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Sudin A, Chong C, Hassan R. Incidence and Factors Associated With Post-Sternotomy Pain Syndrome in the National Heart Institute, Malaysia. J Cardiothorac Vasc Anesth 2024; 38:466-474. [PMID: 38114372 DOI: 10.1053/j.jvca.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE To determine the incidence of poststernotomy pain syndrome (PSPS) after open cardiac surgery in 2021. To determine characteristics and assess the severity of symptoms in patients diagnosed with PSPS. To identify factors that can be associated with patients who were positive for PSPS. DESIGN AND METHODOLOGY This study used a retrospective observational approach. Logistic regression analysis was employed to identify factors associated with the positive group. SETTING This study included all adult patients who underwent open cardiac surgery at the National Heart Institute, Malaysia, in 2021. PARTICIPANTS A total of 1,395 patients were enrolled. INTERVENTIONS The study involved conducting phone interviews to assess the presence of PSPS, followed by administering the Brief Pain Inventory questionnaire in the positive group to identify characteristics and severity of chronic pain. MEASUREMENTS AND MAIN RESULTS The incidence of PSPS after open cardiac surgery in 2021 was 20.35%. A total of 17.7% of patients reported that pain affected their daily activities, sleep, or emotions. Univariate analysis identified factors associated with PSPS, including age <60 years old, body mass index >30 kg/m2, history of previous percutaneous coronary intervention, ejection fraction <50%, the absence of chronic kidney disease (CKD), and internal mammary artery harvesting (p < 0.05). Multivariate analysis revealed that 4 independent factors were associated with PSPS: age <60 years old, history of previous percutaneous coronary intervention, ejection fraction <50%, and the absence of CKD (as compared with CKD) (p < 0.05). CONCLUSIONS Poststernotomy pain syndrome is a complex issue affected by various factors. Although the pain score may not be as severe as previously believed, it remains crucial to recognize PSPS because a significant proportion of patients are affected.
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Affiliation(s)
- Arif Sudin
- Anesthesia & Intensive Care department, National Heart Institute (IJN), Kuala Lumpur, Malaysia.
| | - Collins Chong
- Department of Anaesthesia & Intensive Care, Faculty of Medicine & Health Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Rozaini Hassan
- Anesthesia & Intensive Care department, National Heart Institute (IJN), Kuala Lumpur, Malaysia
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Eraqi M, Diab AH, Matschke K, Alexiou K. Confirmation of Safety of Titanium Wire in Sternotomy Closure, A Randomized Prospective Study. Thorac Cardiovasc Surg 2024; 72:70-76. [PMID: 36918153 PMCID: PMC10786665 DOI: 10.1055/s-0043-1764315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/26/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND There are many factors that are known to increase the risk of sternal wound infection (SWI); some studies have reported that nickel is a risk factor for SWI. Titanium wires have only been used as an alternative to steel wires in patients with known allergy to nickel. However, there is a paucity of literature regarding the safety of using titanium wires compared to that on the safety of steel wires for sternum closure after cardiac surgery. Therefore, this study aimed to demonstrate the noninferiority of titanium wires, even in patients without a known allergy. METHODS A total of 322 patients who underwent elective full median sternotomy were randomly assigned to sternal closure either by titanium wires (n = 161) or by stainless steel wires. RESULTS Fourteen patients had sternal instability, six (3.7%) patients in the titanium group and eight (5%) patients in the stainless steel group (p = 0.585). There was no statistically significant difference between both groups in terms of postoperative wound infection (p = 0.147). Patients in the titanium group experienced statistically significant lower postoperative pain than those in the stainless steel group (p = 0.024). The wire type was not an independent risk factor for SI, as shown by univariate and logistic regression analyses. CONCLUSION Titanium wires are a good alternative and have been proven to be safe and effective for sternal closure. The surgeon should be aware of the possibility of developing an allergic reaction to the wires, especially in patients with previous multiple allergic histories.
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Affiliation(s)
- Mohamed Eraqi
- Klinikum Bayreuth GmbH, Bayreuth, Germany
- Department of Cardiac Surgery, Heart Center Dresden at the University Hospital Carl Gustav Carus, Dresden, Germany
| | - Abdel Hannan Diab
- Department of Cardiac Surgery, Heart Center Dresden at the University Hospital Carl Gustav Carus, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, Heart Center Dresden at the University Hospital Carl Gustav Carus, Dresden, Germany
| | - Konstantin Alexiou
- Department of Cardiac Surgery, Heart Center Dresden at the University Hospital Carl Gustav Carus, Dresden, Germany
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Giardini M, Guenzi M, Arcolin I, Godi M, Pistono M, Caligari M. Comparison of Two Techniques Performing the Supine-to-Sitting Postural Change in Patients with Sternotomy. J Clin Med 2023; 12:4665. [PMID: 37510778 PMCID: PMC10380334 DOI: 10.3390/jcm12144665] [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: 05/20/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with sternotomy are advised to follow sternal precautions to avoid the risk of sternal complications. However, there are no standard recommendations, in particular to perform the supine-to-sitting postural change, where sternal asymmetrical force may be applied. The aim of this study was to compare the rotational movement and the use of a tied rope (individual device for supine-to-sitting, "IDSS") to perform the supine-to-sitting postural change. A total of 92 patients (26% female) admitted to a rehabilitative post-surgery ward with sternotomy were assessed for sternal instability. Levels of pain and perceived effort during the two modalities of postural change and at rest were assessed. Patients reported higher values of pain and perceived effort (both p < 0.0005) during rotational movement with respect to the use of the IDSS. Moreover, patients with sternal instability (14%) and female patients with macromastia (25%) reported higher pain than those stable or without macromastia (both p < 0.05). No other risk factors were associated with pain. Thus, the IDSS seems to reduce the levels of pain and perceived effort during the supine-to-sitting postural change. Future studies with quantitative assessments are required to suggest the adoption of this technique, mostly in patients with high levels of pain or with sternal instability.
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Affiliation(s)
- Marica Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Guenzi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Ilaria Arcolin
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Marco Godi
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Physical Medicine and Rehabilitation of Veruno Institute, 28013 Gattico-Veruno, Italy
| | - Massimo Pistono
- Istituti Clinici Scientifici Maugeri IRCCS, Division of Cardiac Rehabilitation of Veruno Institute, 28103 Gattico-Veruno, Italy
| | - Marco Caligari
- Istituti Clinici Scientifici Maugeri IRCCS, Integrated Laboratory of Assistive Solutions and Translational Research (LISART), Scientific Institute of Pavia, 27100 Pavia, Italy
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Song Y, Chu W, Sun J, Liu X, Zhu H, Yu H, Shen C. Review on risk factors, classification, and treatment of sternal wound infection. J Cardiothorac Surg 2023; 18:184. [PMID: 37208736 DOI: 10.1186/s13019-023-02228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/02/2023] [Indexed: 05/21/2023] Open
Abstract
Sternal wound infection (SWI) is the most common complication of the median sternal incision. The treatment time is long, and the reconstruction is difficult, which causes challenges for surgeons. Plastic surgeons were often involved too late in such clinical scenarios when previous empirical treatments failed and the wound damage was relatively serious. Accurate diagnosis and risk factors against sternal wound infection need to be in focus. Classification of different types of sternotomy complications post-cardiac surgery is important for specific categorization and management. Not familiar with this kind of special and complex wound, objectively increasing the difficulty of wound reconstruction. The purpose of this comprehensive review is to review the literature, introduce various SWI risk factors related to wound nonunion, various classification characteristics, advantages and disadvantages of various wound reconstruction strategies, to help clinicians understand the pathophysiological characteristics of the disease and choose a better treatment method.
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Affiliation(s)
- Yaoyao Song
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Wanli Chu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Jiachen Sun
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Xinzhu Liu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Hongjuan Zhu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Hongli Yu
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China
| | - Chuan'an Shen
- Senior Department of Burns and Plastic Surgery, Fourth Medical Center of Chinese PLA General Hospital, No. 51, Fucheng Road, Haidian District, Beijing, 100048, China.
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Morales-Uribe CH, López A, Sepúlveda SM. Manejo conservador del hemopericardio por trauma: reporte de un caso. REVISTA COLOMBIANA DE CIRUGÍA 2022. [DOI: 10.30944/20117582.1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introducción. El trauma cardíaco penetrante es una patología con alta mortalidad, que alcanza hasta el 94 % en el ámbito prehospitalario y el 58 % en el intrahospitalario. El algoritmo internacional para los pacientes que ingresan con herida precordial, hemodinámicamente estables, es la realización de un FAST subxifoideo o una ventana pericárdica, según la disponibilidad del centro, y de ser positivo se procede con una toracotomía o esternotomía.
Métodos. Se hizo una búsqueda bibliográfica en las bases de datos Medline, Pubmed, Science Direct y UpTodate, usando las palabras claves: “taponamiento cardíaco”, “herida precordial” y “manejo no operatorio”. Se tomaron los datos de la historia clínica y las imágenes, previa autorización del paciente.
Caso clínico. Paciente masculino ingresó con herida en área precordial, estable hemodinámicamente, sin signos de sangrado activo, con FAST subxifoidea “dudosa”. Se procedió a realizar ventana pericárdica, la cual fue positiva para hemopericardio de 150 ml; se evacuaron los coágulos del saco pericárdico, se introdujo sonda Nelaton 10 Fr para lavado con solución salina 500 ml, hasta obtener retorno de líquido claro. Frente al cese del sangrado y estabilidad del paciente se decidió optar por un manejo conservador, sin toracotomía.
Conclusiones. No todos los casos de hemopericardio traumático por herida por arma cortopunzante requieren toracotomía. El manejo conservador con ventana pericárdica, drenaje de hemopericardio más lavado y dren es una opción en aquellos pacientes que se encuentran estables hemodinámicamente y no se evidencia sangrado activo posterior al drenaje del hemopericardio.
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Lender O, Göbölös L, Bajwa G, Bhatnagar G. Sternal wound infections after sternotomy: risk factors, prevention and management. J Wound Care 2022; 31:S22-S30. [PMID: 35678775 DOI: 10.12968/jowc.2022.31.sup6.s22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Olga Lender
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Laszlo Göbölös
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Gurjyot Bajwa
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Gopal Bhatnagar
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
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Oezpeker CU, Barbieri F, Hoefer D, Bonaros N, Grimm M, Mueller L. Upper Hemi-Sternotomy Provides Benefit for Patients with Isolated or Combined Mitral Valve Surgery. Medicina (B Aires) 2022; 58:medicina58020142. [PMID: 35208468 PMCID: PMC8874458 DOI: 10.3390/medicina58020142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/04/2022] [Accepted: 01/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background and objectives: Certain clinical and anatomical conditions are absolute or relative contraindications for safe mitral valve surgery via the right mini-thoracotomy access. It is uncertain whether patients with these contraindications may benefit from the less invasive approach via upper hemi-sternotomy compared to standard full sternotomy. Materials and methods: Out of 2052 mitral valve surgery patients, operated from 6/04 through 2/19, 1535 were excluded due to the different criteria for eligibility to both approaches. Out of these, 350 received full sternotomy and 167 upper hemi-sternotomy. After propensity score matching, 164 pairs were analyzed for operative variables, postoperative complications and 30-day and one-year survival. Results: Upper hemi-sternotomy was associated with a survival benefit of 30 days (99.4% vs. 82.1%; p < 0.001) and one-year (93.9% vs. 79.9% p < 0.001, HR 0.26, 95% CI 0.14–0.49). Cardiopulmonary bypass and aortic cross-clamp times were comparable in both groups. Upper hemi-sternotomy resulted in less low cardiac output syndrome (18.9% vs. 31.1%; p = 0.011); ventilation time (8 vs. 13 h; p < 0.001), length of intensive care stay (1 vs. 2 days; p < 0.001) and total hospital stay (8 vs. 9 days; p < 0.001) were shorter in the upper hemi-sternotomy group. Conclusion: In patients undergoing mitral valve surgery, upper hemi-sternotomy is associated with short- and mid-term survival benefits as well as lower postoperative complication rates compared to full sternotomy. Hence, the less invasive upper hemi-sternotomy can be a valid approach in patients with contraindications for right mini-thoracotomy.
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Affiliation(s)
- Cenk Ulvi Oezpeker
- Department of Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (D.H.); (N.B.); (M.G.); (L.M.)
- Correspondence: ; Tel.: +43-505040-83415; Fax: +43-505040-22502
| | - Fabian Barbieri
- Department of Cardiology, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Daniel Hoefer
- Department of Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (D.H.); (N.B.); (M.G.); (L.M.)
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (D.H.); (N.B.); (M.G.); (L.M.)
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (D.H.); (N.B.); (M.G.); (L.M.)
| | - Ludwig Mueller
- Department of Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria; (D.H.); (N.B.); (M.G.); (L.M.)
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Raheem AA, Hameed P, Whenish R, Elsen RS, G A, Jaiswal AK, Prashanth KG, Manivasagam G. A Review on Development of Bio-Inspired Implants Using 3D Printing. Biomimetics (Basel) 2021; 6:65. [PMID: 34842628 PMCID: PMC8628669 DOI: 10.3390/biomimetics6040065] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/08/2021] [Accepted: 11/15/2021] [Indexed: 01/15/2023] Open
Abstract
Biomimetics is an emerging field of science that adapts the working principles from nature to fine-tune the engineering design aspects to mimic biological structure and functions. The application mainly focuses on the development of medical implants for hard and soft tissue replacements. Additive manufacturing or 3D printing is an established processing norm with a superior resolution and control over process parameters than conventional methods and has allowed the incessant amalgamation of biomimetics into material manufacturing, thereby improving the adaptation of biomaterials and implants into the human body. The conventional manufacturing practices had design restrictions that prevented mimicking the natural architecture of human tissues into material manufacturing. However, with additive manufacturing, the material construction happens layer-by-layer over multiple axes simultaneously, thus enabling finer control over material placement, thereby overcoming the design challenge that prevented developing complex human architectures. This review substantiates the dexterity of additive manufacturing in utilizing biomimetics to 3D print ceramic, polymer, and metal implants with excellent resemblance to natural tissue. It also cites some clinical references of experimental and commercial approaches employing biomimetic 3D printing of implants.
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Affiliation(s)
- Ansheed A. Raheem
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
| | - Pearlin Hameed
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
| | - Ruban Whenish
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
| | - Renold S. Elsen
- School of Mechanical Engineering, Vellore Institute of Technology, Vellore 632014, India;
| | - Aswin G
- School of Advanced Sciences, Vellore Institute of Technology, Vellore 632014, India;
| | - Amit Kumar Jaiswal
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
| | - Konda Gokuldoss Prashanth
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
- Department of Mechanical and Industrial Engineering, Tallinn University of Technology, Ehitajate tee 5, 19086 Tallinn, Estonia
- Erich Schmid Institute of Materials Science, Austrian Academy of Science, Jahnstrasse 12, 8700 Leoben, Austria
| | - Geetha Manivasagam
- Centre for Biomaterials, Cellular and Molecular Theranostics, Vellore Institute of Technology, Vellore 632014, India; (A.A.R.); (P.H.); (R.W.); (A.K.J.); (G.M.)
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Hever P, Singh P, Eiben I, Eiben P, Nikkhah D. The management of deep sternal wound infection: Literature review and reconstructive algorithm. JPRAS Open 2021; 28:77-89. [PMID: 33855148 PMCID: PMC8027694 DOI: 10.1016/j.jpra.2021.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/26/2021] [Indexed: 01/14/2023] Open
Abstract
Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.
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Affiliation(s)
- Pennylouise Hever
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Prateush Singh
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Inez Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Paola Eiben
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
| | - Dariush Nikkhah
- Department of Plastic Surgery, Royal Free London NHS Foundation Trust, Pond Street, London, United Kingdom
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Suelo-Calanao RL, Thomson R, Read M, Matheson E, Isaac E, Chaudhry M, Loubani M. The impact of closed incision negative pressure therapy on prevention of median sternotomy infection for high risk cases: a single centre retrospective study. J Cardiothorac Surg 2020; 15:222. [PMID: 32814569 PMCID: PMC7437015 DOI: 10.1186/s13019-020-01265-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 08/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background Sternal wound infection (SWI) following cardiothoracic surgery is a major complication. It may significantly impact patient recovery, treatment cost and mortality rates. No universal guideline exists on SWI management, and more recently the focus has become prevention over treatment. Recent studies report positive outcomes with closed incision negative pressure therapy (ciNPT) on surgical incisions, particularly for patients at risk of poor wound healing. Objective This study aims to assess the effect of ciNPT on SWI incidence in high-risk patients. Methods A retrospective study was performed to investigate the benefit of ciNPT post sternotomy. Patients 3 years before the introduction of ciNPT (Control group) and 3 years after ciNPT availability (ciNPT group) were included. Only patients that had two or more of the risk factors; obesity, Chronic Obstructive Pulmonary Disease, old age and diabetes mellitus in the High Risk ciNPT cohort were given the ciNPT dressing. Patient demographics, EuroSCOREs and length of staywere reported as mean ± standard deviation. The Fisher’s exact test (two-tailed) and an unpaired t-test (two-tailed) were used to calculate the p-value for categorical data and continuous data, respectively. Results The total number of patients was 1859 with 927 in the Control group and 932 in the ciNPT group. No statistical differences were noted between the groups apart from the Logistic EuroSCORE (Control = 6.802 ± 9.7 vs. ciNPT = 8.126 ± 11.3; P = 0.0002). The overall SWI incidence decreased from 8.7 to 4.4% in the overall groups with the introduction of ciNPT (P = 0.0005) demonstrating a 50% reduction. The patients with two and above risk factor in the Control Group (High Risk Control Group) were 162 while there was 158 in the ciNPT Group (High Risk ciNPT Group). The two groups were similar in all characteristics. Although the superficial and deep sternal would infections were higher in the High Risk Control Group versus the High Risk ciNPT group patients (20(12.4%) vs 9(5.6%); P = 0.049 respectively), the length of postoperative stay was similar in both (13.0 ± 15.1 versus 12.2 ± 15.6 days; p + 0.65). However the patients that developed infections in the two High Risk Groups stayed significantly longer than those who did not (25.5 ± 27.7 versus 12.2 ± 15.6 days;P = 0.008). There were 13 deaths in Hospital in the High Risk Control Group versus 10 in the High Risk ciNPT Group (P = 0.66). Conclusion In this study, ciNPT reduced SWI incidence post sternotomy in patients at risk for developing SWI. This however did not translate into shorter hospital stay or mortality.
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Affiliation(s)
| | - Richard Thomson
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Maxine Read
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | | | - Emmanuel Isaac
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mubarak Chaudhry
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK.
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11
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Liu S, Zhang J, Yin H, Pang L, Wu B, Shi H. The value of
18
F‐FDG PET
/
CT
in diagnosing and localising deep sternal wound infection to guide surgical debridement. Int Wound J 2020; 17:1019-1027. [PMID: 32298049 DOI: 10.1111/iwj.13368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 03/29/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Siwei Liu
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
| | - Jie Zhang
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
| | - Hongyan Yin
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
| | - Lifang Pang
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
| | - Bing Wu
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
| | - Hongcheng Shi
- Department of Nuclear Medicine Zhongshan Hospital, Fudan University Shanghai China
- Nuclear Medicine Institute of Fudan University Shanghai China
- Shanghai Institute of Medical Imaging Shanghai China
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Zanchetta F, Borg M, Troisi L. Reconstruction of a deep sternal wound with exposed pericardium using an IMAP propeller flap: A case report. Clin Case Rep 2019; 7:2371-2374. [PMID: 31893061 PMCID: PMC6935634 DOI: 10.1002/ccr3.2492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 08/31/2019] [Indexed: 11/17/2022] Open
Abstract
The results of this case suggest that the IMAP propeller flap may be a viable and safe option for deep sternal wound reconstruction with minimal donor-site morbidity.
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Affiliation(s)
- Francesco Zanchetta
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Plastic Reconstructive and Aesthetic Surgery UnitUniversity of MessinaPoliclinico “G. Martino”MessinaItaly
| | - Matthew Borg
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Plastic Surgery and Burns UnitMater Dei HospitalL‐ImsidaMalta
| | - Luigi Troisi
- Department of Plastic and Reconstructive SurgerySalisbury District HospitalSalisbury NHS Foundation TrustSalisburyUK
- Orthopaedic DepartmentSouthampton General HospitalUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
- University Department of Hand Surgery & RehabilitationSan Giuseppe HospitalIRCCS MultiMedicaMilan UniversityMilanItaly
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13
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Spindler N, Kade S, Spiegl U, Misfeld M, Josten C, Mohr FW, Borger M, Langer S. Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall. BMC Surg 2019; 19:173. [PMID: 31752814 PMCID: PMC6868737 DOI: 10.1186/s12893-019-0631-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background At present, data describing patients’ long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). Methods This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. Results The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35–85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88–76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26–118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2–118). Conclusions Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Stefanie Kade
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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14
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Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery. Arch Plast Surg 2019; 46:291-302. [PMID: 31336416 PMCID: PMC6657195 DOI: 10.5999/aps.2018.01151] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.
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15
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Gamel AE. Sternal Closure: The Elusive Holy Grail. Heart Lung Circ 2019; 28:358-359. [PMID: 30712657 DOI: 10.1016/j.hlc.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Adam El Gamel
- Waikato Cardiothoracic Unit, Waikato Hospital, Hamilton, New Zealand; Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; University of Waikato Medical Research Centre, The University of Waikato, New Zealand.
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16
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Bota O, Josten C, Borger MA, Spindler N, Langer S. Standardized Musculocutaneous Flap for the Coverage of Deep Sternal Wounds After Cardiac Surgery. Ann Thorac Surg 2019; 107:802-808. [PMID: 30620706 DOI: 10.1016/j.athoracsur.2018.09.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/16/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Deep sternal wound infection remains a serious complication after cardiac surgery, leading to increased morbidity, mortality, and cost. The goal of our study was to develop a standardized, reproducible method to safely cover deep sternal wounds and ensure improved healing rates. METHODS The study was developed as a retrospective cohort study. We included 58 patients who received standardized latissimus dorsi flap coverage of a sternum defect wound after poststernotomy mediastinitis at our institution between September 2015 and June 2017. RESULTS The average age of the cohort was 66.75 years, and 51.72% of patients were men. The mean hospital stay was 26.83 days. Eight patients (14.75%) died during the hospital stay due to sepsis or heart failure. The average flap size was 137.13 cm2. The mean operative time was 155 minutes. Seventy-four percent of patients developed a seroma at the donor site, which was treated conservatively with compression garments and taps, and 7% of patients developed a wound dehiscence of the donor site, which was treated conservatively with dressings. The mean follow-up time was 15 weeks. All 50 surviving patients showed complete wound healing on follow-up. CONCLUSIONS The latissimus dorsi pedicled flap is a safe, reproducible technique for coverage of deep sternal wounds, with few relevant perioperative complications. By setting definite parameters for the flap dissection and by ensuring a reliable blood supply, our method enables the coverage of these complex wounds by an interdisciplinary team in any cardiovascular surgical setting.
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Affiliation(s)
- Olimpiu Bota
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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17
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Zhang R, Feng Z, Zhang Y, Tan H, Wang J, Qi F. Diagnostic value of fluorine-18 deoxyglucose positron emission tomography/computed tomography in deep sternal wound infection. J Plast Reconstr Aesthet Surg 2018; 71:1768-1776. [PMID: 30196022 DOI: 10.1016/j.bjps.2018.07.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 06/03/2018] [Accepted: 07/27/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Rufan Zhang
- Department of Plastic and Reconstructive Surgery, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China
| | - Zihao Feng
- Department of Plastic and Reconstructive Surgery, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China
| | - Yong Zhang
- Department of Plastic and Reconstructive Surgery, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China
| | - Hui Tan
- Department of Nuclear Medicine, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China
| | - Jian Wang
- Department of Radiology, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China
| | - Fazhi Qi
- Department of Plastic and Reconstructive Surgery, Zhong-shan Hospital, 180 Fenglin Road, Xuhui District, Shanghai, China.
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18
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Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings. AJR Am J Roentgenol 2018; 211:1194-1205. [DOI: 10.2214/ajr.18.19782] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Haque M, Sartelli M, McKimm J, Abu Bakar M. Health care-associated infections - an overview. Infect Drug Resist 2018; 11:2321-2333. [PMID: 30532565 PMCID: PMC6245375 DOI: 10.2147/idr.s177247] [Citation(s) in RCA: 529] [Impact Index Per Article: 88.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Health care-associated infections (HCAIs) are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. Multiple studies indicate that the common types of adverse events affecting hospitalized patients are adverse drug events, HCAIs, and surgical complications. The US Center for Disease Control and Prevention identifies that nearly 1.7 million hospitalized patients annually acquire HCAIs while being treated for other health issues and that more than 98,000 patients (one in 17) die due to these. Several studies suggest that simple infection-control procedures such as cleaning hands with an alcohol-based hand rub can help prevent HCAIs and save lives, reduce morbidity, and minimize health care costs. Routine educational interventions for health care professionals can help change their hand-washing practices to prevent the spread of infection. In support of this, the WHO has produced guidelines to promote hand-washing practices among member countries.
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Affiliation(s)
- Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia,
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Judy McKimm
- Swansea University School of Medicine, Swansea University, Singleton Park, Swansea, Wales SA2 8PP, UK
| | - Muhamad Abu Bakar
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Sungai Besi, 57000 Kuala Lumpur, Malaysia,
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Kaul P. Sternal reconstruction after post-sternotomy mediastinitis. J Cardiothorac Surg 2017; 12:94. [PMID: 29096673 PMCID: PMC5667468 DOI: 10.1186/s13019-017-0656-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Pankaj Kaul
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK.
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21
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Sembiring YE. MODIFIED VAC DRESSING IN STERNAL WOUND INFECTION MANAGEMENT. CHEAP AND FEASIBLE TECHNIQUE IN DEVELOPING COUNTRY. FOLIA MEDICA INDONESIANA 2017. [DOI: 10.20473/fmi.v52i3.5456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sternal wound infection is a rare but serious complication of cardiac surgery leading to prolonged hospital stay and higher mortality. In the last decades several treatment modalities have been described, of which vacuum-assisted closure (VAC) shows the most promising results. However, the VAC therapy system is expensive, requires extensive amounts of product and needs a power source at all times. Modified VAC dressing to treat sternal wound infection is cheap and feasible technique to use in develop country. This technique can be use as an alternative to the original vacuum-assisted closure and hadshown to serve its function in providing adequatevacuum pressure for wounds.
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Abstract
Sternal osteomyelitis as a direct consequence of advanced mediastinitis or as in most cases after median sternotomy is still associated with a prolonged hospital stay, increased morbidity and postoperative mortality. Early diagnosis and an adequate surgical treatment are decisive for the prognosis. Prerequisites for a secondary stabilization of the chest wall using wires or plates are sterile wound conditions. Diverse reconstructive techniques are available for anterior chest wall reconstruction depending on the defect size and localization. The various reconstructive methods including local and free flap coverage are described in this review article.
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