal third of the sternum.

CONCLUSIONS

The rectus muscle alone proved superior in coverage to the inferior sternum. Sternal wounds should be covered preferentially by a pectoralis flap to cover a superior infection and by a rectus flap if the dehiscence is localized to the distal third.

Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system

Restoration of sternal integrity after median sternotomy for cardiac interventions better ensures optimal postoperative pulmonary function and minimizes overall morbidity. Sternal dehiscence or nonunion mitigates against such a successful outcome. Under such circumstances, if enough viable and uninfected sternum remains, an anatomic reduction should be attempted. Rewiring usually proves unsuccessful, and rigid plate fixation is more rewarding. A new titanium sternal fixation system that permits transverse orientation of plates has been used in 4 patients who had sterile complete or imminent sternal dehiscence to allow eventual sternal union. The specific advantage of this new system is the presence of a releasing pin in the center of coupled plates to allow rapid chest reentry if required without the specific need for cumbersome plate removal. One patient had delayed removal of an infected plate after sternal union was achieved.

Postoperative mediastinitis in children: improvement of simple primary closed drainage

BACKGROUND

Mediastinitis is a significant cause of postoperative morbidity. In 1989, we proposed simple primary closed drainage as a new treatment. Our goal is to describe improvements made to the original technique.

METHODS

After wound debridement, infected areas were drained with Redon catheters connected to strong negative-pressure drainage bottles. Mediastinal effluents were cultured every day, and the catheters were withdrawn when the effluent culture was negative for microorganisms. Patients were classified into three groups: isolated mediastinitis (group 1), mediastinitis associated with endocarditis (group 2), and mediastinitis associated with other organ failure (group 3).

RESULTS

Sixty-four patients were treated during a 10-year period: 15 neonates, 33 infants, and 16 children. Group 1 consisted of 40 patients. The time to mediastinal sterilization was 4 days (range, 1 to 14 days), and the antibiotic course was 11 days (range, 7 to 28 days), with a hospital stay of 13 days (range, 10 to 30 days). No deaths occurred in this group. Group 2 consisted of 7 patients. The time to mediastinal sterilization was 8 days (range, 3 to 10 days), and the antibiotic course was 30 days (range, 26 to 37 days), with a hospital stay of 37 days (range, 20 to 54 days). One patient in group 2 did not survive. Group 3 consisted of 17 patients. The time to mediastinal sterilization was 6 days (range, 1 to 10 days), and the antibiotic course was 15 days (range, 10 to 31 days), with a hospital stay of 20 days (range, 18 to 36 days). Two patients in group 3 did not survive. None of the deaths was directly related to mediastinitis, as the mediastinum was sterile in all 3 patients before death.

CONCLUSIONS

This simple treatment was efficient and reliable in achieving mediastinal sterilization. In addition, short antibiotic courses decreased restraint, which is poorly tolerated in pediatric patients.

Negative pressure therapy is effective to manage a variety of wounds in infants and children

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days-18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.

Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm

Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.

Vacuum-assisted closure: state of clinic art

Treatment of wounds has been the cornerstone of plastic surgery since its inception. Vacuum-assisted closure provides a new paradigm that can be used in concert with a wide variety of standard existing plastic surgery techniques. It was originally developed as an alternative treatment for debilitated patients with chronic wounds. It has rapidly evolved into a widely accepted treatment of chronic and acute wounds, contaminated wounds, burns, envenomations, infiltrations, and wound complications from failed operations. The ease of technique and a high rate of success have encouraged its adaptation by thoracic, general, trauma, burn, orthopedic, urologic, as well as plastic surgeons. This article discusses multidisciplinary advances in the use of the vacuum-assisted closure technique over the past 10 years and its status as of 2006. Creative surgeons continue to regularly adapt the system to difficult problems. This technique in trained surgical hands greatly enhances the scope and safety of wound treatment.