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

[The split turnover pectoralis muscle flap: an easy and safe method for sternal wound coverage]

The conventional pectoralis muscle flap is well known for the reconstruction of sternal defects after deep sternal wound infection. The pectoralis muscle flap can be harvested as an advancement flap based on the thoracoacromial artery, or it can be harvested as a turnover flap based on intercostal perforators of the internal thoracic artery. A disadvantage of the advancement flap can be seen in its limited reach, especially for covering the lower third of the sternum. The turnover flap is well suited for coverage of the lower and middle sternal third, but then lacks the length for coverage of the cranial third. The authors describe a new method for splitting up the pectoralis turnover muscle flap along its muscle fibres in order to gain additional length. Between 2017 and 2022, we treated 12 patients with this method. Total wound coverage and closure have been achieved in all 12 patients. Thus, the split turnover pectoralis flap is a safe and effective method for sternal wound treatment.

The combined application of antibiotic-loaded bone cement and vacuum sealing drainage for sternal reconstruction in the treatment of deep sternal wound infection

Background

Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Traditional treatment methods for DSWI include complete debridement, vacuum sealing drainage wound therapy and sometimes transposition of muscle flap. This study aimed to evaluate the utility of antibiotic-loaded bone cement combined with vacuum sealing drainage on DSWI and explore the effect of this treatment on lung function.

Methods

Between January 2018 and December 2019, we treated 12 patients suffering a mediastinitis and open thorax using antibiotic-loaded bone cement combined with vacuum sealing drainage. Subsequently, the blood and local concentration of antibiotic were measured. The patient characteristics, pulmonary function, were retrospectively analyzed. Subjects were followed up for 12 months.

Results

There were no intraoperative deaths. All patients’ healing wounds were first-stage healing without complications and reoperation, the mean hospital stay was 20.2 ± 3.5 days. Local vancomycin concentrations largely exceeded the ones needed for their efficacy while little antibiotic was found in the blood. Pulmonary function testing was improved 2 weeks after the operation. No infection reoccurred in12-month follow-up.

Conclusions

The antibiotic-loaded bone cement combined with vacuum sealing drainage might be an effective method for the sternal reconstruction of deep sternal wound infection and it can improve the patient's lung function in a short time.

Antibiotic-loaded bone cement combined with vacuum sealing drainage to treat deep sternal wound infection following cardiac surgery: the first case report

Background

Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Here we first present a case of a patient successfully treated for antibiotic-loaded bone cement (ALBC) combined with vacuum sealing drainage (VSD) of DSWI.

Case presentation

This case report presented a patient who underwent open heart surgery, and suffered postoperatively from a DSWI associated with enterococcus cloacae. Focus debridement combined with ALBC filling and VSD was conducted in stage I. Appropriate antibiotics were started according to sensitivity to be continued for 2 weeks until the inflammatory markers decreased to normal. One month after the surgery, patient’s wound was almost healed and was discharged from hospital with a drainage tube. Two months after the stage I surgery procedure, the major step was removing the previous ALBC, and extensive debridement in stage II. The patient fully recovered without further surgical treatment.

Conclusions

The results of this case suggest that ALBC combined with VSD may be a viable and safe option for deep sternal wound reconstruction.

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Background:

Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon.

Methods:

Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space.

Results:

Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities.

Conclusion:

Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

Reconstruction of sternal defects after sternotomy with postoperative osteomyelitis, using a unilateral pectoralis major advancement muscle flap

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.

Antibiotic-loaded ceramic sternum for sternal replacement in a patient with deep sternal wound infection

A 68-year-old man presented with destruction of his sternum after cardiac surgery. Classical management with multiple debridements, vacuum dressings and antibiotics failed. A replacement of his sternum was performed using an antibiotic-loaded porous alumina ceramic sternum. Despite the infected wound, the ceramic sternum did not get infected due to the high antibiotic concentration obtained locally. Two years after the surgery, no relapse occurred and the pulmonary function tests improved.

An antibiotic loaded ceramic sternum to treat destroyed infected sternum: 4 cases

Background

After its destruction during refractory deep sternal wound infection (DSWI), current sternum reconstructions mainly rely on muscle flaps technique, but such technique have pitfalls and limits. To tackle the limited possibilities to use device implantation because of the risk of infection, we developed a self-protected device allowing its implantation in an infected area.

Methods

We used gentamicin alone or in combination with vancomycin loaded in a porous ceramic sternum to replace sternums destroyed during DSWI. The aim was to mechanically replace the sternum and to secure the implantation by killing the remaining bacteria in the wound thanks to the loaded antibiotic.

Results

This device was implanted in four infected patients during DWSI with sternal dehiscence. No complication occurred during surgeries, and wound healing was obtained quickly. Local antibiotic concentrations largely exceeded the ones needed for their efficacy while no antibiotic was found in the blood. All patients are well-being. However previously unknown gentamicin resistant bacteria, present in the surgical wound at the time of positioning, required sternal implant removal for one patient after 19 months. For all patients, pulmonary function tests (PFT) improved after implantation.

Conclusions

The ceramic sternum played its role consolidating the thoracic cage without stiffening. The antibiotic loaded in the sternum allowed a secure implantation, killing bacteria before the colonization of the implant even in this infected area. These four implantations are promising for patients with sternal destruction after DSWI.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

OBJECTIVE

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

METHODS

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

RESULTS

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

CONCLUSIONS

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.

Sternal reconstruction after post-sternotomy mediastinitis

Background

Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text.

Methodology and review

This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented.

Conclusions

Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.

Defining post-sternotomy mediastinitis for clinical evidence-based studies

Background

Considerable advances have already been made in the treatment of deep thoracic wound infections following a median sternotomy for cardiac surgery. Further improvement in diagnosis, treatment, and outcome will require a targeted approach by multidisciplinary teams. Clear communication and synergy between the various clinical and supportive disciplines would assist in removing the last barriers to standardized evidence-based studies and the development of improved evidence-based guidelines.

Methods

An extensive literature search without language restrictions was carried out on PubMed (Medline), EMBASE, and Web of Science, covering the period 1988 to week 16, 2014, and a manual search of the reference lists was performed regarding all possible definitions and classifications of post-sternotomy mediastinitis. Two hundred and eighteen papers describing post-sternotomy infections in a multitude of terms were identified, and the strengths and weaknesses of the most popular definitions and terms relating specifically to post-sternotomy infections were examined.

Results

This study revealed that clinicians use a multitude of terms to describe post-sternotomy infections without defining the condition under treatment. Occasionally, older epidemiological (surveillance) definitions were used. It also shows that supportive disciplines have their own definitions, or interpretations of existing definitions, to describe these infections.

Conclusion

The outcome of this study is that clinicians have adopted no single definition, which is essential for further improvement for evidence-based studies. We suggest that it is possible to adopt a single term for thoracic infection after a sternotomy (and only sternotomy), and propose a clinical definition for this purpose.

Deep sternal wound infection after open heart surgery--reconstructive options

OBJECTIVES

The management of sternal defects arisen after deep sternal wound infection is challenging and often requires extensive interdisciplinary teamwork between plastic and thoracic surgeons. In this study, the published literature on methods used to reconstruct sternal defects arisen as a result of deep sternal wound infection after open-heart surgery will be reviewed.

DESIGN

The Cochrane, Embase, PubMed, and SveMed + databases were searched in December 2011. Only papers regarding treatment of deep sternal wound infection after open-heart surgery in adults were included.

RESULTS

The literature search identified 224 original papers that met the inclusion criteria. The majority dealt with surgical techniques. None of the studies regarding reconstructive options were designed as randomized controlled trials, and the levels of evidence are generally low.

CONCLUSION

The treatment of deep sternal wound infection has evolved considerably, but there is still little consensus regarding optimal surgical management and a general lack of a standard treatment protocol. The use of muscle flap transposition is well documented. Recent studies recommend the use of topical negative pressure therapy as an adjunct to surgical reconstruction.