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Pignatti M, Dolci G, Zamagni E, Pascale R, Piccin O, Ammar A, Zeneli F, Miralles MEL, Mancuso K, Cipriani R, Viale P, Pacini D, Martin-Suàrez S. Multidisciplinary Management of Sternal Osteomyelitis Due to Klebsiella aerogenes after Open Heart Surgery in a Patient with Multiple Myeloma: A Case Report and Discussion of the Literature. Microorganisms 2023; 11:2699. [PMID: 38004712 PMCID: PMC10673517 DOI: 10.3390/microorganisms11112699] [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: 09/27/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023] Open
Abstract
Sternal wound complications following cardiac surgery, including sternal dehiscence, mediastinitis, and osteomyelitis, pose significant challenges in terms of management and patient outcomes. We present a case report highlighting the complex management of a patient who underwent open heart surgery for severe aortic valve stenosis, followed by sternal wound dehiscence and sternum osteomyelitis due to extended spectrum beta lactamase (ESBL) producing Klebsiella aerogenes. A multiple myeloma diagnosis was also suspected at the positron emission tomography (PET) scan and confirmed with bone marrow biopsy. Multidisciplinary evaluation of the case led to a comprehensive treatment plan. To control the sternal osteomyelitis, total sternectomy was performed followed by immediate reconstruction with a bone (tibia) graft from the tissue bank and fixation with the minimal hardware possible. A microsurgical latissimus dorsi free flap was required to reconstruct the soft tissue defect. After 6 weeks of antibiotic treatment with ertapenem and fosfomycin based on a culture of intraoperative material, no clinical, imaging, or laboratory signs of infection were seen. Multiple myeloma treatment was then started. At 1 year of follow up, no recurrence of infection occurred, and the reconstruction was stable and closed. Multiple myeloma is under chronic treatment with novel agent combination, with an excellent haematological response.
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Affiliation(s)
- Marco Pignatti
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
| | - Giampiero Dolci
- Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Elena Zamagni
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Renato Pascale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ottavio Piccin
- Otorinolaryngology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Alessandro Ammar
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Flavia Zeneli
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Maria Elisa Lozano Miralles
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Katia Mancuso
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Haematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Riccardo Cipriani
- Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (F.Z.); (M.E.L.M.); (R.C.)
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Plastic Surgery, Policlinico di Modena, University of Modena and Reggio Emilia, 41126 Modena, Italy
| | - Davide Pacini
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (E.Z.); (R.P.); (K.M.); (P.V.); (D.P.)
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Sofia Martin-Suàrez
- Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
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Georgiou I, Ioannou CI, Schmidt J, Eschborn J, Mostofizadeh-Haghighi G, Infanger M, Ghods M, Kruppa P. Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience. J Reconstr Microsurg 2023; 39:601-615. [PMID: 36693394 DOI: 10.1055/s-0043-1761208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Adequate treatment of deep sternal wound infections (DSWIs) after open thoracic surgery still presents a major challenge. This study retrospectively analyzes the results of a single center's 12-year experience in treating DSWI, with special emphasis on free flap reconstruction. METHODS In this single-center, retrospective study, all patients admitted with the diagnosis of DSWI after open thoracic surgery between 2009 and 2020 were included. A comparative analysis was performed between: (1) pedicled versus free flaps, (2) the center's two workhorse flaps-the pedicled latissimus dorsi (pLD) versus free anterolateral thigh (fALT) flaps, as well as (3) myocutaneous (MC) versus fasciocutaneous (FC) flaps. Primary endpoints were length of hospital stay (LOS) after reconstruction and in-hospital mortality. RESULTS Of a total of 165 patients included, 152 underwent DSWI defect reconstruction with a total of 12 different reconstruction methods. Although the defect size was larger in patients who underwent free flap coverage, and the risk profile in the fALT and FC flap groups was higher, the LOS after reconstruction (in days) did not differ significantly between the groups (pedicled vs. free flaps: 23 vs. 28, p > 0.05; pLD vs. fALT: 24.5 vs. 26, p > 0.05; MC vs. FC flaps: 23 vs. 26, p > 0.05). Also, no significant differences were found in terms of in-hospital mortality when comparing the groups (pedicled vs. free flaps: 11.2 vs. 17.4%, p > 0.05; pLD vs. fALT: 11.5 vs. 12.5%, p > 0.05; MC vs. FC flaps: 12.9 vs. 12.5%, p > 0.05). CONCLUSION With proper patient selection, free tissue transfer is a valuable alternative in the treatment of sternal dehiscence after a DSWI. Furthermore, our data demonstrate that MC flaps are not necessarily superior to FC flaps in the reconstruction of sternal osteomyelitis defects.
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Affiliation(s)
- Iakovos Georgiou
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
| | | | - Jeremias Schmidt
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Johannes Eschborn
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Giw Mostofizadeh-Haghighi
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Manfred Infanger
- Clinic for Plastic, Aesthetic and Hand Surgery, Otto-von-Guericke-University, Magdeburg, Germany
| | - Mojtaba Ghods
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Philipp Kruppa
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/Hand Surgery, Hospital Ernst von Bergmann, Potsdam, Germany
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Arazi M, Grosman-Rimon L, Yehezkeel S, Rimon J, Gohari J, Gleitman S, Kachel E. Predictors of prolonged hospitalization in modified sternoplasty following postoperative mediastinitis. J Card Surg 2022; 37:4726-4731. [PMID: 36378944 PMCID: PMC10099381 DOI: 10.1111/jocs.17099] [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: 06/13/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Deep sternal wound infection (DSWI) is a serious complication following cardiac surgery, and demands early intervention as any delay in diagnosis and management may lead to increased morbidity and mortality. DSWI is associated with increased length of hospitalization (LOH) and economic burden in this patient population. The aim of this study was to determine predictors for increased length of hospitalization in patients who underwent the Modified Sternoplasty technique for deep sternal wound infection following cardiac surgery. METHODS A retrospective study was undertaken on data from patients who underwent the Modified Sternoplasty surgery for DSWI between September 2010 and January 2020. Patients' characteristics that were recorded included medical history, type of the original heart surgery, length of hospitalizations, and risk factors including hyperlipidemia, diabetes mellitus and hypertension, and morbidity and mortality rates following the Modified Sternoplasty. RESULTS Sixty-eight patients underwent the Modified Sternoplasty surgery with an average length of hospitalization of 24.63 + 22.09 days. Multivariable analysis showed that only gender was considered a predictor of length of hospitalization when controlling for comorbidities, with average length of hospitalization longer for women than men (35.4 vs. 20.9, p = .04). CONCLUSION The Modified Sternoplasty surgery is a novel surgical technique for managing DSWI complicated by sternal dehiscence with exposed heart and great vessels. Female gender was associated with increased length of hospitalization in our patient cohort, with average length of hospitalization for women almost twice that of males.
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Affiliation(s)
- Mattan Arazi
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liza Grosman-Rimon
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shachar Yehezkeel
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Jordan Rimon
- Faculty of Health, York University, Toronto, Ontario, Canada
| | - Jacob Gohari
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Creedmoor Psychiatric Center, Queens Village, New York, New York, USA
| | - Sagi Gleitman
- Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel
| | - Erez Kachel
- Department of Cardiothoracic surgery, Leviev Heart Center, Sheba Medical Center, Tel HaShomer, Israel.,Department of Cardiothoracic Surgery, B Padeh Medical Center, Poriya, Israel.,The Azriely Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
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Shimbo K, Kawamoto H, Koshima I. Rectus Abdominis Musculocutaneous Flap With Supercharging for Reconstruction of Extensive Thoracic Defect Due to Deep Sternal Wound Infection: A Case Report. Cureus 2022; 14:e25862. [PMID: 35836467 PMCID: PMC9275531 DOI: 10.7759/cureus.25862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 11/05/2022] Open
Abstract
Deep sternal wound infection is a serious postoperative complication of cardiac surgery and often requires flap reconstruction. Herein, we report a case of deep sternal wound infection with an extensive thoracic defect that was successfully treated using a modified technique. This technique, defined as “supercharging,” anastomoses the deep inferior epigastric artery and vein of pedicled rectus abdominis musculocutaneous flap to the transverse cervical artery and external jugular vein, respectively. The transverse cervical artery is an easily accessible and reliable recipient vessel. Therefore, we recommend that our technique be used, especially in cases of deep sternal wound infection with extensive thoracic defects.
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The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis. Plast Reconstr Surg Glob Open 2022; 10:e4233. [PMID: 35506023 PMCID: PMC9053136 DOI: 10.1097/gox.0000000000004233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022]
Abstract
Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.
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Bigdeli AK, Falkner F, Thomas B, Hundeshagen G, Mayer SA, Risse EM, Harhaus L, Gazyakan E, Kneser U, Radu CA. The Free Myocutaneous Tensor Fasciae Latae Flap—A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience. J Pers Med 2022; 12:jpm12030427. [PMID: 35330425 PMCID: PMC8951458 DOI: 10.3390/jpm12030427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction: Deep sternal wound infections (DSWI) after cardiac surgery pose a significant challenge in reconstructive surgery. In this context, free flaps represent well-established options. The objective of this study was to investigate the clinical outcome after free myocutaneous tensor fasciae latae (TFL) flap reconstruction of sternal defects, with a special focus on surgical complications and donor-site morbidity. Methods: A retrospective chart review focused on patient demographics, operative details, and postoperative complications. Follow-up reexaminations included assessments of the range of motion and muscle strength at the donor-site. Patients completed the Quality of Life 36-item Short Form Health Survey (SF-36) as well as the Lower Extremity Functional Scale (LEFS) questionnaire and evaluated aesthetic and functional outcomes on a 6-point Likert scale. The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS) were used to rate scar appearance. Results: A total of 46 patients (mean age: 67 ± 11 years) underwent sternal defect reconstruction with free TFL flaps between January 2010 and March 2021. The mean defect size was 194 ± 43 cm2. The mean operation time was 387 ± 120 min with a flap ischemia time of 63 ± 16 min. Acute microvascular complications due to flap pedicle thromboses occurred in three patients (7%). All flaps could be salvaged without complete flap loss. Partial flap loss of the distal TFL portion was observed in three patients (7%). All three patients required additional reconstruction with pedicled or local flaps. Upon follow-up, the range of motion (hip joint extension/flexion (p = 0.73), abduction/adduction (p = 0.29), and internal/external rotation (p = 0.07)) and muscle strength at the donor-sites did not differ from the contralateral sides (p = 0.25). Patient assessments of aesthetic and functional outcomes, as well as the median SF-36 (physical component summary (44, range of 33 to 57)) and LEFS (54, range if 35 to 65), showed good results with respect to patient comorbidities. The median VSS (3, range of 2 to 7) and POSAS (24, range of 18 to 34) showed satisfactory scar quality and scar appearance. Conclusion: The free TFL flap is a reliable, effective, and, therefore, valuable option for the reconstruction of extensive sternal defects in critically ill patients suffering from DSWIs. In addition, the TFL flap shows satisfactory functional and aesthetic results at the donor-site.
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Sternal wound closure by modified bipedicle pectoralis myocutaneous flaps. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01903-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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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Falkner F, Thomas B, Haug V, Nagel SS, Vollbach FH, Kneser U, Bigdeli AK. Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study. Microsurgery 2021; 41:309-318. [PMID: 33780053 DOI: 10.1002/micr.30730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects. METHODS Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis. RESULTS Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size. CONCLUSION To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.
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Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Felix H Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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