Elastic Device Facilitating Delayed Primary Closure of Sternal Wound Infection

Novel mesh suture may resist bone cutting seen with wire-based sternal closures

OBJECTIVE

Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution.

METHODS

Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force.

RESULTS

All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07).

CONCLUSIONS

Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates

Background

Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.

Method

A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.

Results

A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796-15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557-62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).

Conclusions

Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

Use of an abdominal reapproximation anchor system in the closure of large, open myelomeningoceles

Open neural tube defects are complex congenital abnormalities of the nervous system in which nervous tissue is exposed on the patient's back at the time of delivery. These malformations require surgical correction, and although replacement of the neural placode internally is fairly standard, providing skin closure can be very challenging especially in large defects. An abdominal reapproximation anchor (ABRA) device may be of value in attaining skin closure in these large, open myelomeningocele defects in which primary closure cannot be accomplished surgically. In a study period during which 65 patients underwent surgical closure of open myelomeningocele defects, 5 of them underwent ABRA-assisted closure.The average surgical intervention for myelomeningocele repair occurred on day 2.2 of life (range 2-3 days). The average defect size was 37 cm2 (range 16-56 cm2), and the average time to formal closure was 30.8 days (range 8-63 days). One of the patients had natural closure with just ABRA approximation. The remaining 4 patients underwent formal delayed primary closure when the skin edges became approximated. Use of the ABRA system in the closure of a large, open myelomeningocele may be valuable in select patients but requires further follow-up and comparison to identify truly significant differences with traditional techniques.

Tissue expanders with a focus on extremity reconstruction

INTRODUCTION

Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures.

AREAS COVERED

In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database.

EXPERT COMMENTARY

An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

Endoscope-Assisted Pectoralis Major-Rectus Abdominis Bipedicle Muscle Flap for the Treatment of Poststernotomy Mediastinitis

INTRODUCTION

Various management strategies have been reported for sternal wound care; however, they exhibit limited effectiveness or are associated with severe complications. Furthermore, it is difficult for the standard pectoralis major (PM) muscle advance flap to reach the lower third of the sternum. This article examines using the PM-rectus abdominis (RA) bipedicle muscle flap to treat lower-third deep sternal wound infection.

METHODS

The outcomes of patients who received a PM-RA bipedicle muscle flap harvest at our institution between 1996 and 2014 were reviewed. The method involves performing a subfascial and subperiosteal dissection of the PM to elevate the muscle flap. Blunt dissection may be performed carefully under an endoscope. Endoscope visualization enables us to identify the critical structures lateral to the PM muscle. In addition, the connective tissue to the RA muscle was preserved. Continuity was carefully preserved from the pectoral-thoracoepigastric fascia to the anterior rectus sheath. The flap could then be transposed to fill the lower-third sternal tissue defect with ease.

RESULTS

A total of 12 patients, with a mean age of 71 years (45-89 years), were treated using an endoscope-assisted PM-RA bipedicle muscle flap harvest. Wound microbiology of the 12 patients revealed that 3 patients had methicillin-resistant Staphylococcus aureus, 4 had S. aureus, 1 had coagulase-negative Staphylococcus, 1 had Escherichia coli, 1 had Pseudomonas aeruginosa, 1 had Mycobacterium tuberculosis, and 1 had a mixed growth of organisms. One instance of recurrent sternal infection was identified among the patients. Moreover, 1 patient died from heart failure 5 weeks after surgery, but the coverage of the sternal wound was successful. Accidental injury to the surrounding neurovascular structure of the patients was avoided, and only 10 to 15 minutes was required to divide the PM muscle.

CONCLUSIONS

Performing this harvest method under endoscopic assistance has several advantages, such as preventing excess traction of the skin edge to diminish the skin slough. This method could be an effective alternative for harvesting the PM-RA bipedicle muscle flap to reconstruct the lower-third sternal wound.