Flap Reconstruction for Deep Sternal Wound Infections: Factors Influencing Morbidity and Mortality

Piwnica-Worms, William; Azoury, Saïd C.; Kozak, Geoffrey M.; Nathan, Shelby L.; Stranix, John T.; Colen, David L.; Othman, Sammy; Vallabhajosyula, Prashanth; Serletti, Joseph M.; Kovach, Stephen J.

doi:10.1016/j.athoracsur.2019.12.014

Cited by 16 publications

(29 citation statements)

References 30 publications

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“…We treated an aged population with a variety of medical risk factors yet managed to decrease our mortality rate from 16% to 10% in the last 16 years 7,14,28 . Prior groups have shown that poor nutrition, IMA use, renal failure, and longer time interval between operation and reconstruction are associated with increased mortality and morbidity in chest wall flap-based reconstruction 11–13,15 . We found a relationship between increased BMI and mortality in this cohort, which is in line with the literature 29,30 .…”

Section: Discussionsupporting

confidence: 82%

“…The current series of 105 patients examined in this study support our previous findings that this treatment yields excellent functional outcomes in highly morbid patient population 7 . In contrast to the mortality rate of 14% to 47% in the literature, we had a 10% 30-day mortality rate noted 12,14,15,27 . Critically, 80% of the patients in this cohort had at least 1 comorbidity, and 90% of patients who passed away had more than 1 concurrent disease.…”

Section: Discussioncontrasting

confidence: 77%

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Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction

et al. 2022

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Introduction: Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population. Methods: A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed. Results: A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex ( P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure ( P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality ( P < 0.05). Conclusions: Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

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Section: Discussionsupporting

confidence: 82%

Section: Discussioncontrasting

confidence: 77%

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction

et al. 2022

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“…Operations that require extensive dissection and inhibition of muscle function can further inhibit healing and rehabilitation. Piwnica-Worms et al 14 have shown that the use of vertical rectus abdominis musculocutaneous flap in a series of 119 patients was predictive of increased mortality. Other investigators have demonstrated loss of shoulder function with disinsertion of the pectoralis muscle either as a turnover flap or as an advancement flap.…”

Section: Discussionmentioning

confidence: 98%

“…The third factor is the adequacy of debridement of all infected tissue and contaminated foreign bodies. 14 , 24 – 29 Finally, the reconstructive method itself can influence outcomes. Operations that require extensive dissection and inhibition of muscle function can further inhibit healing and rehabilitation.…”

Section: Discussionmentioning

confidence: 99%

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Atwez¹,

Friedman

Durkin

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Background: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. Methods: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. Results: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. Conclusion: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

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“…Pectoralis major muscle flap, omental flaps, rectus abdominis flaps and latissimus dorsi flaps may be used in reconstruction of sternum defects. [13] Prolene patch, titanium plate and pectoral flaps were used to treat in large defect of our patient. We consider that this flap is effective to provide the stability of the thoracic wall and to control the infection of tissues.…”

Section: Discussionmentioning

confidence: 99%

Multidisciplinary Surgery In Thoracic Wall Reconstruction For Sternal Osteomyelitis

Gökçe

Babaroglu²,

Ergani³

et al. 2020

Preprint

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Sternal osteomyelitis and dehisense are a common problem with an incidence rate of 0.5% to 5.0% after major cardiac surgery. However, the management of separation of the sternum in the patient’s thorax remains a challenge for cardiac surgeons and thoracic surgeons using the incision. After cardiac surgery, postop sternal dehiscence and osteomyelitis was developed in the patient. The old steel wires were removed and the sternum was resected due to long-term infection and extensive deformation of the sternum. Pectoralis muscle flaps were partially mobilized and adducted. The large defect was closed using a large prolene patch. Proper sized transversal titanium plates were selected. Due to the sternum bone was severely destroyed by infection, longer transversal titanium plates were chosen to achieve thoracic stability. Healthy tissues were detected on the ribs. A total of 4 titanium plates were placed intermittently. The plates were fixed to the ribs with titanium locking screws. The pectoral muscle flaps adducted to the plates by the plastic surgery team. A total of 3 drains were placed, one in the mediastinum and two between the thoracic wall and muscle structures.

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Flap Reconstruction for Deep Sternal Wound Infections: Factors Influencing Morbidity and Mortality

Cited by 16 publications

References 30 publications

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Multidisciplinary Surgery In Thoracic Wall Reconstruction For Sternal Osteomyelitis

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