Chest Wall Reconstruction Using Sternal Plating in Patients With Complex Sternal Dehiscence

[Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]

The aim of this article is to present the importance of a structured and situation-adapted approach based on the diagnostic and therapeutic strategy in the interdisciplinary treatment of 54 patients with deep sternal wound infections (DSWI) after cardiac surgical interventions and the results achieved. The patients were 41 men and 13 women with an average age of 65.1 years, who developed a DSWI after a cardiac surgical intervention during the period 2003-2016. The treatment strategy included a thorough debridement including the removal of indwelling foreign material, the reconstruction with a stable re-osteosynthesis after overcoming the infection and if necessary, situation-related surgical flaps for a defect coverage with a good blood supply and mandatory avoidance of dead spaces. A total of 146 operations were necessary (average 2.7 operations/patient, range 1-7 operations). In 24.1 % of the cases a one-stage approach could be carried out. In 41 patients negative pressure wound therapy (NPWT) with programmed sponge changing was used for wound conditioning (mean 5 changes, standard deviation, SD± 5.6 changes over 22 days, SD± 23.9 days, change interval every 3-4 days in 40.7% of the cases). In 33 patients a bilateral myocutaneous pectoralis major flap was used, in 4 patients a vertical rectus abdominis myocutaneous (VRAM) flap and in 7 patients both were carried out. A total of 43 osteosynthesis procedures were carried out on the sternum with fixed-angle titanium plates. Of the patients 7 died during intensive care unit treatment (total mortality 13 %, n = 5, 9.3 % ≤ 30 days) or in the later course. Of the patients 47 (87.1 %) could be discharged with a cleansed infection. In 2 patients the implant was removed after 2 years due to loosening.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020

INTRODUCTION

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.

METHODS

A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.

RESULTS

A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05).

CONCLUSIONS

Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

Surgical Complications of Lung Transplantation

Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.

The management of deep sternal wound infection: Literature review and reconstructive algorithm

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.

Complex sternal and rib reconstruction with allogeneic material

Sternal malunion, or loss, developed after a median sternotomy cannot only be difficult to manage and treat, but also may diminish one's quality-of-life drastically. The technique presented here represents a multispecialty approach in one stage for the reconstruction of an unstable thoracic cage. The procedure utilized a donated sternum and ribs. The sternum with ribs harvested from a single donor included adipose derived stromal vascular fraction (ADSVF) cells with marrow also from the same donor. Autologous muscle flaps, stabilized with acellular dermal matrix were utilized to provide a robust blood supply to the ADSVF cells and bone grafts. Acellular dermal matrix was used to construct the ribs and stabilize the plugs of stem cells and bone. These procedures, in the hands of multispecialty physicians, have led to several successful reconstructions involving complex chest wall deformities. This surgical intervention was performed in a one stage operation. This represents the first successful complete sternal transplant in a patient with return to normal activities and increased quality-of-life.

Mid-Term Results After Sternal Reconstruction Using Titanium Plates: Is It Worth It to Plate?

BACKGROUND

Sternal dehiscence after median sternotomy is a challenging problem in situations of frail bone, fractures, or complete sternectomy. Plate osteosynthesis offers a promising approach to restore sternal integrity. However, there is only scarce data on mid-term outcome.

METHODS

Mid-term data on 34 patients with unstable thorax after open heart operation, requiring sternal refixation with the Synthes Titanium Sternal Fixation System (Oberdorf, Switzerland) between 2005 and 2011, were analyzed. The Titanium Sternal Fixation System was used if conventional rewiring had failed or if failure of rewiring was expected because of risk factors. Follow-up examinations included clinical tests, computed tomographic scans, and pain assessment to evaluate sternal integrity and persistent pain.

RESULTS

Median follow-up time was 1.4 years (range, 0.3 to 6.6 years). Clinical examination showed thoracic stability in all patients. Computed tomographic scans demonstrated complete bone consolidation in 25.8%, nearly complete in 38.7%, partial in 9.7%, and missing in 25.8% of patients. Pain assessment revealed no sternal pain in 16 patients (48.5%), mild pain in 9 (27.3%), moderate pain in 3 (9.1%), and severe pain in 5 patients (15.1%). Pain on movement was reported in 12 patients and 5 patients had chronic pain. A total of 13 patients (38%) required plate removal due to pain (n = 8) or infection (n = 5) after a median of 10.9 and 2 months, respectively.

CONCLUSIONS

With the use of plates, it was possible to achieve thoracic stabilization in complicated dehiscence. However, the rate of postoperative infection and pain is not negligible. Thus, we recommend plate reconstruction only in sternal high-risk patients, who are unsuitable for standard reclosure.

The 'Two Bridges Technique' for sternal wound closure. The use of vacuum-assisted closure for the treatment of deep sternal wound defects: a centre-specific technique

The objective is to describe the 'Two Bridges Technique' (TBT), which has proven to be successful and has been the standard technique at our centre for vacuum-assisted closure (VAC) of post-sternotomy mediastinitis. An extensive literature search was performed in four databases to identify all published articles concerning VAC for post-sternotomy mediastinitis. Several VAC methods have been used; however, no article has described our specific technique. TBT consists of a two-bridges construction using two types of foam with different pore sizes, which ensures an equally divided negative pressure over the wound bed and stabilisation of the chest. This guarantees a continuous treatment of the sternal defect and prevents foam displacement. It maintains an airtight seal that prevents skin maceration and provides enough protection to avoid right ventricular rupture. The main advantage of TBT is the prevention of shifting or tilting of the foam during chest movements such as breathing or couching. Along with targeted antibiotic treatment, this alternative VAC technique can be an asset in the sometimes cumbersome treatment of post-sternotomy mediastinitis.

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.