Sternal preservation: a better way to treat most sternal wound complications after cardiac surgery.
BACKGROUND
Postcardiotomy sternal wound complications remain challenging. The prevailing approach for deep sternal wound infection of debridement and flap coverage without osseous closure makes subsequent reoperation difficult.


METHODS
An analysis of all patients undergoing cardiac surgery at a single institution between 1986 and 2001 was conducted. Prospective data collection and chart review were used to compare different treatment strategies for sternal complications.


RESULTS
Of 5337 patients, 122 had sternal wound complications (2.2%) comprising 15 (0.3%) uninfected dehiscences (El Oakley class 1), 45 (0.8%) superficial infections (El Oakley class 2A), and 62 (1.1%) deep sternal wound infections (El Oakley class 2B). Thirty-two patients with deep sternal infection were treated by debridement, rewiring, and delayed primary closure. There were initial treatment failures in 6 patients (18.8%) and ultimate failures in 2 patients (6.3%), both of whom died. One of these patients had previously received external beam radiation after a radical mastectomy for breast cancer. Median length of stay was 32 days and median time to wound healing was 85 days. Twenty-five patients were managed by muscle flap coverage without sternal reclosure. There were 6 initial treatment failures (24%) but no ultimate failures or deaths (p = NS). Median length of stay was 31 days and median infection time was 161 days.


CONCLUSIONS
In patients with postcardiotomy deep sternal wound infection without previous chest radiation, debridement, rewiring, and delayed skin closure is effective. It offers a shorter healing time and probably makes late cardiac reoperation safer. We propose an algorithm for the management of poststernotomy complications.
Douville
E Charles
EC
Division of Cardiothoracic Surgery, The Oregon Clinic PC, Portland, Oregon 97213, USA. ecdouville@orclinic.com
Asaph
James W
JW
Dworkin
Ronald J
RJ
Handy
John R
JR
Canepa
Clifford S
CS
Grunkemeier
Gary L
GL
Wu
YingXing
Y
D000465:Algorithms; D019072:Antibiotic Prophylaxis; D001864:Bone Wires; D006348:Cardiac Surgical Procedures; D003646:Debridement; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011446:Prospective Studies; D011832:Radiation Injuries / Q000150:complications; D011878:Radiotherapy / Q000009:adverse effects; D012042:Registries; D012086:Reoperation; D012307:Risk Factors; D013249:Sternum / Q000601:surgery*; D013524:Surgical Flaps; D013529:Surgical Wound Dehiscence / Q000601:surgery* / Q000628:therapy; D013530:Surgical Wound Infection / Q000601:surgery* / Q000628:therapy; D016896:Treatment Outcome; D014945:Wound Healing