Prevention, Classification and Management Review of Deep Sternal Wound Infection

Abstract

Sternal wound complications are significant problems in cardiac surgery and cause challenges to surgeons as they are associated with high mortality, morbidity, and a tremendous load on the hospital budget. Risk factors and preventive measures against sternal wound infection need to be in focus. Classification of different types of sternotomy complications post cardiac surgery is important for specific categorization and management. Reviewing the literature, a variety of classifications was introduced to help understand the pathophysiology of these wounds and how best to manage them. Initial classifications were based on the postoperative period of the infectious process and risk factors. Recently, the anatomical description of sternal wound, including the depth and location, was shown to be more practical. There is a lack of evidence-based surgical consensus for the appropriate management strategy, including type of closure, choice of sternal coverage post sternectomy, whether primary, delayed and when to use reconstructive flaps.

Results of negative pressure wound therapy for deep sternal wound infections after cardiac surgery

“…[17,18] In methicillin-resistant S. aureus cases, it is necessary to perform extensive and sharp tissue debridement to prevent severe tissue destruction and inflammation due to antibiotic resistance. [19] Female sex, hypertension, diabetes mellitus, obesity, active smoking, chronic pulmonary disease, and chronic renal disease, which are considered risk factors for DSWI in the literature, [2,4,15] were observed at very high rates ranging from 30.9 to 66.2% in our DSWI patients. Among these risk factors, the only risk factor that was shown to be associated with increased mortality was the female sex in our study population.…”

“…[2,3] Risk factors for DSWI reported in the literature include advanced age, diabetes, obesity, use of cigarettes, chronic renal disease, and chronic pulmonary disease. [2,4] The use of bilateral internal thoracic artery (BITA) is also an operation-related risk factor known to increase DSWI risk. [2] Rupprecht and Schmid [5] have classified sternal complications of cardiac surgery according to the associated clinical findings.…”

“…In contrast, DSWI without sternal instability needs to be treated by surgical debridement with negative pressure wound therapy (NPWT) followed by wound revision and sternal closure. [4] Deep sternal wound infection with sternal instability is a more complex pathology and often needs advanced interventions such as muscle flaps. [4] Treatment of DSWI is challenging, long-lasting, and lacks a standardized algorithm.…”

“…[4] Deep sternal wound infection with sternal instability is a more complex pathology and often needs advanced interventions such as muscle flaps. [4] Treatment of DSWI is challenging, long-lasting, and lacks a standardized algorithm. Conventional treatment modalities are associated with increased mortality ranging from 19 to 25%.…”

Comparison of Sternal Fixation Strategies After Open-Heart Surgery Via a Median Sternal Incision

“…Previous studies have reported that sternal wound complications are related to risk factors, such as the female gender, obesity, sternal osteoporosis, advanced age, renal insufficiency, chronic obstructive pulmonary disease (COPD), and harvesting of the bilateral internal thoracic arteries [Gray 2017;Filsoufi 2009;Eklund 2006;Alebrahim 2020]. Furthermore, sternal wound infection is associated with sternal dehiscence and instability [Braxton 2000;Robicsek 2000].…”