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http://dx.doi.org/10.5999/aps.2018.01151

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery  

Schiraldi, Luigi (Department of Surgery, Hospital du Valais)
Jabbour, Gaby (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV))
Centofanti, Paolo (Department of Cardiac Surgery, Mauriziano Hospital)
Giordano, Salvatore (Department of Plastic and General Surgery, Turku University Hospital)
Abdelnour, Etienne (Department of Thoracic Surgery, Lausanne University Hospital (CHUV))
Gonzalez, Michel (Department of Thoracic Surgery, Lausanne University Hospital (CHUV))
Raffoul, Wassim (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV))
di Summa, Pietro Giovanni (Department of Plastic and Reconstructive Surgery, Lausanne University Hospital (CHUV))
Publication Information
Archives of Plastic Surgery / v.46, no.4, 2019 , pp. 291-302 More about this Journal
Abstract
Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.
Keywords
Sternum; Infection; Reconstructive surgical procedure; Sternotomy;
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1 Luan A, Galvez MG, Lee GK. Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: case report and review of the literature. Microsurgery 2016;36:70-6.   DOI
2 Taeger CD, Horch RE, Arkudas A, et al. Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis. Microsurgery 2016;36:121-7.   DOI
3 Wong CH, Senewiratne S, Garlick B, et al. Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap. Eur J Cardiothorac Surg 2006;30: 148-52.   DOI
4 Davison SP, Clemens MW, Armstrong D, et al. Sternotomy wounds: rectus flap versus modified pectoral reconstruction. Plast Reconstr Surg 2007;120:929-34.   DOI
5 Yasuura K, Okamoto H, Morita S, et al. Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery. Ann Surg 1998;227:455-9.   DOI
6 Reade CC, Meadows WM Jr, Bower CE, et al. Laparoscopic omental harvest for flap coverage in complex mediastinitis. Am Surg 2003;69:1072-6.
7 Stump A, Bedri M, Goldberg NH, et al. Omental transposition flap for sternal wound reconstruction in diabetic patients. Ann Plast Surg 2010;65:206-10.   DOI
8 Saint-Cyr M, Wong C, Schaverien M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.   DOI
9 Wettstein R, Weisser M, Schaefer DJ, et al. Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction. J Plast Reconstr Aesthet Surg 2014;67:634-9.   DOI
10 Eburdery H, Grolleau JL, Berthier C, et al. Management of large sternal wound infections with the superior epigastric artery perforator flap. Ann Thorac Surg 2016;101:375-7.   DOI
11 Sjogren J, Malmsjo M, Gustafsson R, et al. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg 2006;30:898-905.   DOI
12 McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg 1999;117:1144-50.   DOI
13 Stelly MM, Rodning CB, Stelly TC. Reduction in deep sternal wound infection with use of a peristernal cable-tie closure system: a retrospective case series. J Cardiothorac Surg 2015;10:166.   DOI
14 Cayci C, Russo M, Cheema FH, et al. Risk analysis of deep sternal wound infections and their impact on long-term survival: a propensity analysis. Ann Plast Surg 2008;61:294-301.   DOI
15 Tang AT, Ohri SK, Haw MP. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg 2000;17:482-4.   DOI
16 Woo KJ, Pyon JK, Lim SY, et al. Deep superior epigastric artery perforator 'propeller' flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63: 1223-6.   DOI
17 Kannan RY. The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds. J Thorac Cardiovasc Surg 2016;152:264-8.   DOI
18 Eklund AM, Lyytikainen O, Klemets P, et al. Mediastinitis after more than 10,000 cardiac surgical procedures. Ann Thorac Surg 2006;82:1784-9.   DOI
19 Greig AV, Geh JL, Khanduja V, et al. Choice of flap for the management of deep sternal wound infection: an anatomical classification. J Plast Reconstr Aesthet Surg 2007;60: 372-8.   DOI
20 Weinand C, Phan TQV, Perbix W, et al. A reconstructive algorithm for deep sternal wound coverage: the Cologne-Merheim approach. Eur J Plast Surg 2013;36:95-104.   DOI
21 Moher D, Altman DG, Liberati A, et al. PRISMA statement. Epidemiology 2011;22:128.   DOI
22 Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg 1984;88: 357-64.   DOI
23 van Wingerden JJ, de Mol BA, van der Horst CM. Defining post-sternotomy mediastinitis for clinical evidence-based studies. Asian Cardiovasc Thorac Ann 2016;24:355-63.   DOI
24 Rupprecht L, Schmid C. Deep sternal wound complications: an overview of old and new therapeutic options. Open J Cardiovasc Surg 2013;6:9-19.
25 El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61: 1030-6.   DOI
26 Centofanti P, Savia F, La Torre M, et al. A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery: an updated risk factor analysis. J Cardiovasc Surg (Torino) 2007;48:641-6.
27 Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg 2001;20:1168-75.   DOI
28 Robinson PJ, Billah B, Leder K, et al. Factors associated with deep sternal wound infection and haemorrhage following cardiac surgery in Victoria. Interact Cardiovasc Thorac Surg 2007;6:167-71.   DOI
29 Cutrell JB, Barros N, McBroom M, et al. Risk factors for deep sternal wound infection after cardiac surgery: influence of red blood cell transfusions and chronic infection. Am J Infect Control 2016;44:1302-9.   DOI
30 Nishida H, Grooters RK, Soltanzadeh H, et al. Discriminate use of electrocautery on the median sternotomy incision: a 0.16% wound infection rate. J Thorac Cardiovasc Surg 1991;101:488-94.   DOI
31 Tang GH, Maganti M, Weisel RD, et al. Prevention and management of deep sternal wound infection. Semin Thorac Cardiovasc Surg 2004;16:62-9.   DOI
32 Irwin RS. Complications of cough: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):54S-58S.   DOI
33 Casha AR, Yang L, Kay PH, et al. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg 1999;15:365-9.   DOI
34 Gatti G, Dell'Angela L, Barbati G, et al. A predictive scoring system for deep sternal wound infection after bilateral internal thoracic artery grafting. Eur J Cardiothorac Surg 2016; 49:910-7.   DOI
35 Calafiore AM, Weltert L, Mauro MD, et al. Internal mammary artery. Multimed Man Cardiothorac Surg 2005;2005: mmcts.2004.001008.
36 Gatti G, Barbati G, Luzzati R, et al. Prospective validation of a predictive scoring system for deep sternal wound infection after routine bilateral internal thoracic artery grafting. Interact Cardiovasc Thorac Surg 2016;22:606-11.   DOI
37 Wang W, Wang S. Titanium plate fixation versus conventional approach in the treatment of deep sternal wound infection. J Cardiothorac Surg 2016;11:46.   DOI
38 Osawa H, Yoshii S, Abraham SJ, et al. Topical spraying of cefazolin and gentamicin reduces deep sternal wound infections after heart surgery: a multicenter, large volume, retrospective study. Gen Thorac Cardiovasc Surg 2016;64:197-202.   DOI
39 Ennker IC, Pietrowski D, Vohringer L, et al. Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis. J Plast Reconstr Aesthet Surg 2009;62: 1479-83.   DOI
40 Chan M, Yusuf E, Giulieri S, et al. A retrospective study of deep sternal wound infections: clinical and microbiological characteristics, treatment, and risk factors for complications. Diagn Microbiol Infect Dis 2016;84:261-5.   DOI
41 Patel AN, Selzman CH, Kumpati GS, et al. Evaluation of autologous platelet rich plasma for cardiac surgery: outcome analysis of 2000 patients. J Cardiothorac Surg 2016;11:62.   DOI
42 Centofanti P, La Torre M, Barbato L, et al. Sternal closure using semirigid fixation with thermoreactive clips. Ann Thorac Surg 2002;74:943-5.   DOI
43 Huh J, Bakaeen F, Chu D, et al. Transverse sternal plating in secondary sternal reconstruction. J Thorac Cardiovasc Surg 2008;136:1476-80.   DOI
44 Coonar AS, Qureshi N, Smith I, et al. A novel titanium rib bridge system for chest wall reconstruction. Ann Thorac Surg 2009;87:e46-8.   DOI
45 Chou SS, Sena MJ, Wong MS. Use of SternaLock plating system in acute treatment of unstable traumatic sternal fractures. Ann Thorac Surg 2011;91:597-9.   DOI
46 Singh K, Anderson E, Harper JG. Overview and management of sternal wound infection. Semin Plast Surg 2011;25: 25-33.   DOI
47 Harston A, Roberts C. Fixation of sternal fractures: a systematic review. J Trauma 2011;71:1875-9.   DOI
48 Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence. Eur J Cardiothorac Surg 2008;34:139-45.   DOI
49 Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997;38:553-62.   DOI
50 Obdeijn MC, de Lange MY, Lichtendahl DH, et al. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2358-60.   DOI
51 Shumacker HB Jr, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86: 384-7.   DOI
52 Bryant LR, Spencer FC, Trinkle JK. Treatment of median sternotomy infection by mediastinal irrigation with an antibiotic solution. Ann Surg 1969;169:914-20.   DOI
53 Schimmer C, Reents W, Elert O. Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure technique. Thorac Cardiovasc Surg 2006;54:408-13.   DOI
54 Morisaki A, Hosono M, Murakami T, et al. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg 2016;23:397-402.   DOI
55 Heilmann C, Stahl R, Schneider C, et al. Wound complications after median sternotomy: a single-centre study. Interact Cardiovasc Thorac Surg 2013;16:643-8.   DOI
56 Brandt C, Alvarez JM. First-line treatment of deep sternal infection by a plastic surgical approach: superior results compared with conventional cardiac surgical orthodoxy. Plast Reconstr Surg 2002;109:2231-7.   DOI
57 Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery: microbiology and pathogenesis. Eur J Cardiothorac Surg 2002;21:825-30.   DOI
58 Leung Wai Sang S, Chaturvedi R, Alam A, et al. Preoperative hospital length of stay as a modifiable risk factor for mediastinitis after cardiac surgery. J Cardiothorac Surg 2013;8:45.   DOI
59 Matros E, Aranki SF, Bayer LR, et al. Reduction in incidence of deep sternal wound infections: random or real? J Thorac Cardiovasc Surg 2010;139:680-5.   DOI
60 Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15-year review of 23,499 sternotomies. Eur J Cardiothorac Surg 2010;37:880-7.   DOI
61 Steingrimsson S, Gottfredsson M, Gudmundsdottir I, et al. Negative-pressure wound therapy for deep sternal wound infections reduces the rate of surgical interventions for early re-infections. Interact Cardiovasc Thorac Surg 2012;15: 406-10.   DOI
62 Clancy CJ, Nguyen MH, Morris AJ. Candidal mediastinitis: an emerging clinical entity. Clin Infect Dis 1997;25:608-13.   DOI
63 Cabbabe EB, Cabbabe SW. Immediate versus delayed one-stage sternal debridement and pectoralis muscle flap reconstruction of deep sternal wound infections. Plast Reconstr Surg 2009;123:1490-4.   DOI
64 Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766-76.   DOI
65 Jabra-Rizk MA, Falkler WA, Meiller TF. Fungal biofilms and drug resistance. Emerg Infect Dis 2004;10:14-9.   DOI
66 Adam B, Baillie GS, Douglas LJ. Mixed species biofilms of Candida albicans and Staphylococcus epidermidis. J Med Microbiol 2002;51:344-9.   DOI
67 Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998;65:1046-9.   DOI
68 Kutsal A, Ibrisim E, Catav Z, et al. Mediastinitis after open heart surgery. Analysis of risk factors and management. J Cardiovasc Surg (Torino) 1991;32:38-41.