Introduction:
Open-heart surgery is one of the most common procedures performed in North America. Median sternotomy infection and bony nonunion are two commonly described complications which occur in 1-3 % of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. Timely reconstruction of the chest wall is required. Debridement of the sternum is critical in removing the infected tissue and bone. Several options have traditionally been used to reconstruct the wound. Sternal rewiring and closure, a variety of flaps, and more recently negative pressure therapy have been recommended as options. Recently a new technique of rigid fixation of the sternum has been introduced. Its potential advantage is the restoration of sternal stability following sternal debridement. This was not previously feasible with rewiring. To evaluate the effectiveness of this new technique, we reviewed our early experience of all patients who had their infections managed by plate fixation.
Methods:
We conducted a retrospective chart review on all adult cardiac patients who required sternal wound reconstruction by debridement, irrigation, sternal plate fixation, and bilateral myocutaneous advancement flaps for deep sternal infection between July 2004 and January 2008. Synthes 2.4-mm locking reconstruction plates were used in conjunction with bilateral pectoralis major advancement flaps. Data collected included patient demographics, complications, and length of stay.
Results:
(n = 40) patients (31 males, 9 females) were treated. Patients were elderly (69.7 yrs), overweight (BMI 30.4 kg/m2), hypertensive (75%), and had undergone a CABG with the left internal mammary artery (72.2%). The common presentation was sternal dehiscence (76.4%) and instability (67.6%). Coag –ve staph (39%) was the most common organism. Twenty-two percent of patients had biopsy confirmed osteomyelitis. Average length of ICU stay post reconstruction was 4.84 days and overall ICU was 14.4 days. The majority of patients (95%) were healed without further complications. The two patients that did not heal were severely immune-compromised and developed recurrent wound infection requiring VAC therapy. There was one mortality secondary to refractory septic shock from infected endocarditis.
Conclusion:
These findings confirm our initial impression that sternal plating, following sternal dehiscence and deep wound infection is superior to the standard muscle flap or wire reconstruction in terms of outcomes; better healing, reduced length of hospital stay and fewer complications.