Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections?

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy

INTRODUCTION

Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI.

METHODS

We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed.

RESULTS

All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps.

CONCLUSIONS

We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs).

METHODS

A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS).

RESULTS

Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF.

CONCLUSIONS

Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

Sternal wound infections after sternotomy: risk factors, prevention and management

A serious complication after cardiac surgery is sternal wound infection. Although incidence rates vary worldwide, this complication raises significant concern in a certain patient demographic. This article uses risk assessment strategies to identify a high-risk patient profile and draws parallels with positive predictors in the preoperative, intraoperative and postoperative setting. It describes the complexity of sternal wound infections and highlights guidelines on detection and treatment. The optimal goal of this article is to help minimise the incidence of sternal wound complications after sternotomy by discussing recommendations for preoperative, intraoperative and postoperative preventive measures.

Bilateral partial pectoralis major muscle turnover flaps for the management of deep sternal wound infection following cardiac surgery

Background

The pectoralis major muscle is a versatile flap used as an advancement or turnover flap for the treatment of deep sternal wound infection (DSWI) after median sternotomy. Advancement flaps provide suboptimal mass volume and sometimes cannot fully fill the dead space in the mediastinum. Turnover flaps can sufficiently cover the inferior sternum and fill dead space; however, the procedure requires disinsertion of the muscle from the humerus, resulting in functional loss and cosmetic deformity. In an attempt to optimize the benefits and minimize the drawbacks of both flaps, we developed a novel turnover flap method using the bilateral partial pectoralis major muscle. In this study, we introduce this new flap method and report its initial clinical results.

Methods

The bilateral pectoralis major muscle is split into upper and lower parts according to the direction of the muscle fibers. The upper part of the pectoralis major muscle on one side and the lower part of the pectoralis major muscle on the other side were selected as the turnover flaps. The parts of the pectoralis major muscle selected as turnover flaps were transected vertically at the midline of the clavicle. Our novel turnover flap method was used to treat 11 patients with DSWI following cardiac surgery.

Results

No deaths occurred in the group. In 10 patients, the chest incision healed without complications and reoperation, while 1 patient experienced delayed healing of the skin incision. None of the patients experienced subcutaneous hematoma or oozing that required reopening and drainage. The average hospitalization time was 14±7.9 days. After 6 months of follow-up, none of the patient had experienced recurrence of DSWI. Abnormal movement of the upper limbs or deformities of the chest wall were not detected in all 11 patients.

Conclusions

Bilateral partial pectoralis major muscle turnover flaps are appropriate for the treatment of DSWI after cardiac surgery. This novel method does not only provide sufficient volume to fill the defect but can also preserve the function of the upper limbs and prevent cosmetic deformity of the chest wall.

Impact of microbial findings on plastic reconstructive surgery outcomes in patients with deep sternal wound infection after cardiac surgery

Deep sternal wound infection (DSWI) is a life threatening complication after cardiac surgery. In severe cases, flaps are needed to cover the wound. However, it is controversial if an aseptic environment is necessary at the time of wound closure. This is a retrospective study of 73 patients with DSWI treated by debridement and local or free flap from June 2008 until December 2017. The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed. Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83). Positive microbial findings at the time of plastic reconstructive surgery in patients with DSWI are not associated with a higher reoperation or mortality rate or a longer in-hospital stay. Repeated debridement and vacuum-assisted therapy to achieve negative microbial results might not be necessary in the treatment of these patients.Key messagesPositive microbial findings at the time of plastic reconstructive surgery in patients with deep sternal wound infection seems not to be associated with a higher reoperation or mortality rate or a longer in-hospital stay.The influence of positive microbiological findings at the time of plastic reconstructive surgery on reoperation rate and length of in-hospital stay was analyzed in 73 patients with deep sternal wound infection.Microbiological exams revealed positive results in 47 (64.4%) and no results in 26 patients. Reoperation had to be performed in 21.3% (positive cultures) versus 15.4% (p = .54), mean in hospital stay was 24.1 days (positive cultures) versus 21.8 days (p = .39) and in-hospital mortality was 6.4% (positive cultures) versus 7.7% (p = .83).