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Chest Wall Reconstruction Using Sternal Plating in Patients With Complex Sternal Dehiscence
Chest Wall Reconstruction Using Sternal Plating in Patients With Complex Sternal Dehiscence Bharat Pancholy, MD, and Jai Raman, MD, PhD
FEATURE ARTICLES
Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
To evaluate the effectiveness of sternal reconstruction using demineralized bone matrix in patients with complex sternal dehiscence. In this retrospective review, 14 patients with complex sternal wounds with dehiscence were evaluated after specific reconstructive methods. The steps involved ensuring sternal salvage by eradicating infection with a combination of vacuum assisted closure and antibiotic therapy. In a separate setting, patients underwent sternal reconstruction with plate fixation and local use of bone morphogenetic protein (BMP; Infuse, Medtronic, Minneapolis, MN) and demineralized bone matrix for remaining sternal defects. Pectoral myocutaneous flaps were then used to cover the sternum. Patients were
evaluated daily in the immediate postoperative period for sternal wound complications and pain and were followed up at 3 and 6 months postoperatively. At 6 month after the procedure, all patients had stable chest walls with no further sternal instability and no recurrent dehiscences or wound infections. All patients returned to normal activity with complete resolution of sternal pain. Complex sternal wounds can be reconstructed and repaired effectively with a combination of bone salvage, local therapy with BMP, and flap closure, with encouraging results.
D
with conventional wire cerclage closure of their sterna and who subsequently experienced complex sternal dehiscence. These sternal dehiscence patients had been managed at other institutions with a variety of techniques including repeat exploration, debridement of the sternum, vacuum assisted closure (VAC), local or transposition flap closure, or Robicsek wire weave. In all instances, patients presented to us with persistent pain (n ¼ 14) and persistent drainage (n ¼ 8). All patients underwent a chest computed tomography (CT) scan to assess the degree of sternal separation and the amount of sternal viability and to look for evidence of persistent fluid collections. If fluid collections or any signs of infection were found, we reexplored the sternum, debrided the sternal edges, and sent samples for quantitative tissue culture. After stabilization and confirmation of clearance of the infection, all patients underwent operative assessment for the viability of the sternal fragments by using manual palpation, probing with a hemostat for sternal stability, and comparing the damaged sternal area with undamaged bone. In a separate setting, once sternal viability was confirmed, the sternal halves were reapproximated with the use of bone reduction forceps and aligned together. The fragments were then fixed with multiple plates and screws. Any gaps between the sternal halves were filled with demineralized bone matrix (DBM), either putty or bone chips. This procedure was accompanied by topical application of Gelfoam (Pfizer, New York, NY) soaked with bone morphogenetic protein (BMP; Infuse, Medtronic, Inc, Minneapolis, MN). Patients were evaluated daily in the immediate postoperative period for sternal wound complications and pain and then again, in the outpatient clinic, at 3 and 6
eep sternal wound infection resulting in sternal wound dehiscence is a serious complication of cardiac surgical procedures that has potentially devastating and occasionally fatal results. The incidence of deep sternal wound infections reportedly ranges from 1% to 4%, with mortality rates ranging from 9.7% to 23.5% [1–3]. Most of these patients have an increased risk of complications related to loss of sternal function, persistent pain, and the possibility of persistent infection. Management of deep sternal wound infections comprises clearing the sternal infection by wound debridement and removal of all necrotic tissue and sternal hardware. This procedure is combined with negative pressure wound therapy and subsequent reconstruction with final closure of the sternal defect, with or without flap reconstruction with variable techniques including omental or pedicled flaps, and primary sternal closure [4, 5]. Previous reports demonstrated the basis of improved sternal healing and reduced pain with the use of rigid plate fixation [6]. We report on our experience of sternal salvage, along with a comprehensive approach to preserving the integrity of the chest in patients with complex sternal wounds with dehiscence.
Technique This is an Institutional Review Board–approved, retrospective review of 14 patients who underwent sternotomy Accepted for publication Feb 10, 2015. Address correspondence to Dr Pancholy, Department of Cardiothoracic Surgery, Department of Surgery (112), James A Haley, Tampa VA Hospital, 13000 Bruce B Downs Blvd, Tampa, FL 33612-4745; e-mail: bharat. [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:2228–30) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.018
Ann Thorac Surg 2015;99:2228–30
HOW TO DO IT PANCHOLY AND RAMAN STERNAL PLATING IN COMPLEX STERNAL DEHISCENCE
2229
Fig 1. Detailed algorithm of an approach to sternal dehiscence. (BMP ¼ bone morphogenetic protein; DBM ¼ demineralized bone matrix; s/p ¼ status post; VAC ¼ vacuum assisted closure.)
months postoperatively. On follow-up, chest CT scans were performed on 6 patients to confirm sternal healing based on clinical examination findings. The other 8 patients did not have any indications for CT scan. Figure 1 is the algorithm we use for a systematic approach to sternal dehiscence.
Detailed Overview of Technique
Fig 2. Sternal dehiscence with viable sternum (note the transverse rectus abdominis myocutaneous flap retracted downward).
Fig 3. Plated sternal fragments; bony defects filled in with demineralized bone matrix overlaid by sponges soaked in bone morphogenetic protein.
FEATURE ARTICLES
When a patient presents with sternal dehiscence, a CT scan with contrast enhancement is used to help delineate the extent of bony separation, provide a sense of sternal fragment viability, and define the extent of underlying fluid collections. Based on the condition of the patient, we proceed with aggressive wound debridement along, with sampling for quantitative cultures of the area. Bone is carefully assessed for viability after curettage, after which a VAC device is applied. The VAC dressing is maintained until infection is controlled and culture results are negative. The sternal wound is then assessed for healthy sternum and viable fragments. Viable fragments are then aligned and approximated.
Any bony defects or gaps in the approximated sternum are filled with DBM. This area is overlaid with small amounts of resorbable fiber soaked with BMP solution. Finally, we mobilize pectoral myocutaneous flaps off the anterior chest wall. The mobilized flaps are then approximated over 19-French Blake drains, and the skin is closed with interrupted #2 nylon vertical mattress sutures. Figures 2 to 4 demonstrate a typical patient with sterile dehiscence after attempted rewiring, Robicsek closure, and a failed transverse rectus abdominis myocutaneous flap. His sternum was clean after several weeks of antibiotic therapy and a muscle flap procedure. This technique was employed in all 14 patients. No prolonged infections, sepsis, sternal wound recurrences, or deaths occurred in this group. All patients were discharged from the hospital with improved symptoms of pain and movement. Six patients who had CT scans of the chest showed radiographic findings of sternal healing. No recurrent sternal dehiscence or wound infections occurred in any of the patients. Clinically, all patients had stable chest walls and returned to normal functional activity with resolution of any pain with movement.
2230
HOW TO DO IT PANCHOLY AND RAMAN STERNAL PLATING IN COMPLEX STERNAL DEHISCENCE
Ann Thorac Surg 2015;99:2228–30
rigid plate fixation in a randomized study of high-risk patients undergoing primary sternal plate fixation for sternal closure; the results showed improved healing and less postoperative pain [8]. This study examined the use of rigid plate fixation in conjunction with filling of bony defects with DBM and the use of BMP to promote osteosynthesis. Complex sternal wounds can be reconstructed and repaired effectively by using this simple technique, which combines sternal bone salvage, rigid fixation, and filling in of defects with bone chips, along with judicious use of bone growth promoters. Our results indicate an effectiveness that is worth further evaluation and treatment in patients who have sternal dehiscence.
References
Fig 4. Three months postoperatively.
FEATURE ARTICLES
Comment In patients with complex sternal dehiscence, in addition to the risk of infection, loss of function and chronic pain pose significant morbidity. Dramatic pain relief, complete sternal healing, and improved functional capacity were observed in all patients. Some patients even discontinued taking antidepressant medications after successful completion of the described sternal restoration and stability. Efforts to control the process and creation of a stable reconstruction go a long way in returning patients to a normal level of activity. Rigid plate fixation is accepted as a well-established technique in the orthopedic, plastic surgery, and neurosurgery subspecialties, and it has been the standard for more than 15 years [7]. Moreover, an earlier study showed the effectiveness of
1. Borger MA, Rao V, Weisel RD, et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 1998;65: 1050–6. 2. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179–87. 3. Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15 year review of 23,499 sternotomies. Eur J Cardiothorac Surg 2010;37:880–7. 4. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps: the Emory 20-year experience. Ann Surg 1997;225:766–78. 5. Juhl AA, Koudahl V, Damsgaard TE. Deep sternal wound infection after open heart surgery—reconstructive options. Scand Cardiovasc J 2012;46:254–61. 6. Divisi D, Crisci R. Use of demineralized bone matrix and plate for sternal stabilization after traumatic dislocation. Gen Thorac Cardiovasc Surg 2011;59:52–6. 7. Raman J. Rigid plate fixation promotes better bone healing after sternotomy. Semin Thorac Cardiovasc Surg 2012;24: 147–50. 8. Raman J, Lehmann S, Zehr K, et al. Sternal closure with rigid plate fixation versus wire closure: a randomized controlled multi-center trial. Ann Thorac Surg 2012;94:1854–61.
FEATURE ARTICLES
Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
To evaluate the effectiveness of sternal reconstruction using demineralized bone matrix in patients with complex sternal dehiscence. In this retrospective review, 14 patients with complex sternal wounds with dehiscence were evaluated after specific reconstructive methods. The steps involved ensuring sternal salvage by eradicating infection with a combination of vacuum assisted closure and antibiotic therapy. In a separate setting, patients underwent sternal reconstruction with plate fixation and local use of bone morphogenetic protein (BMP; Infuse, Medtronic, Minneapolis, MN) and demineralized bone matrix for remaining sternal defects. Pectoral myocutaneous flaps were then used to cover the sternum. Patients were
evaluated daily in the immediate postoperative period for sternal wound complications and pain and were followed up at 3 and 6 months postoperatively. At 6 month after the procedure, all patients had stable chest walls with no further sternal instability and no recurrent dehiscences or wound infections. All patients returned to normal activity with complete resolution of sternal pain. Complex sternal wounds can be reconstructed and repaired effectively with a combination of bone salvage, local therapy with BMP, and flap closure, with encouraging results.
D
with conventional wire cerclage closure of their sterna and who subsequently experienced complex sternal dehiscence. These sternal dehiscence patients had been managed at other institutions with a variety of techniques including repeat exploration, debridement of the sternum, vacuum assisted closure (VAC), local or transposition flap closure, or Robicsek wire weave. In all instances, patients presented to us with persistent pain (n ¼ 14) and persistent drainage (n ¼ 8). All patients underwent a chest computed tomography (CT) scan to assess the degree of sternal separation and the amount of sternal viability and to look for evidence of persistent fluid collections. If fluid collections or any signs of infection were found, we reexplored the sternum, debrided the sternal edges, and sent samples for quantitative tissue culture. After stabilization and confirmation of clearance of the infection, all patients underwent operative assessment for the viability of the sternal fragments by using manual palpation, probing with a hemostat for sternal stability, and comparing the damaged sternal area with undamaged bone. In a separate setting, once sternal viability was confirmed, the sternal halves were reapproximated with the use of bone reduction forceps and aligned together. The fragments were then fixed with multiple plates and screws. Any gaps between the sternal halves were filled with demineralized bone matrix (DBM), either putty or bone chips. This procedure was accompanied by topical application of Gelfoam (Pfizer, New York, NY) soaked with bone morphogenetic protein (BMP; Infuse, Medtronic, Inc, Minneapolis, MN). Patients were evaluated daily in the immediate postoperative period for sternal wound complications and pain and then again, in the outpatient clinic, at 3 and 6
eep sternal wound infection resulting in sternal wound dehiscence is a serious complication of cardiac surgical procedures that has potentially devastating and occasionally fatal results. The incidence of deep sternal wound infections reportedly ranges from 1% to 4%, with mortality rates ranging from 9.7% to 23.5% [1–3]. Most of these patients have an increased risk of complications related to loss of sternal function, persistent pain, and the possibility of persistent infection. Management of deep sternal wound infections comprises clearing the sternal infection by wound debridement and removal of all necrotic tissue and sternal hardware. This procedure is combined with negative pressure wound therapy and subsequent reconstruction with final closure of the sternal defect, with or without flap reconstruction with variable techniques including omental or pedicled flaps, and primary sternal closure [4, 5]. Previous reports demonstrated the basis of improved sternal healing and reduced pain with the use of rigid plate fixation [6]. We report on our experience of sternal salvage, along with a comprehensive approach to preserving the integrity of the chest in patients with complex sternal wounds with dehiscence.
Technique This is an Institutional Review Board–approved, retrospective review of 14 patients who underwent sternotomy Accepted for publication Feb 10, 2015. Address correspondence to Dr Pancholy, Department of Cardiothoracic Surgery, Department of Surgery (112), James A Haley, Tampa VA Hospital, 13000 Bruce B Downs Blvd, Tampa, FL 33612-4745; e-mail: bharat. [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:2228–30) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.02.018
Ann Thorac Surg 2015;99:2228–30
HOW TO DO IT PANCHOLY AND RAMAN STERNAL PLATING IN COMPLEX STERNAL DEHISCENCE
2229
Fig 1. Detailed algorithm of an approach to sternal dehiscence. (BMP ¼ bone morphogenetic protein; DBM ¼ demineralized bone matrix; s/p ¼ status post; VAC ¼ vacuum assisted closure.)
months postoperatively. On follow-up, chest CT scans were performed on 6 patients to confirm sternal healing based on clinical examination findings. The other 8 patients did not have any indications for CT scan. Figure 1 is the algorithm we use for a systematic approach to sternal dehiscence.
Detailed Overview of Technique
Fig 2. Sternal dehiscence with viable sternum (note the transverse rectus abdominis myocutaneous flap retracted downward).
Fig 3. Plated sternal fragments; bony defects filled in with demineralized bone matrix overlaid by sponges soaked in bone morphogenetic protein.
FEATURE ARTICLES
When a patient presents with sternal dehiscence, a CT scan with contrast enhancement is used to help delineate the extent of bony separation, provide a sense of sternal fragment viability, and define the extent of underlying fluid collections. Based on the condition of the patient, we proceed with aggressive wound debridement along, with sampling for quantitative cultures of the area. Bone is carefully assessed for viability after curettage, after which a VAC device is applied. The VAC dressing is maintained until infection is controlled and culture results are negative. The sternal wound is then assessed for healthy sternum and viable fragments. Viable fragments are then aligned and approximated.
Any bony defects or gaps in the approximated sternum are filled with DBM. This area is overlaid with small amounts of resorbable fiber soaked with BMP solution. Finally, we mobilize pectoral myocutaneous flaps off the anterior chest wall. The mobilized flaps are then approximated over 19-French Blake drains, and the skin is closed with interrupted #2 nylon vertical mattress sutures. Figures 2 to 4 demonstrate a typical patient with sterile dehiscence after attempted rewiring, Robicsek closure, and a failed transverse rectus abdominis myocutaneous flap. His sternum was clean after several weeks of antibiotic therapy and a muscle flap procedure. This technique was employed in all 14 patients. No prolonged infections, sepsis, sternal wound recurrences, or deaths occurred in this group. All patients were discharged from the hospital with improved symptoms of pain and movement. Six patients who had CT scans of the chest showed radiographic findings of sternal healing. No recurrent sternal dehiscence or wound infections occurred in any of the patients. Clinically, all patients had stable chest walls and returned to normal functional activity with resolution of any pain with movement.
2230
HOW TO DO IT PANCHOLY AND RAMAN STERNAL PLATING IN COMPLEX STERNAL DEHISCENCE
Ann Thorac Surg 2015;99:2228–30
rigid plate fixation in a randomized study of high-risk patients undergoing primary sternal plate fixation for sternal closure; the results showed improved healing and less postoperative pain [8]. This study examined the use of rigid plate fixation in conjunction with filling of bony defects with DBM and the use of BMP to promote osteosynthesis. Complex sternal wounds can be reconstructed and repaired effectively by using this simple technique, which combines sternal bone salvage, rigid fixation, and filling in of defects with bone chips, along with judicious use of bone growth promoters. Our results indicate an effectiveness that is worth further evaluation and treatment in patients who have sternal dehiscence.
References
Fig 4. Three months postoperatively.
FEATURE ARTICLES
Comment In patients with complex sternal dehiscence, in addition to the risk of infection, loss of function and chronic pain pose significant morbidity. Dramatic pain relief, complete sternal healing, and improved functional capacity were observed in all patients. Some patients even discontinued taking antidepressant medications after successful completion of the described sternal restoration and stability. Efforts to control the process and creation of a stable reconstruction go a long way in returning patients to a normal level of activity. Rigid plate fixation is accepted as a well-established technique in the orthopedic, plastic surgery, and neurosurgery subspecialties, and it has been the standard for more than 15 years [7]. Moreover, an earlier study showed the effectiveness of
1. Borger MA, Rao V, Weisel RD, et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg 1998;65: 1050–6. 2. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179–87. 3. Baillot R, Cloutier D, Montalin L, et al. Impact of deep sternal wound infection management with vacuum-assisted closure therapy followed by sternal osteosynthesis: a 15 year review of 23,499 sternotomies. Eur J Cardiothorac Surg 2010;37:880–7. 4. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps: the Emory 20-year experience. Ann Surg 1997;225:766–78. 5. Juhl AA, Koudahl V, Damsgaard TE. Deep sternal wound infection after open heart surgery—reconstructive options. Scand Cardiovasc J 2012;46:254–61. 6. Divisi D, Crisci R. Use of demineralized bone matrix and plate for sternal stabilization after traumatic dislocation. Gen Thorac Cardiovasc Surg 2011;59:52–6. 7. Raman J. Rigid plate fixation promotes better bone healing after sternotomy. Semin Thorac Cardiovasc Surg 2012;24: 147–50. 8. Raman J, Lehmann S, Zehr K, et al. Sternal closure with rigid plate fixation versus wire closure: a randomized controlled multi-center trial. Ann Thorac Surg 2012;94:1854–61.