Sternocutaneous fistulas after cardiac surgery: incidence and late outcome during a ten-year follow-up.
BACKGROUND
Sternocutaneous fistulas (SCFs) after cardiac surgery represent a complex surgical problem involving multiple hospital admissions, prolonged antibiotic treatment, and repeated debridements. Our objective was to identify the incidence of and risk factors for SCF, and to evaluate long-term survival.


METHODS
A total of 12,297 patients underwent sternotomy for cardiac surgery between January 1999 and December 2008, and 32 patients were diagnosed as having SCF during follow-up. Risk factors were identified with multivariate analysis and survival was compared using the log-rank test.


RESULTS
The cumulative incidence of SCF at one year was 0.23%. There was no significant difference in mean time from sternal closure after cardiac surgery to intervention for SCF with (n = 9) or without (n = 23) preceding sternal wound infection (SWI); 6.1 +/- 4.2 versus 6.9 +/- 4.6 months, (p = ns). Risk factors for developing SCF were previous SWI (odds ratio [OR] = 15.7), renal failure (OR = 12.5), smoking (OR = 4.7), and use of bone wax during cardiac surgery (OR = 4.2). Negative-pressure wound therapy was applied in 20 cases of extensive SCFs. Five-year survival of SCF patients was 58% +/- 1% as compared with 85% +/- 4% in the control group (p = 0.003).


CONCLUSIONS
Sternocutaneous fistula is a devastating diagnosis with significant morbidity and mortality. Previous SWI, renal failure, smoking, and use of bone wax are major risk factors. However, in a majority of patients SCF is not preceded by SWI and our results indicate that SCF may be a foreign body infection that develops in susceptible patients with risk factors for poor wound healing. Negative-pressure wound therapy may be a valuable adjunct in the treatment of extensive SCF.
Steingrímsson
Steinn
S
Department of Cardiothoracic Surgery, Lund University Hospital, Lund, Sweden.
Gustafsson
Ronny
R
Gudbjartsson
Tomas
T
Mokhtari
Arash
A
Ingemansson
Richard
R
Sjögren
Johan
J
D000368:Aged; D001847:Bone Diseases / Q000453:epidemiology / Q000209:etiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D017577:Cutaneous Fistula / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D013249:Sternum; D015996:Survival Rate / Q000639:trends; D013548:Sweden / Q000453:epidemiology; D013997:Time Factors