Sternal reconstruction after post-sternotomy mediastinitis

Poststernotomy Imaging: Pictorial Review of Expected Postsurgical Findings and Complications

Sternotomy is a widely used incision technique in cardiac and thoracic surgeries. Multiple sternotomy techniques exist, such as the Robicsek technique for redo sternotomy and transverse (clamshell) thoracosternotomy for bilateral lung transplantation. Various complications after sternotomy can occur, and imaging plays a key role in their identification. Complications may involve the hardware, sternum, and peristernal soft tissues and are divided into acute, subacute, and late. Acute complications primarily involve hemorrhage and dehiscence, while subacute complications include superficial or deep sternal wound infections and late complications are typically osseous or hardware related. Imaging also plays a critical role in assessment of cardiovascular structures and their relations to the sternum in those undergoing redo sternotomy, which has become increasingly performed. CT allows radiologists to identify the relationship of vascular anatomy to the sternum as well as other factors that may complicate repeat surgery, allowing surgeons to strategize safe surgical approaches. ©RSNA, 2025 Supplemental material is available for this article.

First Report on Rigid Plate Fixation for Enhanced Sternal Closure in Minimally Invasive Cardiac Surgery: Safety and Outcomes

INTRODUCTION

This study reports of the use of a rigid-plate fixation (RPF) system designed for sternal closure after minimally invasive cardiac surgery (MICS).

METHODS

This retrospective analysis included all patients undergoing MICS with RPF (Zimmer Biomet, Jacksonville, FL, USA) at our institution. We analyzed in-hospital complications, as well as sternal complications and sternal pain at discharge and at follow-up 7 to 14 months after surgery.

RESULTS

Between June and December 2023, 12 patients underwent RPF during MICS, of which 9 patients were included in the study. The median (IQR) age was 64 years (63 to 71) and two patients (22%) were female. All patients underwent aortic valve replacement, with two patients (22%) undergoing concomitant aortic surgery. RPF was successfully performed in all patients. ICU and in-hospital stay were 1 day (1 to 1) and 9 days (7 to 13), respectively. Patients were first mobilized in the standing position on postoperative day 2 (2 to 2). Four patients (44%) required opiates on the general ward. In-hospital mortality was 0%. At discharge, rates of sternal pain, sternal instability or infection were 0%. After a follow-up time of 343.6 days (217 to 433), median pain intensity using the Visual Analog Scale was 0 (0 to 2). Forty-four percent (n = 4) of patients reported pain at rest. No sternal complications (sternal dehiscence, sternal mal-union, sternal instability, superficial wound infections and deep sternal wound infections) were reported.

CONCLUSIONS

In the evolving landscape of cardiac therapies with incentives to reduce surgical burden, RPF showed safety and feasibility. It might become an important tool for sternal closure in minimally invasive cardiac surgery.

Wound Healing Complications After Sternotomy-Causes, Prevention, and Treatment-A New Look at an Old Problem

Median sternotomy is one of the most common procedures in cardiac surgery. This corresponds to the relatively high frequency of infections where surgical incisions are performed. In the prevention of healing disorders, the medical staff intervention is important, as is the patient. The management of wound infection after sternotomy requires a holistic approach. It requires the implementation of adequate antibiotic therapy, surgical treatment of the wound, and, if necessary, reconstruction of tissue defects using skin, muscle, and skin-muscle grafts or greater omentum. The prevention of surgical site infection should be based on asepsis and antisepsis at every stage of surgical treatment; the elimination of modifiable risk factors; and an appropriate, staged, and tension-free technique of chest closure. The described actions are aimed at avoiding the most serious complication associated with a high mortality rate in the form of mediastinitis. The therapeutic procedures are strictly dependent on the degree of tissue involvement and the presented clinical manifestation. During the preparation of this manuscript, scientific publications available on the Pubmed platform were analyzed. The scope of the search was limited to the years 2014-2024. The key words were "sternotomy wound infection". A total of 114 publications were analyzed, and 56 of them were included. A total of 23 papers were used to discuss the topic.

In Vivo Testing of a Second-Generation Prototype Accessory for Single Transapical Left Ventricular Assist Device Implantation

A new accessory was developed to allow implantation of left ventricular assist devices (LVADs) without requiring an anastomosis to the ascending aorta. The accessory combines the LVAD inflow and outflow into a dual-lumen device. Initial prototypes encountered reduced pump performance in vitro, but a second-generation prototype successfully addressed this issue. This feasibility study aimed to demonstrate the anatomic fit, safe implantation, and hemodynamic effectiveness of the LVAD with the accessory. The accessory was implanted in ten female pigs (104 ± 13 kg). Following sternotomy and apical coring under cardiopulmonary bypass, a balloon catheter was retrogradely inserted and exteriorized through the coring site, where it was inflated within the distal third of the outflow graft. It was utilized to pull the accessory's outflow across the aortic valve. After LVAD attachment, the catheter was removed. Echocardiography revealed no relevant valve regurgitation post-implantation. During ramp testing, pump flow increased from 3.7 ± 1.2 to 5.4 ± 1.2 L/min. Necropsy confirmed correct accessory placement in nine animals. No valve lesions or device thrombosis were observed. The accessory enabled LVAD implantation without compromising pump performance. Future work includes design refinements for implantation without cardiopulmonary bypass and long-term testing in a chronic heart failure model.

Sternal wound types after median sternotomy and reconstruction using dead space-based approach

Background

This study aims to classify wound complications after median sternotomy and provide an up-to-date reconstructive algorithm for multidisciplinary use.

Methods

A total of 15 patients (9 males, 6 females; mean age: 68±5 years; range, 60 to 75 years) who underwent sternal reconstruction for wound complications following median sternotomy between August 2020 and October 2023 were retrospectively analyzed. Wound complications requiring reconstruction were classified into three categories based on the extent of the dead space caused by sternal debridement. Type 1, 2, and 3 wounds presented with only skin defects and an intact sternum, with partial and total sternectomy, respectively. The time to consultation for plastic surgery and the duration of hospitalization were compared.

Results

Among the wounds, type 2 wounds were the most common type seen in 11 patients. Two patients each had type 1 and type 3 wounds. A superior epigastric artery perforator skin flap was used for type 1 wounds. Bilateral pectoral and split pectoral turnover muscle flaps from the side where the internal mammary artery was intact were used for type 2 wounds. A rectus abdominis muscle flap was used for type 3 wounds. Early consultation from plastic surgery reduced the length of hospital stay.

Conclusion

For type 1 wounds, skin flaps ensured sufficient coverage as they involved skin and subcutaneous fat, matching the defect. However, sternal excision required muscle flaps to fill the dead space, in which the vital organs were exposed.

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy

INTRODUCTION

Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI.

METHODS

We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed.

RESULTS

All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps.

CONCLUSIONS

We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

Triple Barrel Free Fibula Flap for Sternal Stabilization: A Case Report

Sternal non-union is a rare complication of median sternotomies following cardiac surgery. It results in sternal instability and is associated with a high rate of morbidity. Patients with sternal non-union usually complain of pain and sternal clicking with movement of the chest wall. Diagnosis is confirmed on computed tomography showing a gap between two sternal halves. Surgical correction of sternal instability is challenging. The key objective is to reconstruct a thoracic cage that allows for biomimesis and preserves normal physiologic cardiac and pulmonary functions all whilst achieving an aesthetically pleasing result. In this article, we describe a novel technique for sternal instability reconstruction using a triple-barrel vascularized free fibula flap fixed with rib titanium plates. This approach provides rigid long-lasting stability while preserving chest wall biomechanics.

[Pay attention to the prevention and treatment of deep sternal wound infection after sternotomy]

Deep sternal wound infection (DSWI) is one of the potential and catastrophic complications after cardiac surgery. Despite the use of smaller incisions, routine application of prophylactic antibiotic and optimized blood glucose management, the incidence rate of DSWI still fluctuates between 1% and 5%. The early symptoms and signs of DSWI are not often obvious, making it too late for the clinicians to intervene in the process. Once left untreated, DSWI carries a very high mortality rate. Therefore, early prevention, diagnosis, and appropriate management of DSWI are crucial in preventing its progression to life-threatening outcomes. Considering the clinical severity and treatment complexity of DSWI, this article focuses on preventive experiences in each stage of DSWI, and reconstructive strategies after DSWI happens, raising attention among the medical community regarding DSWI.

[Perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy and its clinical effects]

Objective: To investigate the perioperative management of wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy, and to evaluate its clinical effects. Methods: This study was a retrospective observational study. From January 2017 to December 2022, 36 patients with wounds associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy who were conformed to the inclusion criteria were admitted to the Burn Center of PLA of the First Affiliated Hospital of Air Force Medical University, including 23 males and 13 females, aged 25 to 81 years. Preparation for surgery was made. For patients with suspected retrosternal mediastinal abscess cavity, all cancellous bone of the unhealed sternum was bitten off to fully expose the retrosternal mediastinum, remove the source of infection and granulation tissue, and to fill the sternum defect with flipped unilateral pectoralis major muscle. For patients who had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, the necrotic tissue and a small amount of necrotic sternum were palliatively removed, and bilateral pectoralis major muscles were advanced and abutted to cover the sternal defect. After the skin in the donor area was closed by tension-relieving suture, continuous vacuum sealing drainage was performed, and continuous even infusion and lavage were added 24 hours later. The thorax was fixed with an armor-like chest strap, the patients were guided to breathe abdominally, with both upper limbs fixed to the lateral chest wall using a surgical restraint strap. The bacterial culture results of wound exudation specimens on admission were recorded. The wound condition observed during operation, debridement method, muscle flap covering method, intraoperative bleeding volume, days of postoperative infusion and lavage, lavage solution volume and changes on each day, and postoperative complications and wound healing time were recorded. After discharge, the wound healing quality, thorax shape, and mobility functions of thorax and both upper limbs were evaluated during follow-up. The stability and closure of sternum were observed by computed tomography (CT) reexamination. Results: On admission, among 36 patients, 33 cases were positive and 3 cases were negative in bacterial culture results of wound exudation specimens. Intraoperative observation showed that 26 patients had no retrosternal mediastinal infection but had fresh granulation tissue in unhealed sternal wounds, palliative debridement was performed and bilateral pectoralis major muscles were advanced and abutted to cover the defect. In 10 patients with suspected retrosternal mediastinal abscess cavity, the local sternum was completely removed by bite and the defect was covered using flipped unilateral pectoralis major muscle. During the operation, one patient experienced an innominate vein rupture and bleeding of approximately 3 000 mL during mediastinal exploration, and the remaining patients experienced bleeding of 100-1 000 mL. Postoperative infusion and lavage were performed for 4-7 days, with a lavage solution volume of 3 500-4 500 mL/d. The lavage solution gradually changed from dark red to light red and finally clear. Except for 1 patient who had suture rupture caused by lifting the patient under the armpit during nursing on the 3rd day after surgery, the wounds of the other patients healed smoothly after surgery, and the wound healing time of all patients was 7-21 days. Follow-up for 3 to 9 months after discharge showed that the patient who had suture rupture caused by armpit lifting died due to multiple organ failure. In 1 patient, the armor-like chest strap was removed 2 weeks after surgery, and the shoulder joint movement was not restricted, resulting in local rupture of the suture, which healed after dressing change. The wounds of the remaining patients healed well, and they resumed their daily life. The local skin of patient's pectoralis major muscle defect was slightly sunken and lower than that of the contralateral thorax in the patients undergoing treatment of pectoralis major muscle inversion, while no obvious thoracic deformity was observed in patients undergoing treatment with pectoralis major muscle propulsion and abutment. The chest and upper limb movement in all patients were slightly limited or normal. CT reexamination results of 10 patients showed that the sternum was stable, the local sternum was closed or covered completely with no lacuna or defects. Conclusions: Once the wound associated with secondary sternal osteomyelitis and/or mediastinitis after sternotomy is formed, individualized and precise debridement should be performed as soon as possible, different transfer ways of pectoralis major muscle flap should be chosen to cover the defect, and postoperative continuous infusion and lavage together with strict thorax and shoulder joint restraint and immobilization should be performed. This treatment strategy can ensure good wound healing without affecting the shape and function of the donor area.

Development of a risk score to predict occurrence of deep sternal dehiscence requiring operative debridement

OBJECTIVE

Severe deep sternal wound (DSW) complications after cardiac surgery are a source of cost, morbidity, and mortality. Our objective was to develop and validate a clinical risk score for predicting risk of DSW requiring operative bone debridement, the most severe form of sternal dehiscence.

METHODS

A retrospective review was conducted of patients who underwent open cardiac surgery at a single institution between October 2007 and March 2019. Primary outcome was DSW requiring sternal bone debridement. Potential risk factors were screened using Least Absolute Shrinkage and Selection Operator (LASSO) and significant covariates were included in a logistic regression prediction model. Interval validation was performed using 10-fold cross-validation. A novel sternal wound dehiscence risk score was derived from the relative parameterization estimates.

RESULTS

One hundred thirty-four of 8403 patients (1.6%) were identified as having a DSW. Female sex (odds ratio [OR], 2.75; 95% CI, 2.58-2.93), body mass index (OR, 1.0946; 95% CI, 1.09-1.09), percent glycated hemoglobin (OR, 1.31; 95% CI, 1.28-1.33), peripheral vascular disease (OR, 2.38; 95% CI, 2.2005-2.5752), smoking (OR, 1.66; 95% CI, 1.53-1.79) and elevated creatinine level (OR, 1.20; 95% CI, 1.18-1.22) were independent predictors of DSW. Patients were categorized as minimal risk (0%-1%), low risk (2%-3%), intermediate risk (4%-7%), and high risk (9%-64.0%) on the basis of risk score.

CONCLUSIONS

This risk stratification model for DSW requiring operative debridement might provide individualized estimates of risk, and guide counseling and potential risk mitigation strategies.

Evaluating the Clinical Equivalence of Truwax® and Ethicon® Bone Waxes for Sternal Wound Hemostasis: A Prospective Randomized Study

BACKGROUND

Incidence of sternal dehiscence, wound infection, and mortality are prevalent following sternotomy. Bone wax is widely used over the sternal edges for augmenting hemostasis. This study evaluated the clinical equivalence of Truwax® (Healthium Medtech Limited, Bengaluru, India) with Ethicon® (Johnson & Johnson, New Brunswick, New Jersey, United States) bone wax for sternal wound hemostasis in subjects undergoing surgical procedures by sternotomy.

METHODS

The primary endpoint of this prospective (May 2022-April 2023), parallel-group, two-arm, randomized, single-blind, multicenter study was to evaluate the proportion of subjects having sternal dehiscence within 26 weeks of median sternotomy closure. Secondary endpoints assessed the average time to hemostasis on sternum sides, bone wax properties, number of dressing changes, sternal bone instability (clinically/chest radiography), pain, perioperative/postoperative complications, blood and blood products used, duration of intensive care unit (ICU)/hospital stay, reoperations, time taken to return back to work and normal day-to-day activities, subject satisfaction and quality of life (QoL), and adverse events. A probability of <0.05 was considered significant.

RESULTS

No incidence of sternal dehiscence or postoperative complications was witnessed. Time to hemostasis, bone wax properties, number of dressing changes, sternal stability, pain, blood and blood products used, duration of ICU/hospital stay, reoperations, time taken to return back to normal day-to-day activities and to work, and subject satisfaction and QoL were comparable between Truwax® and Ethicon® bone wax groups.

CONCLUSION

Truwax® and Ethicon® bone waxes are safe and effective and provide sternal wound hemostasis in people undergoing sternotomy.

The impact of two radical sternectomy surgical techniques on the outcome of deep sternal wound infections

BACKGROUND

Deep sternal wound infection (DSWI) is a rare, yet devastating complication after cardiac surgery. While the surgical treatment always implies the soft tissue and bone debridement, there is little data about this procedure. The aim of our study was to evaluate the impact of the radical sternectomy on the outcome in patients with DSWI and to identify the risk factors which could influence the result. The surgical techniques of piecemeal sternectomy and the newly developed en bloc sternectomy were also evaluated.

METHODS

The study was developed as a retrospective cohort study. 86 patients with DSWI who received a radical sternal resection at our institution between March 2018 and December 2021 were included.

RESULTS

The average age of the cohort was 67.3 ± 7.4 years, and 23.3% of patients were female. The average length of stay trended shorter after en bloc sternectomy (median 26 days) compared to piecemeal sternectomy (37 days). There were no significant differences between the piecemeal and en bloc sternal resection techniques. Anticoagulant and antiplatelet drugs had no significant influence on bleeding and transfusion rates. Obese patients showed an increased risk for postoperative bleeding requiring reintervention. Transfusion of packed red blood cells was significantly associated with lower hemoglobin values before surgery and ASA Class 4 compared to ASA Class 3. The in-hospital mortality was 9.3%, with female sex and reintervention for bleeding as significant risk factors. Nine patients developed an infection relapse as a chronic fistula at the level of clavicula or ribs, with ASA Class 4 as a risk factor.

CONCLUSION

Radical sternectomy is a safe procedure to treat DSWI with compromised sternal bone. Both piecemeal and en bloc techniques ensure reliable results, while complications and mortality appear to be patient-related.

A radiologist's guide to median sternotomy

Median sternotomy is widely recognised as the primary incision technique in cardiac surgery. This surgical procedure involves dividing the sternum to gain access to the heart and lungs, making it invaluable in correcting congenital heart defects. Furthermore, it is frequently employed in adult patients, particularly during coronary artery bypass graft (CABG) procedures. In this imaging review, we present a comprehensive overview of the pre-procedural assessment and various post-sternotomy complications encountered within our clinical experience at a tertiary cardiothoracic centre. The focus of this review is to outline the imaging features associated with mediastinal adhesions and establish the minimal safe distance between the sternum and common mediastinal structures when considering re-sternotomy. By providing visual examples, we aim to facilitate a better understanding of these key concepts. Moreover, we delve into a detailed discussion of a spectrum of postoperative complications that may arise following median sternotomy including those related to metalwork (sternal wire fracture), bone (sternal dehiscence, non-union and osteomyelitis), and soft tissue (abscess, haematoma).

Antibiotic therapy in reconstructive surgery of deep sternal wound infections

BACKGROUND

The choice of antibiotics and length of administration in the treatment of deep sternal wound infections (DSWI) is unclear. The reason for this is the lack of studies and local differences in resistance. An increase in resistance can be observed in gram-positive cocci, which are the most frequently detected in deep sternal infections. The duration of administration is often 2- 6 weeks or longer, although the benefit of prolonged antibiotic administration has not been confirmed by studies. We evaluated the antibiotic treatment during surgical treatment, consisting of surgical wound debridement and plastic chest reconstruction.

METHODS

Retrospective analysis of patients (n = 260) who underwent reconstructive surgery in the Department of Plastic Surgery at Leipzig University Hospital from 01.05.2012 - 31.12.2020. The duration of intake, results of microbiological swabs and resistance were investigated.

RESULTS

At the time of discharge, closed wound conditions were noted in 177 of 260 cases (68.1%). The largest proportion of patients (n = 238) was treated with a latissimus dorsi flap (91.5%).Antibiotic treatment was conducted in 206 of 260 cases (79.2%). The mean duration of antibiotic administration was 21.4 days (±17.6). Prolonged treatment over 14 days did not alter outcome (p = 0.226), in contrast, the number of multidrug resistances (p < 0.001). There was no prove of resistance against linezolid which is effective against the most common found infectious agents Staphylococcus epidermidis (n = 93; 24.0 %) & Staphylococcus aureus (n = 47; 12.1 %).

CONCLUSION

There is no evidence of benefit from antibiotic therapy over 14 days, whereas multidrug resistance increases with prolonged antibiotic use. In the absence of infectious agents or clinical signs of inflammation, surgical treatment without additional antibiotic treatment is effective.Linezolid is a suitable antibiotic in the treatment of gram-positive infections which are the most frequent in DSWI.

The usefulness of chest drain and epicardial pacing wire culture for diagnosing mediastinitis after open-heart surgery

PURPOSE

Culture of extracted drains or epicardial pacing wires is an easy and noninvasive method for detecting mediastinitis after open-heart surgery, although studies on its sensitivity and specificity are limited. We, therefore, investigated the usefulness of this approach for diagnosing mediastinitis.

METHODS

We retrospectively studied the culture results of drains and epicardial pacing wires extracted from 3308 patients. Prediction models of mediastinitis with and without culture results added to clinical risk factors identified by a logistic regression analysis were compared.

RESULTS

The incidence of mediastinitis requiring surgery was 1.89% (n = 64). Staphylococcus was the causative bacterium in 64.0% of cases. The sensitivity, specificity, and positive and negative predictive values of positive culture results were 50.8%, 91.8%, 10.7%, and 99.0%, respectively. Methicillin-resistant Staphylococcus aureus had the highest positive predictive value (61.5%). A multivariate analysis identified preoperative hemodialysis (OR 5.40 [2.54-11.5], p < 0.01), long operative duration (p < 0.01), postoperative hemodialysis (OR 2.25 [1.01-4.98], p < 0.05), and positive culture result (OR 10.2 [5.88-17.7], p < 0.01) as independent risk factors. The addition of culture results to pre- and postoperative hemodialysis and a lengthy operative time improved the prediction of mediastinitis.

CONCLUSIONS

A culture survey using extracted drains and epicardial pacing wires may provide useful information for diagnosing mediastinitis.

Successful pedicled vertical rectus abdominis myocutaneous flap reconstruction with negative-pressure wound therapy for deep sternal wound infection: a case report and comprehensive review

INTRODUCTION

Deep sternal wound infection (DSWI) is a serious complication that may occur after median sternotomy, with potentially devastating consequences. By reporting our case and analyzing the existing literature, this article aimed to provide a thorough understanding of the role of negative-pressure wound therapy (NPWT) and the importance of flap choice in managing DSWI accompanied by severe heart injury and high hemodynamic risk.

CASE DESCRIPTION

A 60-year-old woman with severe aortic stenosis, aortic valve regurgitation, and heart failure underwent redo sternotomy, which resulted in an intraoperative right ventricle injury. She required extracorporeal membrane oxygenation support because of low blood pressure and subsequently developed complications, including surgical site hematoma, wound dehiscence, and fat necrosis. She was referred for wound closure, where a significant 10 × 20-cm soft tissue defect in the anterior chest wall was observed. A pedicled vertical rectus abdominis myocutaneous flap addressed the soft tissue defect. The wound showed remarkable improvement at the 8-month follow-up visit.

CONCLUSIONS

DSWI management is a complex and multifaceted challenge. NPWT, when combined with appropriate surgical strategies, including wound debridement and flap selection, may promote successful wound healing. This case report highlights the successful management of a complex DSWI using a multidisciplinary approach, including debridement, appropriate antibiotic therapy, and free-flap reconstruction, which resulted in favorable outcomes.

Impact of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum bones after sternotomy

Median sternotomy is the surgical method of choice for many procedures where one of the main problems is the long post-operative wound healing process leading to sternal dehiscence and the development of infection. This leads to prolonged hospital stay and increased mortality due to post-operative complications. A promising solution seems to be the use of allogeneic chondrocytes for wound treatment, whose properties in the field of cartilage reconstruction are widely used in medicine, mainly in orthopedics. In the present study, we investigated the effect of local delivery of allogeneic chondrocytes on the biological response and healing of the sternum after sternotomy. We optimized the culture conditions for the isolated chondrocytes, which were then applied to the sternal incision wound. Chondrocytes in the culture were assessed on the basis of the presence of chondrocyte-specific genes: Sox9, Aggrecan and Collagen II. In turn, the histopathological and immunohistochemical evaluation was used to assess the safety of implantation. In our work, we demonstrated the possibility of obtaining a viable culture of chondrocytes, which were successfully introduced into the sternal wound after sternotomy. Importantly, implantation of allogeneic chondrocytes showed no significant side effects. The obtained results open new possibilities for research on the use of allogeneic chondrocytes in the process of accelerating wound healing after median sternotomy.

Novel mesh suture may resist bone cutting seen with wire-based sternal closures

OBJECTIVE

Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution.

METHODS

Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force.

RESULTS

All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07).

CONCLUSIONS

Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.

Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience

Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock^® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.

Management of Sternal Wounds, Infections, and Sternal Non-Union with Plate Fixation: Result from a Single Site Experience

Background: Patients with sternal wounds, infection, or non-union after cardiac surgery continue to have increased morbidity and mortality rates compared with those without sternal complications. Reconstructive methods have largely centered on soft tissue approaches, including muscle or omental flaps, which result in functional loss. Some data show early positive advantages using sternal rigid plate fixation (SRPF), however, it is debated in the setting of active infection. The goal of this study is to examine the outcomes of SRPF in patients with and without infections. Patients and Methods: This is a retrospective study of consecutive patients who underwent SRPF by a single plastic surgeon from April 2013 to August 2021. Patients treated without SRPF, lacking at least six months of follow-up, or those plated more than once were excluded. Ninety-seven patients were included. Demographic and peri-operative factors associated with sternal infection after SRPF were evaluated. Results: Sixty-eight patients were clinically infected/culture positive or open (INFECTED), and 29 were clean/primary plating (CLEAN). Sixteen percent of the INFECTED cases (11/68) returned with infection. Fourteen percent of the CLEAN cases (4/29) had subsequent infections. Additionally, we did note a decrease in rates of infections overall (p < 0.0001) as experience and frequency of plate fixation increased (p < 0.0001). Regardless of infection status, all but one patient had a healed and stable sternum at the end of data collection. Conclusions: There is no statistically significant difference between wound class prior to SRPF and development of infection after SRPF. Even in infected settings, patients can be treated successfully with SRPF. Further study is needed.

Optimal Timing of Multidisciplinary Management of Sternal Wound Complications

Background

Sternal wound complications after median sternotomy increase morbidity and mortality, and plastic and reconstructive surgery is often consulted to provide closure with flap reconstruction. In this study, we investigated how the timing of plastic surgery involvement may influence outcomes in this setting.

Methods

We performed a retrospective review of patients with sternal wound complications cared for at our institution during a 10-year period. Patients were stratified into quartiles based on time from detected complication to plastic surgery consultation. Primary outcome variables included morbidity (postoperative complications and reoperation) and all-cause mortality at 1 year. Univariable followed by multivariable logistic regression was performed to characterize risk factors for these adverse outcomes.

Results

A total of 188 patients composed the study population. The time to plastic surgery consultation quartiles were as follows: immediate, 0 to 1 days (n = 46); early, 2 to 5 days (n = 50); delayed, 6 to 14 days (n = 42); and late, >14 days (n = 50). Patient demographics, comorbidities, and reconstructive characteristics did not differ across groups. Increased time to plastic surgery consultation was associated with sternal wound reoperations (P = .026), 1-year mortality (P = .008), hematoma (P = .044), and sternal dehiscence recurrence (P = .019). Multivariable regression demonstrated that increased time to plastic surgery consultation was associated with increased sternal wound reoperations (odds ratio [OR], 1.1; P = .041), sternal wound recurrence (OR, 1.5; P = .018), and mortality (OR, 1.3; P = .037).

Conclusions

Early involvement of plastic surgery in treating sternal wounds is significantly associated with a reduction in mortality, recurrence of sternal dehiscence, and reoperation. Successful treatment of these challenging complications requires multidisciplinary collaboration, and prompt plastic surgery consultation is recommended.

[Surgical approach for destructive pneumonia associated with COVID-19]

There were over 400 million people with COVID-19 pneumonia worldwide and over 12 million in the Russian Federation after 2020. Complicated course of pneumonia with abscesses and gangrene of lungs was observed in 4% of cases. Mortality ranges from 8 to 30%. We report 4 patients with destructive pneumonia following SARS-CoV-2 infection. In one patient, bilateral lung abscesses regressed under conservative treatment. Three patients with bronchopleural fistula underwent staged surgical treatment. Reconstructive surgery included thoracoplasty with muscle flaps. There were no postoperative complications that required redo surgical treatment. We observed no recurrences of purulent-septic process and mortality.

A Reliable Procedure for Reconstruction of the Sternum Defects: The Pectoralis Major Muscle Flap Combination with Negative Pressure Wound Therapy

Objective: Sternotomy defects may present mildly as isolated skin separation or severely as mediastinitis. A combination of treatment options can support treatment. Methods: Patients who were treated with pectoralis major flap with the combination of negative pressure wound therapy (NPWT) between 2016-2020, were retrospectively reviewed. Demographic features, microorganisms causing wound infection, flap reconstruction preference, time of hospitalization, remission, recurrence and associated morbidity and mortality data were evaluated. Results: Thirteen patients were included with a mean age of 65.4 years. All patients previously underwent coronary artery bypass graft surgery. Wound cultures from patients were positive in nine (69%). Isolated microorganisms were Staphylococcus spp. (n=4), Klebsiella pneumoniae (n=3) and Acinetobacter baumannii complex (n=2). The most common comorbidities were hypertension (76%) and diabetes mellitus(46%). The average hospital stay was 23.4 days. One patient died on the seventh postoperative day, two had seromas at the flap donor site, and one had hematoma. Conclusion: Pectoralis major muscle flap and NPWT after complete removal of dead tissues is an effective method to repair and treat sternum defects.

[Chest wall morphological changes after sternal reconstruction with titanium mesh implant in patients with sternum instability]

Sternal instability is the one of the unresolved problems in open cardiac surgery (1-8%). The risk of recurrence after repeated osteosynthesis is up to 20% in these patients. Repeated osteosynthesis is impossible in some cases, and this complicates anterior chest wall reconstruction. Among various methods of sternal reconstruction, there are options for repair with own tissues and various fixing devices. Mesh prostheses from titanium and its alloys are modern materials for chest defect closure. There are literature data on soft tissue structural changes after hernia repair with titanium mesh implants, but biological compatibility and advantages of titanium alloys for chest wall instability are unclear. We present 2 patients after sternal reconstruction with titanium mesh implant and subsequent partial removal of prosthesis for various reasons with morphological examination.

Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery

INTRODUCTION

Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons.

METHODS

Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy.

RESULTS

All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful.

CONCLUSION

OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.

Predictors of prolonged hospitalization in modified sternoplasty following postoperative mediastinitis

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.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis

BACKGROUND

Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes.

METHODS

A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI.

RESULTS

Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01).

CONCLUSION

Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction

BACKGROUND

Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes.

METHODS

A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations.

RESULTS

In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).

CONCLUSION

Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.

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.

Sternal wound infections after sternotomy: risk factors, prevention and management

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.

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.

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

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.

Clinical Use of Tailored Computed Tomography to Prevent Poststernotomy Dehiscence

BACKGROUND

 Morphological and tissue density analysis of the sternum can be performed in the preoperative computed tomography (CT). The purpose of this study was to analyze morphology and tissue density of sternum in CT and effect for comparison sternal instability.

METHODS

 Patients with sternal instability (n = 61) and sternal stability (n = 66) were enrolled in this study. All of the patients were studied using same thorax CT procedure. All the measurements were performed by one specific cardiovascular radiologist. The Hounsfield units (HUs) were measured in axial sections of the sternum trabecular bone.

RESULTS

 Sternal instability group mean HU was 75.36 ± 13.19 and sternal stability group HU was 90.24 ± 12.16 (p < 0.000). HU is the statically significant predictor of sternal instability.

CONCLUSION

 Our study showed a significant correlation between the mean HU value of sternum and sternal instability. We think that it is important to evaluate the existing thorax CT while performing preoperative risk analysis for sternal dehiscence.

Using antibiotic-loaded bone cement for a patient with deep sternal wound infection after cardiac surgery

A 67-year-old male presented with sternal dehiscence following open cardiac surgery. Extensive debridement and attempted closure failed, and the wound had since been managed with vacuum-assisted closure therapy, with little progress. We treated him with antibiotic-loaded bone cement to repair the wound defect. After 3 weeks, the wound healed with excellent result. To our knowledge, this is the first report of antibiotic-loaded bone cement for deep sternal wound infection.

Decreasing complications of pectoralis major muscle flap reconstruction with two modalities of negative pressure wound therapy

BACKGROUND AND OBJECTIVE

Deep sternal wound infection is a feared complication of open-heart surgery. Negative pressure wound therapy has gained an important role in the treatment of deep sternal wound infection. Incisional negative pressure wound therapy has been introduced as a method to prevent wound complications after sternotomy, and lately, after flap reconstructions in the treatment of deep sternal wound infection. We aimed to study if incisional negative pressure wound therapy with PICO™ had similar beneficial effect described earlier with competing commercial devices.

METHODS

This study included 82 patients treated with pectoralis major muscle flap for deep sternal wound infection during the years 2006-2020. PICO group consisted of 24 patients treated with preoperative negative pressure wound therapy and postoperative incisional negative pressure wound therapy (PICO™). Two control groups included 48 patients with conventional treatment and 10 patients with preoperative negative pressure wound therapy only.

RESULTS

In the PICO group, the complication rate declined from 50.0% to 33.30%, major complication rate from 29.2% to 12.5%, and need for an additional flap from 14.6.% to 4.2% when compared to conventional treatment. The length of hospital stay decreased as well. Preoperative negative pressure wound therapy alone was associated with moderate decline in the complication rates. In addition, we described the use of split pectoralis major muscle flap reconstruction in 57 patients. To our knowledge, this is the largest published patient series describing this method in the treatment of deep sternal wound infection.

CONCLUSIONS

Incisional negative pressure wound therapy with PICO™ seems beneficial after flap reconstruction. Split pectoralis major muscle flap is a versatile reconstruction option suitable to be used as a workhorse in the treatment of deep sternal wound infection.

Incidence of Venous Thromboembolism after Sternal Reconstruction: A Single-center Retrospective Review

Background:

Deep sternal wound infection and mediastinitis following sternotomy are associated with significant morbidity and mortality, and often require sternal reconstruction by plastic surgeons. Despite this patient population having a substantial risk of venous thromboembolism, there are no reports of the incidence of venous thromboembolism in patients undergoing sternal reconstruction. The authors sought to evaluate the incidence of venous thromboembolism in sternal reconstruction patients and to identify common risk factors for venous thromboembolism in this patient population.

Methods:

A single-center retrospective review was completed of all patients who underwent sternal reconstruction by plastic surgeons between January 2012 and July 2020. Demographic data, antiplatelet and anticoagulant use, 2005 Caprini score, operative time, bleeding events, and postoperative venous thromboembolism events were recorded.

Results:

A total of 44 patients were identified for analysis. The average 2005 Caprini score for the cohort was 10.9. In total, 93.2% of patients received perioperative antiplatelet and anticoagulant therapy (either chemoprophylaxis or systemic). Two patients developed postoperative venous thromboembolism events, for a total venous thromboembolism rate of 4.6%. Four patients had bleeding events requiring reoperation. No deaths were reported from either of these complications.

Conclusions:

Patients undergoing sternal reconstruction are at a high risk for venous thromboembolism and postoperative bleeding events. Despite the growing body of literature on venous thromboembolism in various surgical populations, the optimal management of thromboembolic risk in patients with high Caprini scores undergoing sternal reconstruction requires additional investigation.

Negative pressure wound therapy in the treatment of deep sternal wound infections - a critical appraisal

Introduction. Negative pressure wound therapy (NPWT) has widely become the first-line option in the treatment of deep sternal wound infections. After several positive reports in comparison with conventional treatment, very recent studies comparing NPWT with early reconstruction have favored the latter. Our aim was to evaluate the effectiveness and safety of NPWT in comparison with early flap reconstruction. Materials and methods. We concluded a retrospective analysis of 125 patients with deep sternal wound infection treated in a single institution between the years 2006 and 2018. NPWT became the first-line treatment in our hospital in 2011. The study group consisted of 55 patients treated primarily with NPWT with or without subsequent flap reconstruction. The control group consisted of 60 patients treated with flap reconstruction without prior NPWT. Ten patients with an immediate re-fixation and direct wound closure were excluded. Results. There were no significant differences between the two groups concerning the type or urgency of the original open-heart surgery, age, gender, or co-morbidities. In the NPWT group there was significantly higher mortality (p = .002), longer stay in the intensive care unit (p = .028), and in the university hospital (p < .001) as well as higher number of operations (p < .001). However, there were somewhat more surgical complications in the control group as well as a higher number of distant flap reconstructions. Overall, five patients suffered from NPWT associated bleeding. Conclusion. Our results raise concerns about the wide use of NPWT as a first-line treatment of deep sternal wound infections. Further evaluative studies are warranted to confirm the results.

Case Report: A New Tool for Anterior Chest Wall Reconstruction After Sternal Resection for Primary Or Secondary Tumors

Sternal resection and anterior chest wall reconstruction techniques for malignant processes are not always standardized. We report an innovative method of sternal osteosynthesis in two patients, 65-year-old and 41-year-old women, with Ewing's sarcoma, and infiltrating thymoma, respectively. The first case manifested itself as a voluminous palpable mass while the second case was characterized for a paramediastinal mass widely extended to the anterior chest wall. Reconstruction with titanium mesh allowed the quick restoration of parietal stability, facilitating respiratory dynamic and recovery of patients.

Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review

Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.

[Surgical treatment of sternal osteomyelitis and sternomediastinitis following cardiac surgery]

OBJECTIVE

To analyze the incidence of cardiac surgeries and postoperative sternal osteomyelitis/sternomediastinitis, as well as treatment outcomes in these patients.

MATERIAL AND METHODS

We summarized 171 patients with postoperative sternal osteomyelitis and sternomediastinitis.

RESULTS

Organization of the Khabarovsk center for cardiovascular surgery in the Far Eastern Federal District was followed by 7.9- and 24.9-fold increase of the number of cardiac surgeries and CABG in 2005-2019, respectively. As a result, the number of patients with sternal osteomyelitis and sternomediastinitis after cardiac surgery increased from 0.50±0.10 to 1.59±0.17 cases per 100.000 (t=3.01; p<0.01). CPB and aortic clamping time (t=3.97; p<0.01), as well as surgery time (t=2.4; p<0.05) were significant risk factors of early postoperative complications. Two-stage surgical treatment of postoperative sternal osteomyelitis and sternomediastinitis (removal of ligatures and foreign bodies, sternal curettage with removal of sequesters at the first stage; resection of sternum with chest wall repair at the second stage) reduced hospital-stay from 31.9±13.4 to 29.2±10.8 days.

[Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection]

Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).

Negative pressure wound therapy for patients with mediastinitis: A meta-analysis

To evaluate clinical effects between conditional treatment and negative pressure wound therapy for mediastinal infection. Multiple databases were searched to identify relevant studies, and the articles that eventually satisfied the criteria were included. All the meta-analyses were conducted with the Review Manager 5.2. To estimate the quality of each article, risk of bias table was performed. Finally, nine studies including 648 patients met the eligibility criteria. The negative pressure wound therapy (NPWT) group and the control group included 353 and 295 patients, respectively. The meta-analysis showed no significant difference in operative time (RR = -6.13, 95%CI [-50.00, 37.74], P = .78; P for heterogeneity <.000001, I2 = 100%). The length of hospital stay (MD = -3.07, 95%CI [-4.38, -1.77], P < .00001; P for heterogeneity = .99, I2 = 0%), re-infection (RR = 0.18, 100%CI [0.08, 0.40], P < .00001; P for heterogeneity = 0.48, I2 = 0%), and mortality were significantly different between the two groups (RR = 0.27, 95%CI [0.12, 0.63], P of overall effect = .002). NPWT is a better therapy than conventional treatment for mediastinitis.

Cardioplastic Approach to Omental Flap Coverage for Severe Aortic Root Infections in the Opioid Era

Aortic root abscesses are severe sequelae of endocarditis that clinically manifest as life-threatening infection. As the opioid epidemic continues to yield a national crisis, the incidence and severity of this disease process have increased. Reconstruction of the aortic root is a challenging undertaking and carries the risk of recurrent infection. The omentum has an established reputation as a reliable flap in thoracic reconstruction, given its amorphous form and immunogenic properties, but it has not been utilized for aortic root infections. We present a novel indication for the omental flap using a cardioplastic approach in coverage of aortic root reconstruction. Four patients were treated with pedicled omental flap coverage after aortic root reconstruction. All patients had successful flap healing with no evidence of recurrent infection. This series demonstrates the technical feasibility and clinical utility for providing soft tissue coverage and antimicrobial protection when used in aortic root reconstruction.

Recent developments in controlling sternal wound infection after cardiac surgery and measures to enhance sternal healing

One of the major risks of cardiac surgery is the occurrence of infection at the sternal wound site. Sternal wound infections are primarily classified into superficial infection and deep sternal wound infection or mediastinitis. A patient is diagnosed with mediastinitis if microorganisms are present in their mediastinal tissue/fluid or with the observation of sternal wound infection during operation and with characteristic symptoms including chest pain, fever, and purulent drainage from the mediastinum. It is usually caused by Staphylococcal organisms in 75.8% of cases and the rest is caused by gram-negative bacteria. Currently, in cardiac surgery, hemostasis is achieved using electrocautery and bone wax, and the sternum is closed using wire cerclage. Several studies show that bone wax can act as a nidus for initiation of infection and the oozing blood and hematoma at the site can promote the growth of infectious organisms. Many research groups have developed different types of biomaterials and reported on the prevention of infection and healing of the sternum. These materials are reported to have both positive and negative effects. In this review, we highlight the current clinical practices undertaken to prevent infection and bleeding as well as research progress in this field and their outcomes in controlling bleeding, infection, and enhancing sternal healing.

Aorto-cutaneous fistula from an infected ascending aorta graft resulting in massive hemorrhage after a Valsalva maneuver for a heavy weight lift

In the setting of an infected prosthetic ascending thoracic aorta, prompt and definitive surgical treatment is mandatory to avoid catastrophic bleeding complications.

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.