An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference

Abstract

Background: Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. Methods: Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, débridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. Results: Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdébridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). Conclusions: Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible.

An Analysis of 400 Sternal Wound Reconstructions at a Single Institution

“…Our methodology of splitting groups into 0 to 30 days and beyond 30 days from initial cardiac surgery mirrors Centers for Disease Control and Prevention guidelines for defining surgical site infections. As we have previously shown, 30 days is a clinically useful timepoint for defining a myriad of surgical outcomes after SW reconstruction 12 . The significantly higher rates of culture positivity in the ≤30-day group may partially be explained by early fulminant presentations in these patients, which may allow greater ease of identifying and sampling of an infectious nidus.…”

“…Myocutaneous flap elevation was done to the extent that the flaps could be approximated in the midline with minimal tension, as previously described. 4,12,19 For the lower third of the sternal defects below the level of the pectoralis muscle, the anterior rectus sheath was raised in continuity with the muscle flaps to provide a single vascularized tissue layer. In all patients, submuscular drains were placed, and an additional drain was often inserted in the mediastinum.…”

“…has achieved excellent outcomes with early surgical debridement and definitive chest closure with bilateral pectoralis major myocutaneous flaps 9,10,11 . Recently, our group documented that early reconstructive closure (≤30 days) is associated with significantly decreased rates of recurrent infections and wound dehiscence when compared with delayed reconstructive closure (>30 days) 12 . During each chest reconstruction, the debrided sternal fragments and deep sternal wound tissues are cultured.…”

Impact of local delivery of allogenic chondrocytes on the biological response andhealing of the sternum bones after sternotomy

“…obesity, age, gender, which hinder the proper course of the healing process (30). It has been shown in the literature that the use of existing reconstructive techniques reduces the length of hospital stay but does not reduce the risk of infection (31). A promising solution could be the use of cell cultures, in particular chondrocytes.…”

A Review of 559 Sternal Wound Reconstructions at a Single Institution

“…Muscle flap coverage is a workhorse technique in sternal wound reconstruction 4,5 . At our institution, pectoralis major myocutaneous advancement flaps are the preferred method for providing sternal wound coverage due to favorable intraoperative accessibility, excellent postoperative results, and positive patient-reported functional and aesthetic outcomes 6–9 . Limitations of pectoralis major advancement flaps include a limited ability to cover the lower third of the sternum and deeper mediastinal recesses 5 .…”