Treatment Of Sternal Wound Infection Research Articles

Primary or delayed closure for the treatment of poststernotomy wound infections?

The methods of primary versus delayed wound closure for the treatment of sternal wound infections after cardiac surgery were retrospectively compared. From January 2001 to March 2003, 132 patients (median age 66 years, male to female ratio 88:44) with sternal wound infection after cardiac surgery were treated at our department. After thorough debridement, 35 patients received preconditioning of the wound before implementation of definitive therapy; the remainder (97 patients) were treated with immediate closure. From the 35 patients with preconditioning, 19 patients proceeded to delayed primary closure, whereas the remaining 14 patients were referred to plastic reconstruction with a pectoralis muscle flap. Primary success rate in this group was 100%. In the immediate primary closure group, 33 patients experienced 1 or more therapy failures, resulting in a recurrence rate of 39%. Fifteen patients received a pectoralis muscle flap as definite treatment modality. Immediate primary closure is associated with a high rate of local infection recurrence. Surgical debridement and conditioning of the wound until resolution of infections with delayed primary closure or plastic reconstruction is suggested as the more appropriate treatment modality, with promising results.

Use of the SpaceMaker Balloon in Sternal Wound Closure: Comparison with Other Techniques

Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time-consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon-assisted advancement flap technique (n = 10 each). The balloon-assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloon-assisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds.

Sternal wound infection after heart transplantation: incidence and results with aggressive surgical treatment

Background. Sternal wound infection remains a significant complication. We reviewed the incidence and the treatment of sternal wound infection after heart transplantation. Methods. Of 226 patients who had a heart transplantation, 20 (8.8%) underwent postoperative wound debridement for superficial or deep sternal wound infection. The incidence and the survival of patients with sternal wound infection were analyzed. Results. The incidence of sternal wound infection was similar among patients treated with four protocols of immunosuppressive drugs: cyclosporine and prednisone (0 of 22; 0%); cyclosporine, prednisone, and azathioprine (2 of 24; 8.3%); cyclosporine, prednisone, azathioprine, and antithymocyte globulin (15 of 139; 10.8%); and cyclosporine, prednisone, mycophenolate mofetil, and antithymocyte globulin (3 of 41; 7.3%) ( p = 0.4). Six-month and 5-year survival of patients with sternal wound infection averaged 85% ± 8% and 74% ± 10% compared with 92% ± 2% and 82% ± 3% in patients without wound infection ( p = 0.15). Patients with deep sternal wound infection, debridement, and reconstruction had a 5-year survival averaging 80% ± 10%. Conclusions. The incidence of sternal wound infection remains similar between patients treated with the triple drug therapy. Surgical debridement and reconstruction can result in long-term survival after heart transplantation.

CO2 laser sterilization in the surgical treatment of infected median sternotomy wounds.

We examined the use of CO2 laser sterilization in the surgical treatment of infected median sternotomy wounds. Deep wound infection after median sternotomy is infrequent (1% to 5% of all cases) but is associated with significant morbidity, mortality, and cost. Twenty-four consecutive patients with median sternotomy wound infection were treated by one plastic surgeon using a CO2 laser to sterilize wounds after debridement and before flap closure. The rectus abdominis muscle flap was primarily used, but the choice of muscle flap was case dependent. To date, no patient in this series has had postoperative wound infection, breakdown, or flap loss. One patient did have superficial skin loss. Although the morbidity rate was 17%, all patients had intact wounds. None of the 5 deaths was related to wound infection. We found that CO2 laser sterilization in the surgical treatment of sternal wound infections decreased morbidity, mortality, and cost.

Brief report: Ciprofloxacin treatment of sternal wound infections following open heart surgery

Brief report: Ciprofloxacin treatment of sternal wound infections following open heart surgery

Plastic Surgery

The past year has seen a flurry of activity by plastic surgeons exploring the exciting applications of tissue-derived factors in wound healing and bone formation. Other studies show promising new uses for tissue expansion and are revealing the mysteries of fetal scar formation. An increased understanding of the pathogenesis and treatment of sternal wound infections has improved the recovery from this catastrophic occurrence, while refinements in head and neck reconstruction using free flaps offer a significant improvement to patients disfigured by congenital deformity, trauma, or tumor. Tissue-derived growth factors are now available in greater quantities due to biosynthesis through recombinant DNA technology. Researchers are now able to study their effects on the most basic problem in plastic surgery, wound healing, and have obtained exciting and promising results. Mustoe et al¹have found that plateletderived growth factors promote wound healing in rats and partially restore wound healing in surface-irradiated animals

Delayed primary closure after sternal wound infection

Infected median sternotomy is a major complication of cardiac operations. Over a 30-month period, 25 sternal wound infections were treated at a single institution. Twenty-four (2.7%) followed 883 operations with cardiopulmonary bypass, and 1 followed median sternotomy for a noncardiac procedure. Twenty-one of the 25 patients survived to sternal closure. Eighteen patients were treated with delayed primary closure and 3 with pectoralis muscle flaps. Fifteen patients (83%) had an uneventful postoperative course after delayed primary closure. In 2 patients reoperation was required for sternal dehiscence, and in 1 patient a superficial wound infection developed, which was treated with local wound care. In all 18 patients the sternum eventually healed. Criteria for delayed primary closure included clean tissue surfaces without purulent debris, the absence of pockets of purulent drainage, and negative wound cultures obtained 24 hours before closure. The average time from operation to sternal incision and drainage was 11 days (range, five to 59 days). Delayed primary closure was performed nine days after incision and drainage (range, five to 27 days). The average hospital stay was 24 days after sternal incision and drainage (range, nine to 85 days). Cultures from specimens taken at the time of sternal incision and drainage were positive in all patients. Wound cultures were positive at the time of sternal closure in 5 patients. Wound complications developed in 2 of these 5 patients. Delayed primary closure has many of the advantages of classic methods, but fewer complications. Results are comparable, while allowing simpler wound care and less cosmetic deformity. Delayed primary closure is an acceptable alternative in the treatment of sternal wound infections.

A Survey of 77 Major Infectious Complications of Median Sternotomy: A Review of 7,949 Consecutive Operative Procedures

Sternal wound infections developed following 77 (0.97%) of 7,949 operative procedures involving median sternotomy at New York University Medical Center from 1976 to 1984. Risk factors associated with the development of a sternal wound infection included combined revascularization and valve replacement, early reexploration for bleeding, prolonged low cardiac output syndrome, and prolonged ventilatory support (greater than 24 hours). Concomitant infection at other sites with the same organism as cultured from the sternum was present in 42% of the patients. Thirty-seven patients (48%) were treated with radical debridement followed by closed antibiotic irrigation. In 31 other patients (40%), the wounds were debrided and left to heal by open granulation. Both initial treatments had equally high success rates (78.4% and 74.2%, respectively). However, the open granulation method resulted in a hospital stay that was an average of 10 days longer than the closed antibiotic irrigation method. Muscle flaps were used to expedite healing of open granulation in 9 patients. Analysis of the results of different treatment strategies revealed that if debridement was accomplished within 20 days of the initial cardiac procedure, 76% of the patients could be successfully treated with closed antibiotic irrigation. Conversely, if treatment was delayed for longer than 20 days, 81% of the patients were treated with open granulation ( p < 0.001). Also noted was an inverse relationship between the serum blood urea nitrogen (BUN) level and the success rate of initial treatment with closed antibiotic irrigation. Patients with a serum BUN level of less than 40 mg/dl at the time of debridement had a 90% success rate as opposed to a success rate of 38% when the BUN level was 40 mg/dl or greater. The data presented suggest the following conclusions. Early diagnosis is crucial to successful treatment of sternal wound infection. When diagnosis can be established within 20 days, 80% of infections can be eradicated by the simple approach of debridement and closed antibiotic irrigation. When diagnosis is delayed, however, prompt debridement followed by muscle flaps is the procedure of choice. Open granulation alone, while successful, unnecessarily prolongs the hospital course.