Overview and Management of Sternal Wound Infection

ABSTRACT

Sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality. Past treatment options have included closed suction and continuous irrigation. Current paradigms in the management of sternal wound infection include surgical debridement, vacuum-assisted closure therapy, flap coverage, and sternal plating. We provide a general overview of sternal wound infection and treatment options for the plastic surgeon.

Sternal wound infection - treatment - flap - VAC - sternal plating

REFERENCES

• 1 Gummert J F, Barten M J, Hans C et al.. Mediastinitis and cardiac surgery—an updated risk factor analysis in 10,373 consecutive adult patients.  Thorac Cardiovasc Surg. 2002;  50 87-91
• 2 Braxton J H, Marrin C A, McGrath P D et al.. 10-year follow-up of patients with and without mediastinitis.  Semin Thorac Cardiovasc Surg. 2004;  16 70-76
• 3 Gummert J F, Barten M J, Hans C et al.. Mediastinitis and cardiac surgery—an updated risk factor analysis in 10,373 consecutive adult patients.  Thorac Cardiovasc Surg. 2002;  50 87-91
• 4 Losanoff J E, Richman B W, Jones J W. Disruption and infection of median sternotomy: a comprehensive review.  Eur J Cardiothorac Surg. 2002;  21 831-839
• 5 Lee J C, Raman J, Song D H. Primary sternal closure with titanium plate fixation: plastic surgery effecting a paradigm shift.  Plast Reconstr Surg. 2010;  125 1720-1724
• 6 Salehi Omran A, Karimi A, Ahmadi S H et al.. Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality.  BMC Infect Dis. 2007;  7 112
• 7 Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality.  Eur J Cardiothorac Surg. 2001;  20 1168-1175
• 8 Garner J S, Jarvis W R, Emori T G, Horan T C, Hughes J M. CDC definitions for nosocomial infections, 1988.  Am J Infect Control. 1988;  16 128-140
• 9 Pairolero P C, Arnold P G. Management of infected median sternotomy wounds.  Ann Thorac Surg. 1986;  42 1-2
• 10 Tang G H, Maganti M, Weisel R D, Borger M A. Prevention and management of deep sternal wound infection.  Semin Thorac Cardiovasc Surg. 2004;  16 62-69
• 11 Lu J C, Grayson A D, Jha P, Srinivasan A K, Fabri B M. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery.  Eur J Cardiothorac Surg. 2003;  23 943-949
• 12 Borger M A, Rao V, Weisel R D et al.. Deep sternal wound infection: risk factors and outcomes.  Ann Thorac Surg. 1998;  65 1050-1056
• 13 Ridderstolpe L, Gill H, Granfeldt H, Ahlfeldt H, Rutberg H. Superficial and deep sternal wound complications: incidence, risk factors and mortality.  Eur J Cardiothorac Surg. 2001;  20 1168-1175
• 14 Prabhakar G, Haan C K, Peterson E D, Coombs L P, Cruzzavala J L, Murray G F. The risks of moderate and extreme obesity for coronary artery bypass grafting outcomes: a study from the Society of Thoracic Surgeons' database.  Ann Thorac Surg. 2002;  74 1125-1130 discussion 1130-1131
• 15 Nelson D R, Buxton T B, Luu Q N, Rissing J P. The promotional effect of bone wax on experimental Staphylococcus aureus osteomyelitis.  J Thorac Cardiovasc Surg. 1990;  99 977-980
• 16 Nishida H, Grooters R K, Soltanzadeh H, Thieman K C, Schneider R F, Kim W P. Discriminate use of electrocautery on the median sternotomy incision. A 0.16% wound infection rate.  J Thorac Cardiovasc Surg. 1991;  101 488-494
• 17 Peterson M D, Borger M A, Rao V, Peniston C M, Feindel C M. Skeletonization of bilateral internal thoracic artery grafts lowers the risk of sternal infection in patients with diabetes.  J Thorac Cardiovasc Surg. 2003;  126 1314-1319
• 18 Cimochowski G E, Harostock M D, Brown R, Bernardi M, Alonzo N, Coyle K. Intranasal mupirocin reduces sternal wound infection after open heart surgery in diabetics and nondiabetics.  Ann Thorac Surg. 2001;  71 1572-1578 discussion 1578-1579
• 19 Sutherland R D, Martinez H E, Guynes W A. A rapid, secure method of sternal closure.  Cardiovasc Dis. 1981;  8 54-55
• 20 Ståhle E, Tammelin A, Bergström R, Hambreus A, Nyström S O, Hansson H E. Sternal wound complications—incidence, microbiology and risk factors.  Eur J Cardiothorac Surg. 1997;  11 1146-1153
• 21 Olbrecht V A, Barreiro C J, Bonde P N et al.. Clinical outcomes of noninfectious sternal dehiscence after median sternotomy.  Ann Thorac Surg. 2006;  82 902-907
• 22 Gårdlund B, Bitkover C Y, Vaage J. Postoperative mediastinitis in cardiac surgery - microbiology and pathogenesis.  Eur J Cardiothorac Surg. 2002;  21 825-830
• 23 Gur E, Stern D, Weiss J et al.. Clinical-radiological evaluation of poststernotomy wound infection.  Plast Reconstr Surg. 1998;  101 348-355
• 24 Quirce R, Carril J M, Gutiérrez-Mendiguchía C, Serrano J, Rabasa J M, Bernal J M. Assessment of the diagnostic capacity of planar scintigraphy and SPECT with 99mTc-HMPAO-labelled leukocytes in superficial and deep sternal infections after median sternotomy.  Nucl Med Commun. 2002;  23 453-459
• 25 Shumacker Jr H B, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection.  Arch Surg. 1963;  86 384-387
• 26 Bryant L R, Spencer F C, Trinkle J K. Treatment of median sternotomy infection by mediastinal irrigation with an antibiotic solution.  Ann Surg. 1969;  169 914-920
• 27 Grossi E A, Culliford A T, Krieger K H et al.. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures.  Ann Thorac Surg. 1985;  40 214-223
• 28 Calvat S, Trouillet J-L, Nataf P, Vuagnat A, Chastre J, Gibert C. Closed drainage using Redon catheters for local treatment of poststernotomy mediastinitis.  Ann Thorac Surg. 1996;  61 195-201
• 29 Catarino P A, Chamberlain M H, Wright N C et al.. High-pressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis.  Ann Thorac Surg. 2000;  70 1891-1895
• 30 Durandy Y, Batisse A, Bourel P, Dibie A, Lemoine G, Lecompte Y. Mediastinal infection after cardiac operation. A simple closed technique.  J Thorac Cardiovasc Surg. 1989;  97 282-285
• 31 Kirsch M, Mekontso-Dessap A, Houël R, Giroud E, Hillion M-L, Loisance D Y. Closed drainage using redon catheters for poststernotomy mediastinitis: results and risk factors for adverse outcome.  Ann Thorac Surg. 2001;  71 1580-1586
• 32 Morykwas M J, Argenta L C, Shelton-Brown E I, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation.  Ann Plast Surg. 1997;  38 553-562
• 33 Obdeijn M C, de Lange M Y, Lichtendahl D H, de Boer W J. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis.  Ann Thorac Surg. 1999;  68 2358-2360
• 34 Wackenfors A, Gustafsson R, Sjögren J, Algotsson L, Ingemansson R, Malmsjö M. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy.  Ann Thorac Surg. 2005;  79 1724-1730; discussion 1730–1731
• 35 Lambert K V, Hayes P, McCarthy M. Vacuum assisted closure: a review of development and current applications.  Eur J Vasc Endovasc Surg. 2005;  29 219-226
• 36 Domkowski P W, Smith M L, Gonyon Jr D L et al.. Evaluation of vacuum-assisted closure in the treatment of poststernotomy mediastinitis.  J Thorac Cardiovasc Surg. 2003;  126 386-390
• 37 Chen Y, Almeida A A, Mitnovetski S, Goldstein J, Lowe C, Smith J A. Managing deep sternal wound infections with vacuum-assisted closure.  ANZ J Surg. 2008;  78 333-336
• 38 Tang A TM, Ohri S K, Haw M P. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection.  Eur J Cardiothorac Surg. 2000;  17 482-484
• 39 Cayci C, Russo M, Cheema F H 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
• 40 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;  37 880-887
• 41 Fleck T, Kickinger B, Moidl R et al.. Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience.  Interact Cardiovasc Thorac Surg. 2008;  7 801-804
• 42 Gdalevitch P, Afilalo J, Lee C. Predictors of vacuum-assisted closure failure of sternotomy wounds.  J Plast Reconstr Aesthet Surg. 2010;  63 180-183
• 43 Mokhtari A, Petzina R, Gustafsson L, Sjögren J, Malmsjö M, Ingemansson R. Sternal stability at different negative pressures during vacuum-assisted closure therapy.  Ann Thorac Surg. 2006;  82 1063-1067
• 44 Sjögren J, Malmsjö M, Gustafsson R, Ingemansson R. 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
• 45 Bapat V, El-Muttardi N, Young C, Venn G, Roxburgh J. Experience with vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use.  J Card Surg. 2008;  23 227-233
• 46 Grauhan O, Navarsadyan A, Hussmann J, Hetzer R. Infectious erosion of aorta ascendens during vacuum-assisted therapy of mediastinitis.  Interact Cardiovasc Thorac Surg. 2010;  11 493-494
• 47 Jones G, Jurkiewicz M J, Bostwick J et al.. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.  Ann Surg. 1997;  225 766-776 discussion 776-778
• 48 Cabbabe E B, Cabbabe S W. Immediate versus delayed one-stage sternal débridement and pectoralis muscle flap reconstruction of deep sternal wound infections.  Plast Reconstr Surg. 2009;  123 1490-1494
• 49 Brandt C, Alvarez J M. 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 2231-2237
• 50 Rand R P, Cochran R P, Aziz S et al.. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection.  Ann Thorac Surg. 1998;  65 1046-1049
• 51 Hugo N E, Sultan M R, Ascherman J A, Patsis M C, Smith C R, Rose E A. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps.  Plast Reconstr Surg. 1994;  93 1433-1441
• 52 Yasuura K, Okamoto H, Morita S et al.. Results of omental flap transposition for deep sternal wound infection after cardiovascular surgery.  Ann Surg. 1998;  227 455-459
• 53 Reade C C, Meadows Jr W M, Bower C E, Lalikos J F, Zeri R S, Wooden W A. Laparoscopic omental harvest for flap coverage in complex mediastinitis.  Am Surg. 2003;  69 1072-1076
• 54 Stump A, Bedri M, Goldberg N H, Slezak S, Silverman R P. Omental transposition flap for sternal wound reconstruction in diabetic patients.  Ann Plast Surg. 2010;  65 206-210
• 55 Davison S P, Clemens M W, Armstrong D, Newton E D, Swartz W. Sternotomy wounds: rectus flap versus modified pectoral reconstruction.  Plast Reconstr Surg. 2007;  120 929-934
• 56 Ascherman J A, Patel S M, Malhotra S M, Smith C R. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in technique and outcomes analysis.  Plast Reconstr Surg. 2004;  114 676-683
• 57 Patel N V, Woznick A R, Welsh K S, Bendick P J, Boura J A, Mucci S J. Predictors of mortality after muscle flap advancement for deep sternal wound infections.  Plast Reconstr Surg. 2009;  123 132-138
• 58 Gottlieb L J, Pielet R W, Karp R B, Krieger L M, Smith Jr D J, Deeb G M. Rigid internal fixation of the sternum in postoperative mediastinitis.  Arch Surg. 1994;  129 489-493
• 59 Sargent L A, Seyfer A E, Hollinger J, Hinson R M, Graeber G M. The healing sternum: a comparison of osseous healing with wire versus rigid fixation.  Ann Thorac Surg. 1991;  52 490-494
• 60 Voss B, Bauernschmitt R, Will A et al.. Sternal reconstruction with titanium plates in complicated sternal dehiscence.  Eur J Cardiothorac Surg. 2008;  34 139-145
• 61 Wu L C, Renucci J D, Song D H. Sternal nonunion: a review of current treatments and a new method of rigid fixation.  Ann Plast Surg. 2005;  54 55-58
• 62 Wu L C, Renucci J, Song D H. Rigid-plate fixation for the treatment of sternal nonunion.  J Thorac Cardiovasc Surg. 2004;  128 623-624
• 63 Cicilioni Jr O J, Stieg III F H, Papanicolaou G. Sternal wound reconstruction with transverse plate fixation.  Plast Reconstr Surg. 2005;  115 1297-1303
• 64 Hallock G G, Szydlowski G W. Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system.  Ann Plast Surg. 2007;  58 640-644
• 65 Plass A, Grünenfelder J, Reuthebuch O et al.. New transverse plate fixation system for complicated sternal wound infection after median sternotomy.  Ann Thorac Surg. 2007;  83 1210-1212
• 66 Song D H, Lohman R F, Renucci J D, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis.  Eur J Cardiothorac Surg. 2004;  26 367-372
• 67 Schimmer C, Keith P, Neukam K, Beissert M, Leyh R. Large thoracic wall hematoma following sternal reconstruction with transversal plate fixation after deep sternal wound infection.  Thorac Cardiovasc Surg. 2007;  55 402-405