Titanium plate fixation for a dehisced sternum following coronary artery bypass grafting: a case report

Sternal dehiscence is one of the most troublesome complications following cardiac surgery. Treatment failure and consequent lethal results are very common, even with all the efforts to resolve sternal dehiscence such as removal of infectious tissue, muscle flap interposition, and sternal rewiring. We report on a case of sternal osteomyelitis following coronary artery bypass grafting that was successfully treated with wide sternal resection, titanium plate fixation, and pectoralis muscle flap interposition.     

Candida albicans Infection of Sternum and Costal Cartilages: Combined Operative Treatment and Drug Therapy with 5-Fluorocytosine

Two patients with candidal sternal osteomyelitis have been successfully treated by operative debridement and adjuvant drug therapy with 5-fluorocytosine. One patient had developed postoperative candidal wound infection after sternotomy, and the other acquired candidal sternal osteomyelitis following Candida fungemia. The diagnosis, suggested by culture, was confirmed by identification of Candida pseudohyphae in debrided tissue. Histological confirmation of candidal sternal osteomyelitis indicates the need for operative debridement and specific systemic antifungal therapy. The drug 5-fluorocytosine appears to provide effective oral therapy in this situation.     

Treatment of postoperative osteomyelitis using an omental pedicle flap

We described two patients with postoperative sternal osteomyelitis with mediastinal abscess who were successfully treated by omentopexy. One was a 15-year-old boy. Five days after accessory pathway division for Wolff-Parkinson-White syndrome, he was diagnosed as having sternal osteomyelitis. Cultures of the exudate yielded staphylococcus epidermidis. Closed continuous irrigation with diluted povidone-iodine was not effective. After open drainage, omentopexy with an omental pedicle flap was performed. Postoperatively, computed tomography showed no abnormal findings in the omental flap and surrounding tissue. The second patient was a 33-year-old man. Re-aortic valve replacement for aortic regurgitation was performed. Eleven days after the operation, he was diagnosed as having postoperative sternal osteomyelitis. Cultures of the drainage fluid yielded staphylococcus epidermidis. Continuous closed irrigation with povidone-iodine was ineffective. Thus, the wound was opened and omentopexy with an omental pedicle flap was performed. The postoperative course was uneventful. Computed tomography showed no residual abscess or recurrent inflammation. We conclude that the omentopexy is useful in the treatment of postoperative sternal osteomyelitis.     

Management of intractable sternal wound infections with topical negative pressure dressing

BACKGROUND: Sternal osteomyelitis after cardiac surgery is a life-threatening complication. The potential spread of infection into the mediastinum, involving the prosthetic valve, grafts, and suture lines, makes this an extremely serious complication confronting both cardiac and plastic surgeons. Aim: Topical negative pressure (TNP) dressing has been proven to be effective for wound healing. We want to take advantages of this equipment to improve the results of intractable sternal wound infection. The results are discussed. METHODS: From December 1996 to July 2002, 25 patients with sternal wound infections were treated at Kaohsiung Medical University Hospital. Nine patients suffering intractable sternal osteomyelitis were managed with debridement and TNP dressings. These patients received 1-3 debridements (an average of 2.2 debridements), and the average TNP dressing treatment period was 20.2 days (ranging from 3 to 43 days). After management, the infections were controlled and healthy vascularized wounds were achieved. Then, flap reconstruction could be performed for complete wound closure. Seven of the nine patients survived, and there was no recurrence of sternal osteomyelitis during follow-up period (ranging from 5 to 70 months). CONCLUSION: The advantages of applying TNP dressings in cases of intractable sternal wound infections include (1) protecting the underlying mediasternal structure from infection, (2) permitting delayed sternal closure to avoid cardiac compression induced compromised cardiopulmonary function, (3) possibility of repeated wound inspection and bedside debridement, (4) cost-effectiveness of wound care, and (5) providing an option to promote sternal wound secondary healing for patients in poor physical condition.     

Successful treatment of sternal osteomyelitis after pneumonectomy using a pedicled omental flap

We report here the case of a 64-year-old man with sternal osteomyelitis after pneumonectomy through a median sternotomy who was successfully treated using a pedicled omental flap. This is the first report in the literature to describe sternal osteomyelitis and mediastinitis after pneumonectomy. In this case, the visceral pleura of the remnant right lung was located just under the infected sternum. Careful management is recommended because empyema pleurae can be a fatal complication.     

Acute purulent mediastinitis and sternal osteomyelitis after closed chest cardiopulmonary resuscitation: a case report and review of the literature

Numerous complications have been associated with cardiopulmonary resuscitation. Acute purulent staphylococcal mediastinitis and sternal osteomyelitis are, however, unusual and do not appear to have been reported previously in association with closed chest resuscitation. Sternal fracture during chest compressions and subsequent hematogenous seeding of the resultant retrosternal hematoma with Staphylococcus aureus led to purulent mediastinitis and sternal osteomyelitis in our patient. The source of bacteremia may have been a resolving phlebitis at an intravenous catheter insertion site. Early diagnosis, aggressive surgical debridement, and antibiotic therapy were key to a successful outcome.     

Single-stage repair of the anterior chest wall following sternal destruction complicated by mediastinitis

Purpose

Although various techniques have been described, the ideal reconstructive procedure for treating massive sternal fragmentation and necrosis is still a matter of debate. Sometimes, reconstruction is so challenging that repetitive operations are required, particularly when complicated by mediastinitis and sternal osteomyelitis.

Methods

Five patients (three males, two females, median age 66) with severe osteomyelitis and sternal destruction after receiving myocardial revascularization underwent partial or radical sternal resection, omental flap transposition, titanium mesh implantation and rectus abdominis muscle flap transposition. The final procedure involved single-stage closure.

Results

One patient died 9 days after the final procedure due to pneumonia and septicemia. The other patients received antibiotics for at least 6 weeks postoperatively. The mean hospital stay was 36 days. Optimal wound healing was observed, with acceptable cosmetic disorders.

Conclusions

Although lateral sternal support is the first-line surgical treatment for sternal dehiscence, performing primary closure of complicated defects is often impossible. Aggressive treatment modalities are required in such cases for anterior chest wall defects. This technique provides the ability to perform rigid and stable sternal closure in complicated cases.     

Sternumosteomyelitis

Deep sternal infections with sternal osteomyelitis are rare conditions with extensive consequences for the patient. The incidence of complications after median sternotomy is as high as 0.4–8?%. Wound and sternal dehiscence and a septic course with mediastinitis leading to septic shock is a feared complication with a high mortality next to the chronic course of the infection with the clinical correlation of presternal fistulas. An early diagnosis and surgical intervention is decisive to enhance the prognosis of the disease, leading to a significant increase in the survival rate of patients.     

Tuberculosis of the sternum presenting as metastatic disease.

The case is presented of a 59 year old Saudi Arabian woman with sternal and vertebral tuberculous osteomyelitis and a benign breast mass simulating metastatic disease. This case illustrates the diagnostic difficulties that may be encountered in the diagnosis of tuberculous osteomyelitis.     

Sternal segment dislocation in children

Three cases of sternal segment dislocation in children are described. The primary mechanisms were direct blow in a 4-year-old boy, indirect forces in a 3-year-old boy, and osteomyelitis in a 10-year-old boy. The two former cases were dislocated at the junction of the manubrium with the sternal body, and the latter case was at the junction of the first and second sternal segments. The dislocated segments were gradually rotated for approximately 2 weeks and were finally stabilized after rotation. While in the dislocated state, the patients were observed conservatively, although all the dislocated segments were remodeled. Surgical treatment of sternal segment dislocation is not inevitable.     

Case Report on Sternal Osteomyelitis by Trichosporon inkin Complicating Lung Transplantation: Effective Treatment With Vacuum-Assisted Closure and Surgical Reconstruction

Sternal osteomyelitis is a serious complication that significantly increases morbidity and mortality after thoracic surgery. We describe a case of sternal osteomyelitis by Trichosporon inkin following lung transplantation and the excellent results achieved with vacuum-assisted closure therapy.     

Sternumosteomyelitis – chirurgische Behandlungskonzepte

Sternal osteomyelitis is a potentially fatal condition following cardiac surgery. Sternal osteomyelitis should be diagnosed as early as possible followed by an interdisciplinary radical debridement. Subsequently plastic reconstructive surgery is necessary for defect reconstruction. This can be achieved by a number of established pedicled and free flap plastic surgery procedures. The choice of flap procedures is based on defect geometry and the individual patient situation, including potential flap donor sites. Smaller defects can generally be reconstructed by pedicled flap transfer. For extensive sternal defects, free flap transplantation is now a well-established therapeutic option. In some patients lacking sufficient recipient vessels, the creation of an arteriovenous (AV) loop as recipient vessel is necessary. In summary, successful therapy of sternal osteomyelitis is based on early interdisciplinary treatment by the various surgical subspecialties.     

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%–8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2–5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.     

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis.

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.     

Bridging the cleft over the throbbing heart

Primary repair of sternal cleft deformities are best achieved in the neonatal period. Conversion of a partial defect to a complete sternal cleft with sternal bar mobilization is able to achieve sternal approximation in most cases. We describe a new technique of fracturing the clavicles in unyielding cases as was our experience in a 6-week-old infant.     

Sternotomy After Muscle Flap Repair of Sternal Osteomyelitis and Mediastinitis

A 61-year-old man who had undergone aortocoronary bypass developed sternal osteomyelitis and mediastinitis which required sternal debridement and muscle flap interposition. Two years later the midline incision was used for an orthotopic heart transplantation. No major technical difficulties were encountered at the time of transplantation.     

Poly-lactic-acid (PLA) sternal pins for the closure of median sternotomy--report of a case]

Poly-lactic-acid (PLA) sternal pins were used for the closure of median sternotomy in a case of bilateral pneumothorax. After placement 7 sutures of polyester and 2 wires, PLA sternal pins were inserted into the bone marrow of the sternum. The wires were then twisted and tightened, and all sutures were tightened, and the wires were removed. No significant postoperative complications, i.e., osteomyelitis and mediastinitis, sternal dehiscence, or bone marrow dysfunction, were observed. In addition, the PLA sternal pins were absorbed. In the closure of median sternotomy, PLA sternal pins provide stable sternal adhesion, which is essential to the prevention of sternal dehiscence and other complications. Moreover, with the use of PLA sternal pins, the retention of steel wires in the body is unnecessary.     

Surgical Treatment of Primary Sternal Osteomyelitis

Four patients with primary sternal osteomyelitis are described. Pseudomonas aeruginosa was the infective organism. Three of the 4 were heroin addicts. Limited surgical resection with preservation of the posterior periosteum is recommended for an infected sternum. Postoperative antibiotic therapy for a period of six weeks is also recommended. Preservation of the posterior sternal periosteum rather than conventional radical excision is important for maintaining physical stability and avoiding chest wall deformity in this group of patients.     

Postoperative chondritis and osteomyelitis of the ribs and sternum]

Postoperative chondritis and osteomyelitis of the ribs and sternum were observed in 90 of 4620 operated patients. The main causes contributing to the development of this complication are errors in treatment of cartilages during thoracotomy and suppurative complications in the pleural cavity or in the operative wound. A radical removal of the affected costal and sternal portions as early as possible is considered to be the method of choice in treatment of chondirtis and osteomyelitis of the ribs and sternum.     

Sternal osteomyelitis: use of vacuum-assisted closure device as an adjunct to definitive closure with sternectomy and muscle flap reconstruction

OBJECTIVES: Sternal osteomyelitis following cardiac surgery often requires debridement and flap coverage. The VAC (vacuum-assisted closure) device has been useful in complex wound coverage. A retrospective review of a single surgeon's experience with sternal reconstruction using the VAC device as an adjunct to debridement and muscle flap reconstruction was performed. METHODS: Thirteen consecutive patients over a 34-month period underwent debridement and reconstruction of sternal wounds. Eleven patients (85%) were males, and two (15%) were females. Mean age was 61 years (range: 43-73 years). Acute purulent sternal infections occurred in seven patients, while chronic sternal osteomyelitis was seen in six patients. Use of the VAC device during the perioperative period was evaluated. RESULTS: Of the 13 patients, the VAC device was used prior to flap closure in six patients, and after flap closure in two patients. Sternal debridement with bilateral pectoralis muscle flaps was used to reconstruct 12 patients, and one patient underwent debridement only with VAC placement. All 13 patients (100%) had complete closure of their complex wounds at an average of follow-up of 14 months. CONCLUSIONS: The VAC device is useful in the treatment of sternal osteomyelitis in three contexts: (1) as a temporary wound care technique preoperatively that minimizes dressing changes and prevents shear stresses of an open sternum, (2) as the sole method of wound closure in specific cases, and (3) as a technique to facilitate healing in postoperative flap reconstruction cases complicated by reinfection.