Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure

Abstract

Background Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single‐institution experience with pediatric SWIs. Methods Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. Results Of the 14 patients, 8 (57%) were diagnosed with culture‐positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. Conclusions The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.

Efficiency of an algorithm for the prevention of sternal infection after cardiac surgery in children under 1 year of age: A single-center retrospective study

“… Careful handling of instruments dealing with soft tissues is required [ 16 ]. Avoid devascularization and minimize the risks of impaired blood supply to the soft tissues, skin, and sternum [ 11 , 16 ]. Electrocoagulation should be applied locally to stop bleeding from soft tissues and the periosteum.…”

“…High early mortality rates are noted if sternal wound infection occurs. For instance, in children under one month old, mortality ranges from 31 to 46 % [ 4 , 11 ]. In addition, it should be taken into account that plastic surgery of chest defects using various muscle flaps is a highly traumatic, crippling method and it is often accompanied by a risk of severe secondary complications.…”

“…In addition, it should be taken into account that plastic surgery of chest defects using various muscle flaps is a highly traumatic, crippling method and it is often accompanied by a risk of severe secondary complications. Among the latter are persistent infection (mediastinitis, abscess), flap necrosis, impaired respiratory mechanics, shoulder and upper limb function, as well as hernia formation at the site of the sternal defect and the donor zone [ [11] , [12] , [13] , [14] ].…”

“…The authors of most studies on the management of sternal infection in children believe that prevention of this complication is the most desirable approach [ 3 , 11 , 15 , 16 ]. An important component of preventing the development of sternal infection is the assessment of all risk factors [ 17 , 18 ].…”

“…An important component of preventing the development of sternal infection is the assessment of all risk factors [ 17 , 18 ]. There are few recommendations on measures to prevent sternal wound infection in children after cardiac surgery, so one has either to refer to recommendations for adults or to develop methods for its prevention [ 3 , 11 , [19] , [20] , [21] ]. However, the risk factors in pediatric cardiac surgery are different, and therefore methods to prevent the development of wound infection are partially applicable.…”