Infected Median Sternotomy Wound: Successful Treatment by Muscle Flaps

The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aorta, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.     

Pectoralis major muscle flaps for closure of sternal defects

Summary A reliable and simple technique involving the use of pectoralis major muscle flaps is described for the closure of sternal and costal cartilage defects caused by debridement for chronic osteomyelitis following median sternotomy. No bone grafts, omentum flaps or skin grafts have been needed in more than 20 patients.     

Management of sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.     

Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis.

Infection of a median sternotomy wound is a rare though potentially fatal complication. Despite early diagnosis and proper treatment, prognosis is poor because of the chance of mediastinal spread of the infection and the poor physical state of these patients. Muscle repair is superior to more conservative surgical options such as sternal resuturing with mediastinal irrigation. During the last 10 years, complications--including sternal infections and dehiscences--have been encountered in 172/4725 median sternotomy wounds after cardiac surgery procedures (4%). Thirty-four patients (of whom 30 had acute sternal infections and four chronical sternal infections) underwent aggressive sternal debridement followed by muscle flap closure. Seventy-two muscle flaps were carried out, a pectoralis major bilateral muscle flap being the most common either alone or in combination with a rectus abdominis muscle flap. Five perioperative deaths (15%) were recorded. Of the 29 surviving patients, 25 patients (74%) were free of infection and four (12%) developed recurrence of the infection after a mean follow up of 3 years (range 49 days-8 years). We conclude that although muscle repair is not free of complications, it is reliable in reducing mediastinitis-related morbidity and mortality.     

Closure of infected sternal wounds with a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps

We have recently added to our regimen a unilateral rectus abdominis muscle flap to cover the lower sternum and adjacent soft tissues, in addition to bilateral pectoralis major myocutaneous advancement flaps for closure of infected sternal wounds. Twenty patients underwent this procedure for closure of infected sternal wounds after initial débridement at our institutions. There were no intraoperative deaths in this series, but three patients died of other medical conditions. Two patients developed hematomas and one developed recurrent sternal wound infection after surgery; two had superficial wound infections and five had minor wound problems (i.e., skin edge necrosis). All surviving patients (17/20, 85%) had healed sternal wounds with normal chest contour and there were no instances of flap necrosis, sternal wound dehiscence, or abdominal wall hernia during the follow-up (18–60 months). Based upon our experience, we recommend a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps for selected patients with infected sternal wounds. This approach provides reliable soft tissue coverage with acceptable morbidity and mortality in this high-risk patient population. Received: 29 July 1998 / Accepted: 1 March 1999     

Reconstruction of the infected median sternotomy wound

Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.     

Delayed primary closure after sternal wound infection

Infected median sternotomy is a major complication of cardiac operations. Over a 30-month period, 25 sternal wound infections were treated at a single institution. Twenty-four (2.7%) followed 883 operations with cardiopulmonary bypass, and 1 followed median sternotomy for a noncardiac procedure. Twenty-one of the 25 patients survived to sternal closure. Eighteen patients were treated with delayed primary closure and 3 with pectoralis muscle flaps. Fifteen patients (83%) had an uneventful postoperative course after delayed primary closure. In 2 patients reoperation was required for sternal dehiscence, and in 1 patient a superficial wound infection developed, which was treated with local wound care. In all 18 patients the sternum eventually healed. Criteria for delayed primary closure included clean tissue surfaces without purulent debris, the absence of pockets of purulent drainage, and negative wound cultures obtained 24 hours before closure. The average time from operation to sternal incision and drainage was 11 days (range, five to 59 days). Delayed primary closure was performed nine days after incision and drainage (range, five to 27 days). The average hospital stay was 24 days after sternal incision and drainage (range, nine to 85 days). Cultures from specimens taken at the time of sternal incision and drainage were positive in all patients. Wound cultures were positive at the time of sternal closure in 5 patients. Wound complications developed in 2 of these 5 patients. Delayed primary closure has many of the advantages of classic methods, but fewer complications. Results are comparable, while allowing simpler wound care and less cosmetic deformity. Delayed primary closure is an acceptable alternative in the treatment of sternal wound infections.     

Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps

BACKGROUND: Advanced pectoralis major muscle flaps can be used to treat deep sternal wound infections in children; however, the long-term outcomes have not been widely reported. METHODS: We retrospectively reviewed 11 patients (median age, 3.8 months), who had developed deep sternal wound infections following median sternotomy, among 1380 consecutive pediatric cardiac procedures from January 1995 to July 2001. RESULTS: Advanced pectoralis major muscle flaps were used in 10 patients bilaterally and in 1 patient unilaterally. All survived and were discharged without evidence of infection. During a mean +/- standard deviation follow-up of 42.1 +/- 20.9 months, there was no evidence of recurrent or chronic infection. All patients demonstrated normal development with no limitations to their upper trunk or limb movements. All of the 6 patients who had undergone a palliative operation initially had additional operations without difficulty through the existing sternotomy incision. CONCLUSIONS: This technique proved to be easy and promoted wound healing that covered all of the sternal wound defects without tension and without requiring additional flaps. It produced minimal growth and developmental problems, and it might facilitate additional operations.     

Transposition of the great omentum for infected sternotomy wounds in cardiac surgery. Report of 16 cases and review of published reports.

The expanding indications for coronary artery bypass graft (CABG) and cardiac valves replacement have caused an increase in the number of sternal infections. The common treatment includes appropriate antibiotics, early debridement, and transposition of muscle flaps with or without skin grafts. When other treatments have proved unsatisfactory, we have used the great omentum for wound closure. During the last five years, 16 patients (10 women, six men, median age 63 years) underwent repair of infected sternotomy wounds by the transposition of the great omentum, after failure of pectoralis major or rectus abdominis muscle flaps (n = 9). Seven patients underwent transposition of the great omentum as the first choice. The omentum covers the sternal defect well and the closure was reliable.     

The pectoralis major muscle extended island flap for complete obliteration of the median sternotomy wound

The sequence of adverse events initiated by a sternal wound infection today can typically be ameliorated by interposing a vascularized flap. The pectoralis major muscle due to its propinquity has universally been the workhorse flap for minimizing this dilemma, with our experience over the past 25 years being no exception as 123 of 156 patients so inflicted required this donor site in some format. However, a rectus abdominis muscle had to be used in combination in 22 patients, particularly for coverage of the xiphoid region, and this can add significant morbidity in an already compromised patient population. This conundrum provided the impetus starting in 2003 for the development of a pectoralis major muscle extended island flap, whereby skeletonizing its vascular pedicle back to near the origin of the thoracoacromial axis, the desired extended reach can be obtained. Since that time, 18 pectoralis major muscle extended island flaps have been successfully used, with only a single wound complication still requiring use of a rectus abdominis muscle flap. This has proven to be a reliable option that alone allows complete closure of the median sternotomy wound while avoiding the need for combined flaps with preservation of the rectus abdominis muscle.     

Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience.

OBJECTIVE: The purpose of the study is to define those patient variables that contribute to morbidity and mortality of median sternotomy wound infection and the results of treatment by debridement and closure by muscle flaps. BACKGROUND: Infection of the median sternotomy wound after open heart surgery is a devastating complication associated with significant mortality. Twenty years ago, these wounds were treated with either open packing or antibiotic irrigation, with a mortality approaching 50% in some series. In 1975, the authors began treating these wounds with radical sternal debridement followed by closure using muscle or omental flaps. The mortality of sternal wound infection has dropped to < 10%. METHODS: The authors' total experience with 409 patients treated over 20 years is described in relation to flap choices, hospital days after sternal wound closure, and incidence rates of morbidity and mortality. One hundred eighty-six patients treated since January 1988 were studied to determine which patient variables had impact on rates of flap closure complications, recurrent sternal wound infection, or death. Variables included obesity, history of smoking, hypertension, diabetes, poststernotomy septicemia, internal mammary artery harvest, use of intra-aortic balloon pump, and perioperative myocardial infarction and were analyzed using chi square tests. Fisher's exact tests, and multivariable logistic regression analysis. RESULTS: The mortality rate over 20 years was 8.1% (33/49). Additional procedures for recurrent sternal wound infection were necessary in 5.1% of patients. Thirty-one patients (7.6%) required treatment for hematoma, and 11 patients (2.7%) required hernia repair. Among patients treated since 1988, variables strongly associated with mortality were septicemia (p < 0.00001), perioperative myocardial infarction (p = 0.006), and intra-aortic balloon pump (p = 0.0168). Factors associated with wound closure complications were intra-aortic balloon pump (p = 0.0287), hypertension (p = 0.0335), and history of smoking (p = 0.0741). Factors associated with recurrent infection were history of sternotomy (p = 0.008) and patients treated for sternal wound infection from 1988 to 1992 (p = 0.024). Mean hospital stay after sternal wound reconstruction declined from 18.6 days (1988-1992) to 12.4 days (1993-1996) (p = 0.005). To clarify management decisions of these difficult cases, a classification of sternal wound infection is presented. CONCLUSIONS: Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.     

经胸骨正中手术切口感染创面的修复

目的对比观察不同方法修复经胸骨正中手术切口感染创面的治疗效果。方法1997年12月～2006年12月,分别用胸大肌内侧头肌瓣、胸大肌瓣、上蒂腹直肌瓣及大网膜移位修复经胸骨手术切口感染创面13例。男8例,女5例;年龄28～72岁,平均52岁。合并糖尿病8例,肺炎及心力衰竭4例,脓胸3例,慢性肺功能不全4例,恶性肿瘤1例,严重肥胖6例。11例为较新鲜裂开创面,2例为慢性创面。创面范围10cm×5cm～22cm×10cm。结果3例分别于术后3d因血管吻合处破裂大出血、肺炎及癌转移死亡。其余10例伤口期愈合6例,随访6个月～5年,均无复发;2例切口皮肤拉拢缝合处部分皮肤坏死,经再次手术扩创植皮后愈合;2例创口引流处感染,经换药愈合。结论创面较小且位于手术切口上端者适合用胸大肌内侧头肌瓣修复;创面较大且位于切口上端者适合用全胸大肌瓣修复;创面较小且位于切口下端的适合用上蒂腹直肌瓣修复;创面较长可联合应用胸大肌瓣、上蒂腹直肌瓣修复创面;创面巨大合并重要脏器外露时,可用大网膜移位修复创面。残余创面可经植皮及换药愈合。     

TRANSPOSITION OF THE GREAT OMENTUM FOR INFECTED STERNOTOMY WOUNDS IN CARDIAC SURGERY. REPORT OF 16 CASES AND REVIEW OF PUBLISHED REPORTS

The expanding indications for coronary artery bypass graft (CABG) and cardiac valves replacement have caused an increase in the number of sternal infections. The common treatment includes appropriate antibiotics, early debridement, and transposition of muscle flaps with or without skin grafts. When other treatments have proved unsatisfactory, we have used the great omentum for wound closure. During the last five years, 16 patients (10 women, six men, median age 63 years) underwent repair of infected sternotomy wounds by the transposition of the great omentum, after failure of pectoralis major or rectus abdominis muscle flaps (n = 9). Seven patients underwent transposition of the great omentum as the first choice. The omentum covers the sternal defect well and the closure was reliable.     

Pectoralis major muscle transposition for treatment of infected median sternotomy wounds

Median sternotomy, currently the standard incision in open heart procedures, is rarely complicated by wound infection, but when present, it is associated with a high morbidity and mortality. Adequate treatment can be provided by means of transposition of the pectoralis major muscle. After thorough sternal wound debridement the muscle, based on the thoraco-acromial pedicle, is transposed into the defect. From September 1986 until December 1992 14 patients (mean age 67 years) with sternal infection were treated using this technique. Mean hospital stay after operation was 23 days; mean follow-up was 24 months. In 10 patients (72%) a successful treatment, i.e. a permanently cured infection, was achieved. Three patients (21%) developed a recurrence; one of them died during follow-up as a consequence of cardiac failure, the other two underwent reoperation and healing occurred at a later stage. In one patient (who died of a unknown cause 2 months after muscle transposition) the result was classified as unknown. In conclusion, transposition of the pectoralis major muscle is an adequate treatment for severe sternal infections. In comparison with conservative methods, mortality and morbidity can be reduced and hospital stay can be shortened.     

Definitive closure of the infected median sternotomy wound: a treatment algorithm utilizing vacuum-assisted closure followed by rigid plate fixation

Mediastinitis and sternal wound dehiscence are devastating and life-threatening complications of median sternotomy incision. Ten consecutive patients between July 2001 and May 2005 were diagnosed with sternal wound infection and dehiscence following median sternotomy. Patients were managed by precise debridement and wound excision in the operating room and then dressed with vacuum-assisted closure device. Intravenous antibiotics were prescribed for wound and blood culture microbiological sensitivity. When wounds were bacteriologically controlled, patients returned to the operating room for definitive closure using rigid sternal plating. All patients were extubated postoperatively. No patients died. Average total hospital stay was 21 days. The pectoralis advancement flap was exclusively used for soft tissue reconstruction in 7 patients. There were 2 cases of chronic superficial sternal infection requiring plate removal; however, bony union of the sternum was achieved in all patients. This treatment algorithm provides a useful management strategy for patients with complicated median sternotomy.     

Sternal osteomyelitis: treatment with rectus abdominis muscle

Sternal osteomyelitis complicates recovery in a small number of patients following median sternotomy. Techniques for operative treatment have in common the wide debridement of devitalised tissue and administration of culture-specific antibiotics. The resultant wound can be managed by delayed primary closure or transposition of well-vascularised adjacent tissue. Omentum, pectoralis major muscle and rectus abdominis muscle are suitable for transposition either alone or in combination. Our series is composed of ten patients who underwent rectus abdominis muscle transfer for the treatment of sternal osteomyelitis. The rectus abdominis obliterates dead space in the lower third of the wound, a difficult area to reach with the pectoralis major muscle. Five patients had one rectus abdominis muscle alone transposed, avoiding the aesthetic and functional deficits of pectoralis major transposition and the risks of omental transfer. Wound healing occurred in every case with a minimum of postoperative complications.     

Experience with Vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use

OBJECTIVES: We report our experience in use of Vacuum-assisted closure therapy (VAC) in the treatment of poststernotomy wound infection with emphasis on recurrent wound-related problems after use of VAC and their treatment. METHODS: Between July 2000 and June 2003, 2706 patients underwent various cardiac procedures via median sternotomy. Forty-nine patients with postoperative sternal wound infection (1.9%) were managed with VAC. Wounds were classified as either superficial sternal wound infection (28 patients) or deep sternal wound infection (21 patients). In the superficial sternal wound infection group, 23 patients had VAC as definitive treatment (GroupA), while five patients (Group B) had VAC followed by surgical closure. Similarly, in the deep sternal wound infection group, 12 patients had VAC as definitive treatment (Group C), while nine patients had VAC followed by surgical closure (Group D). Patients were discharged after satisfactory wound closure. Upon discharge patients were followed up at interval of three to six months. Recurrent sternal problems when identified were investigated and additional surgical procedures were carried out when necessary. RESULTS: There were nine deaths, all due to unrelated causes except in one patient who died of right ventricular rupture (Group C). Nine patients in Group A had recurrent wound problems of which six had VAC system for > 21 days. Three patients underwent extensive debridement due to sternal osteomyelitis. All eight patients in Group B presented with chronic wound-related problems and underwent multiple debridements. Four patients had laparoscopic omental flaps. In contrast 14 patients (Group B and D) who were treated with shorter duration of VAC followed by either a flap or direct surgical closure, did not present with recurrent problems. CONCLUSION: VAC therapy is a safe and reliable option in the treatment of sternal wound infection. However, prolonged use of VAC system as a replacement for surgical closure of sternal wound appears to be associated with recurrent problems of the sternal wound. Strategy of use of VAC for a short duration followed by early surgical closure appears favorable.     

Vacuum-assisted closure in the treatment of poststernotomy mediastinitis in the paediatric patient.

INTRODUCTION: Delayed sternal closure after paediatric open heart procedure is often necessary. The risk of delayed sternal closure is infection: superficial wound or sternal and mediastinal infection. The incidence of sternal wound infection reported in the literature varies from 0.5 to 10%. The mortality for poststernotomy deep sternal infection continues to be high--from 14 to 47%. Established treatment includes surgical debridement, drainage and irrigation, antibiotics, frequent change of wound dressing and direct or secondary closure with omentum or pectoral muscle flap. PATIENTS AND METHODS: Between October 2003 and August 2005, three children, aged from 9 days to 2 years and who had developed severe mediastinitis after cardiac surgery were treated with the vacuum-assisted closure (VAC) system. RESULTS: The duration of VAC treatment ranged from 12 to 21 days. The response to VAC was rapid with local purulence and C-reactive protein (CRP) both decreasing within 72 h in all cases. After good granulation was obtained, two patients required a thin skin graft. DISCUSSION: All three children had peritoneal dialysis which did not permit omental use. The use of pectoralis major is a difficult technique in neonates and the haemodynamic conditions were poor in our cases. The VAC technique is a good indication in post-cardiotomy mediastinitis in children: it plays a role in the reduction of infection and provides good healing.     

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21‐year‐old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.     

Management of postoperative mediastinitis in infants and children by muscle flap rotation

Between July 1, 1976, and June 30, 1986, at the Henrietta Egleston Hospital for Children, 2,242 infants and children underwent palliation or repair of a congenital heart defect. Twenty-one (0.94%) of these patients developed mediastinitis following a median sternotomy. Nineteen of these twenty-one patients had required cardiopulmonary bypass. All patients had positive mediastinal cultures. The first 8 patients were managed traditionally by debridement and irrigation. Three of these patients suffered serious metabolic complications related to the povidone-iodine irrigant, which resulted in 1 death. Another patient died from persistent sepsis following debridement. Subsequently, 13 patients were managed by early debridement and rotation of the pectoralis major or rectus abdominis muscle flaps, or both. Following muscle flap rotation and early wound closure, 2 patients had subsequent incisional complications. One patient had incisional dehiscence and 1 had a superficial skin separation. Two deaths in this group, 28 and 51 days, respectively, following muscle flap rotation, resulted from nonincisional problems in patients with healed median sternotomies. The group having muscle flap rotation required a significantly shorter duration of postoperative ventilatory support (3.2 versus 24 days, p less than 0.05) and a significantly shorter confinement in the intensive care unit (6.2 versus 33 days, p less than 0.01). Also, the physiological and physical trauma of continued wound care in the awake child was minimized in the group with muscle flap rotation.