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Chen Y, He F, Wu F, Hu X, Zhang W, Li S, Zhang H, Duan W, Guan H. Developing a calculable risk prediction model for sternal wound infection after median sternotomy: a retrospective study. BURNS & TRAUMA 2024; 12:tkae031. [PMID: 39282020 PMCID: PMC11401447 DOI: 10.1093/burnst/tkae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 02/25/2024] [Indexed: 09/18/2024]
Abstract
Background Diagnosing sternal wound infection (SWI) following median sternotomy remains laborious and troublesome, resulting in high mortality rates and great harm to patients. Early intervention and prevention are critical and challenging. This study aimed to develop a simple risk prediction model to identify high-risk populations of SWI and to guide examination programs and intervention strategies. Methods A retrospective analysis was conducted on the clinical data obtained from 6715 patients who underwent median sternotomy between January 2016 and December 2020. The least absolute shrink and selection operator (LASSO) regression method selected the optimal subset of predictors, and multivariate logistic regression helped screen the significant factors. The nomogram model was built based on all significant factors. Area under the curve (AUC), calibration curve and decision curve analysis (DCA) were used to assess the model's performance. Results LASSO regression analysis selected an optimal subset containing nine predictors that were all statistically significant in multivariate logistic regression analysis. Independent risk factors of SWI included female [odds ratio (OR) = 3.405, 95% confidence interval (CI) = 2.535-4.573], chronic obstructive pulmonary disease (OR = 4.679, 95% CI = 2.916-7.508), drinking (OR = 2.025, 95% CI = 1.437-2.855), smoking (OR = 7.059, 95% CI = 5.034-9.898), re-operation (OR = 3.235, 95% CI = 1.087-9.623), heart failure (OR = 1.555, 95% CI = 1.200-2.016) and repeated endotracheal intubation (OR = 1.975, 95% CI = 1.405-2.774). Protective factors included bone wax (OR = 0.674, 95% CI = 0.538-0.843) and chest physiotherapy (OR = 0.446, 95% CI = 0.248-0.802). The AUC of the nomogram was 0.770 (95% CI = 0.745-0.795) with relatively good sensitivity (0.798) and accuracy (0.620), exhibiting moderately good discernment. The model also showed an excellent fitting degree on the calibration curve. Finally, the DCA presented a remarkable net benefit. Conclusions A visual and convenient nomogram-based risk calculator built on disease-associated predictors might help clinicians with the early identification of high-risk patients of SWI and timely intervention.
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Affiliation(s)
- Yang Chen
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Fei He
- School of Public Management, Northwest University, Xi'an, 710127, Shaanxi, People's Republic of China
| | - Fan Wu
- Department of Cardiovascular Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Xiaolong Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Wanfu Zhang
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Shaohui Li
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Hao Zhang
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
| | - Hao Guan
- Department of Burns and Cutaneous Surgery, Xijing Hospital of Air Force Medical University, Xi'an, 710032, Shaanxi, People's Republic of China
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Arazi M, Grosman-Rimon L, Yehezkeel S, Rimon J, Gohari J, Gleitman S, Kachel E. Predictors of prolonged hospitalization in modified sternoplasty following postoperative mediastinitis. J Card Surg 2022; 37:4726-4731. [PMID: 36378944 PMCID: PMC10099381 DOI: 10.1111/jocs.17099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Deep sternal wound infection (DSWI) is a serious complication following cardiac surgery, and demands early intervention as any delay in diagnosis and management may lead to increased morbidity and mortality. DSWI is associated with increased length of hospitalization (LOH) and economic burden in this patient population. The aim of this study was to determine predictors for increased length of hospitalization in patients who underwent the Modified Sternoplasty technique for deep sternal wound infection following cardiac surgery. METHODS A retrospective study was undertaken on data from patients who underwent the Modified Sternoplasty surgery for DSWI between September 2010 and January 2020. Patients' characteristics that were recorded included medical history, type of the original heart surgery, length of hospitalizations, and risk factors including hyperlipidemia, diabetes mellitus and hypertension, and morbidity and mortality rates following the Modified Sternoplasty. RESULTS Sixty-eight patients underwent the Modified Sternoplasty surgery with an average length of hospitalization of 24.63 + 22.09 days. Multivariable analysis showed that only gender was considered a predictor of length of hospitalization when controlling for comorbidities, with average length of hospitalization longer for women than men (35.4 vs. 20.9, p = .04). CONCLUSION The Modified Sternoplasty surgery is a novel surgical technique for managing DSWI complicated by sternal dehiscence with exposed heart and great vessels. Female gender was associated with increased length of hospitalization in our patient cohort, with average length of hospitalization for women almost twice that of males.
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Affiliation(s)
- Mattan Arazi
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liza Grosman-Rimon
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shachar Yehezkeel
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Jordan Rimon
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jacob Gohari
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Creedmoor Psychiatric Center, Queens Village, New York, New York, USA
| | - Sagi Gleitman
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel
| | - Erez Kachel
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
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The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis. Plast Reconstr Surg Glob Open 2022; 10:e4233. [PMID: 35506023 PMCID: PMC9053136 DOI: 10.1097/gox.0000000000004233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
Abstract
Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.
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Yu CM, Yu CM, Yao WT, Chen YF, Lee AL, Liu YC, Tu CP, Huang WC, Tung KY, Tsai MF. Efficacy and safety of pectoralis muscle flap combined rectus abdominis muscle sheath fasciocutaneous flap for reconstruction of sternal infection. Int Wound J 2022; 19:1829-1837. [PMID: 35289489 PMCID: PMC9615267 DOI: 10.1111/iwj.13788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
Few studies have assessed the efficacy and safety of reconstruction of sternal infection using a pectoralis muscle flap combined with a rectus abdominis muscle (RAM) sheath fasciocutaneous flap. We report here our experience with this procedure to reconstruct the sternal defect in patients (n = 46) with a deep sternal wound infection (DSWI) after cardiac surgery. After wound reconstruction, the proportion of prolonged mechanical ventilation use and intensive care unit (ICU) stay were 17.4% (n = 8) and 21.7% (n = 10), respectively. The 30‐day all‐cause mortality was 15.2%; recurrence rate was 17.4%; postoperative complications were 15.2%; and median hospital stay was 31 (0‐157) days. Multivariate logistic regression analysis revealed that hypertension (β = 21.32, 95%CI 4.955‐37.68, P = .014), drainage‐tube use (β = 0.944, 95%CI 0.273‐1.614, P = .008), and prolonged intensive care unit stay (β = 53.65, 95%CI 31.353‐75.938, P < .001) were significantly correlated with hospital stay. In conclusion, a procedure including surgical debridement, sternal reconstruction with bilateral PM and RAM sheath flap, long‐term antibiotics, and adequate drainage is a beneficial technique in the reconstruction of deep sternal wound infection after cardiac surgery. Duration of drainage tube use may be as an index for a hospital stay or wound healing.
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Affiliation(s)
- Chieh-Ming Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Chia-Meng Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Wen-Teng Yao
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Yu-Fan Chen
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - An-Li Lee
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Ying-Chun Liu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Chih-Peng Tu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Wen-Chen Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Kwang-Yi Tung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Ming-Feng Tsai
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, Collage of Medical Science and Technology, Taipei Medical University, Taipei City, Taiwan
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Harder Y, Krapf J, Rieck B, Schaefer DJ, Djedovic G, Kutschka I, Graf K, Kneser U, Horch RE, Lehnhardt M, Pierer G. [Deep sternal wound infection after sternotomy - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]. HANDCHIR MIKROCHIR P 2021; 53:519-525. [PMID: 33951736 DOI: 10.1055/a-1425-5987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.
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Affiliation(s)
- Yves Harder
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Ospedale Regionale di Lugano (ORL), Ente Ospedaliero Cantonale (EOC), Lugano, Schweiz.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Schweiz
| | - Johanna Krapf
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Innsbruck, Österreich
| | - Bernd Rieck
- Kaiser-Friedrich-Straße, Hildesheim, Deutschland
| | - Dirk J Schaefer
- Klinik für Plastische, Rekonstruktive, Ästhetische und Handchirurgie, Universitätsspital Basel, Schweiz
| | - Gabriel Djedovic
- Abteilung für Plastische, Rekonstruktive und Ästhetische Chirurgie, Landekrankenhaus Feldkirch, Österreich
| | - Ingo Kutschka
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Universitätsmedizin Göttingen, Deutschland
| | - Karolin Graf
- Zentralinstitut für Krankenhaushygiene, Paracelsus- Kliniken Deutschland, Langenhagen, Deutschland
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Klinik für Plastische und Handchirurgie, Universität Heidelberg, Deutschland
| | - Raymund E Horch
- Plastisch- und Handchirurgische Klinik, Universitätsklinikum Erlangen, Deutschland
| | - Marcus Lehnhardt
- Klinik für Plastische Chirurgie und Handchirurgie, Schwerbrandverletztenzentrum, BG Universitätsklinikum Bergmannsheil Bochum, Deutschland
| | - Gerhard Pierer
- Universitätsklinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Medizinische Universität Innsbruck, Österreich
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Wyckman A, Abdelrahman I, Steinvall I, Zdolsek J, Granfeldt H, Sjöberg F, Nettelblad H, Elmasry M. Reconstruction of sternal defects after sternotomy with postoperative osteomyelitis, using a unilateral pectoralis major advancement muscle flap. Sci Rep 2020; 10:8380. [PMID: 32433505 PMCID: PMC7239941 DOI: 10.1038/s41598-020-65398-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The pectoralis major flap, which is usually harvested bilaterally, is considered a workhorse flap in the reconstruction of sternal defects. After a median sternotomy for open heart surgery, 1%-3% of patients develop deep infection and dehiscence of the sternal wound, some of which will eventually require reconstructive surgery. Our aim was to describe the clinical feasibility and associated complications of the unilateral pectoralis major advancement flap in the reconstruction of sternal defects. Methods: A retrospective analysis of all adult patients who were operated on using a unilateral pectoralis major flap for reconstruction of the chest wall at the Linköping University Hospital during 2008–18 was made using data retrieved from medical records. Results: Forty-three patients had reconstructions with unilateral pectoralis major flaps. Three flaps failed completely, and another 10 patients developed complications that required further operation. The factors that were independently associated with loss of the flaps and complications were: older age, male sex, the number of different antibiotics used, and a long duration of treatment with negative wound pressure. Fewer wound revisions before the reconstruction resulted in more complications. The factors that were independently associated with prolonged time to complete healing were emergency reoperation after the initial operation and complications after reconstruction. Conclusion: The unilateral pectoralis major advancement flap has proved to be a useful technique in the reconstruction of most sternal defects after sternal wound infection in older patients. There is, however, need for a follow-up study on a larger number of procedures to evaluate the long-term outcome compared with other methods of sternal reconstruction.
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Affiliation(s)
- Alexander Wyckman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
| | - Islam Abdelrahman
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Plastic Surgery Unit, Surgery Department, Suez Canal University, Ismailia, Egypt
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johann Zdolsek
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hans Granfeldt
- Department of Thoracic and Vascular Surgery in Östergötland, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Folke Sjöberg
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hans Nettelblad
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Discussion: Predictors of Complications After Pectoralis Major Transposition for Sternum Dehiscence. Ann Plast Surg 2017. [PMID: 28650406 DOI: 10.1097/sap.0000000000001165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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