• Comorbidities
• Interdisciplinary approach
• Osteosynthesis
• Outcome
• Sternotomy

• Male
• Humans
• Female
• Aged
• Cardiac Surgical Procedures/adverse effects
• Clinical Protocols
• Foreign Bodies
• Fracture Fixation, Internal
• Intensive Care Units

• Bundeswehrzentralkrankenhaus Koblenz (9891)

• infections
• median sternotomy
• sternal infection
• sternal plating
• sternal reconstruction
• surgery

• cardiac surgery
• infection
• mediastinitis
• post-surgical mediastinitis
• sternal wound infections
• surgical wound infection

• AUC
• Appropriate Use Criteria
• Appropriateness Criteria
• Chest wall metastasis
• Chest wall pain
• Chest wall syndrome
• Sternal insufficiency fracture
• Sternal osteomyelitis
• costochondritis

• cardiovascular pathology
• cardiovascular research

• NPWT
• conventional
• mediastinitis
• negative pressure wound therapy

• Humans
• Mediastinitis/etiology
• Mediastinitis/therapy
• Negative-Pressure Wound Therapy
• Surgical Wound Infection/therapy
• Wound Healing

• Adult
• Aged
• Aged, 80 and over
• Candidiasis/diagnosis
• Female
• Fluorodeoxyglucose F18
• Humans
• Klebsiella Infections/diagnosis
• Male
• Mediastinitis/diagnostic imaging
• Mediastinitis/microbiology
• Middle Aged
• Osteomyelitis/diagnostic imaging
• Osteomyelitis/microbiology
• Positron Emission Tomography Computed Tomography/methods
• Prospective Studies
• Pseudomonas Infections/diagnosis
• Radiopharmaceuticals
• Retrospective Studies
• Sensitivity and Specificity
• Staphylococcal Infections/diagnosis
• Sternum/microbiology
• Sternum/surgery
• Surgical Wound Infection/diagnostic imaging
• Surgical Wound Infection/microbiology
• Thoracic Surgical Procedures/adverse effects
• Tietze's Syndrome/diagnostic imaging
• Tietze's Syndrome/microbiology

• Cardiac surgery
• General thoracic surgery
• Guideline
• Mediastinitis
• Prevention
• Treatment

Management of deep sternal wound infection (DSWI) in cardiac surgical patients still remains challenging. A variety of treatment strategies has been described. Aim of this cohort study was to analyse two different treatment strategies for DSWI: titanium sternal plating system (TSFS) and muscle flap coverage (MFC).

Between January 2007 and December 2011, from 3122 patients undergoing cardiac surgery 42 were identified with DSWI and treated with one of the above mentioned strategies. In-hospital data were collected, follow-up performed by telephone and assessment of Quality of Life (QoL) using the SF-12 Health Survey Questionnaire.

20 patients with deep sternal wound infection were stabilized with TSFS and 22 patients treated with MFC. Preoperative demographics and risk factors did not reveal any significant differences. Patients treated with TSFS had a significantly shorter operation time (p<0.05) and shorter hospitalization (p<0.05). A tendency towards lower mortality rate (p = n.s.) and less re-interventions were also noted (plating 0.6 vs. flap 1.17 per patient, n.s.). Quality of Life in the TSFS group for the physical-summary-score was significantly elevated compared to the MFC group (p<0.05). Relating to chest stability and cosmetic result the treatment with TSFS showed superior results, but the usage of MFC gave the patients more freedom in breathing and less chest pain.

Our results demonstrate that the use of TSFS is a feasible and safe alternative in DSWI. However, MFC remains an absolutely essential option for complicated DSWI since the amount of perfused tissue can be the key for infection control.

Deep sternal wound infection (DSWI) is a serious complication post cardiac surgery and associated with increased mortality, morbidity and cost. Sternal titanium plate fixation could be an effective approach to treat DSWI. We sought to compare the effectiveness of titanium plate fixation with conventional approach in the treatment of DSWI.

Retrospective data was analyzed from consecutive patients with DSWI post cardiac surgery who received either titanium plate fixation (sternal plate group) or conventional treatment with sternal debridement and rewiring (control group). Pre-operative risk factors and post-operative clinical outcome were compared between the 2 groups.

A total of 36 patients (mean age 65.0 ± 8.6, 63.9 % male) with DSWI were in the sternal plate group whereas 26 patients (mean age 64.0 ± 13.4, 65.4 % male) were in the control group. The mean follow-up period was 15.92 months. The major pre-operative comorbidities were comparable between the 2 groups. The rate of receiving multiple debridement procedures (≥3) was significantly lower in the sternal plate group (5.6 % vs. 26.9 %, P = 0.03). Patients in the sternal plate group had no treatment failure, whereas 42.3 % of patients in the control group had treatment failure requiring muscle flaps reconstruction by plastic surgery (0 % vs. 42.3 %, P < 0.001). There was a trend of lower in-hospital mortality (11.1 % vs. 19.2 %, P = 0.47) in the sternal plate group.

Compared to conventional treatment, titanium plate fixation appears to have favorable clinical outcome.

• Sternum
• Wound infection

• Osteosynthesis
• Rigid plate fixation
• Sternal dehiscence

• Allogeneic bone graft of sternum
• Deep sternal wound infection
• Massive post-sternotomy defect
• Sternotomy

A primary chondromyxoid fibroma (CMF) arising from sternum is quite uncommon tumor in thoracic surgery. Removal of giant sternal tumors requires extensive resection of the anterior chest wall, and results in deformity and paradoxical movement.

A 40-year-old female presented a progressively enlarging mass of her anterior chest wall. Computed tomography revealed an osteolytic lesion with discrete calcification in the bone marrow of the sternum. The tumor extended across the destroyed cortex to the parietal and visceral soft aspects, involving some of the costal cartilage and most of the sternal body. Partial sternal resection was performed successfully and an individual-specific stainless steel plate was used to reconstruct the anterior chest wall. The early result was good, however, nine months after the first surgery, fractures of plate were found at bilateral plate-clavicular junction. The plate had to be removed, and a titanium mesh was used to reconstruction of the chest wall. The patient has been of disease free for more than 18 month after the second surgery.

Our experience indicated that the individual-specific plate may not be suitable for reconstructing both the anterior chest wall as well as the sternoclavicular joint after subtotal sternum resection.

Despite many advances in prevention and perioperative care, deep sternal wound infection (DSWI) remains a pressing concern in cardiac surgery, with a still relevant incidence and with a considerable impact on in-hospital mortality and also on mid- and long-term survival. The permanent high impact of this complication is partially related to the increasing proportion of patients at high-risk for infection, as well as to the many patient and surgical risk factors involved in the pathogenesis of DSWI. The prophylactic antibiotic therapy is one of the most important tools in the prevention of DSWI. However, the choice of antibiotic, the dose, the duration, the adequate levels in serum and tissue, and the timing of antimicrobial prophylaxis are still controversial. The treatment of DSWI ranges from surgical revision with primary closure to surgical revision with open dressings or closed irrigation, from reconstruction with soft tissue flaps to negative pressure wound therapy (NPWT). However, to date, there have been no accepted recommendations regarding the best management of DSWI. Emerging evidence in the literature has validated the efficacy and safety of NPWT either as a single-line therapy, or as a “bridge” prior to final surgical closure. In conclusion, the careful control of patient and surgical risk factors - when possible, the proper antimicrobial prophylaxis, and the choice of validated techniques of treatment could contribute to keep DSWIs at a minimal rate.

• Risk factors
• Sternotomy
• Wound healing
• Wound infection
• Postoperative care

• Bi-pectoral flap
• Post-sternotomy mediastinitis
• Sternotomy

• Debridement
• Female
• Follow-Up Studies
• Humans
• Length of Stay
• Male
• Mediastinitis/etiology
• Mediastinitis/surgery
• Pectoralis Muscles
• Plastic Surgery Procedures/methods
• Severity of Illness Index
• Sternotomy/adverse effects
• Surgical Flaps
• Surgical Wound Infection/etiology
• Surgical Wound Infection/surgery
• Treatment Outcome

• Allogenous bone graft
• Deep sternal wound infection
• Sternal bone tissue
• Sternotomy dehiscence

Early recognition and, where possible, avoidance of risk factors that contribute to the development of poststernotomy mediastinitis (PSM) form the basis for successful prevention. Once the presence of PSM is diagnosed, the known risk factors have been shown to have limited influence on management decisions. Evidence-based knowledge on treatment decisions, which include the extent and type of surgical intervention (other than debridement), timing and others is available but has not yet been incorporated into a classification on management decisions regarding PSM. Ours is a first attempt at developing a classification system for management of PSM, taking the various evidence-based reconstructive options into consideration. The classification is simple to introduce (there are four Types) and relies on the careful establishment of two variables (sternal stability and sternal bone viability and stock) prior to deciding on the best available reconstructive option. It should allow better insight into why treatment decisions fail or have to be altered and will allow better comparison of treatment outcomes between various institutions.

Introduction. Mediastinitis has been reported to complicate 5% of sternotomy surgery. We have adopted an open reduction and rigid internal fixation (ORIF) approach during the conventional rescue surgery in the treatment of mediastinitis. Methods. A retrospective review was performed to compare the outcomes of patients that had an ORIF to correct postoperative mediastinitis following median sternotomy. These were compared with the outcome of the patients that did not undergo ORIF. Results. In the 5-year study period, we reviewed 35 mediastinitis patient charts. Postoperatively, the ORIF patient group remained in the Intensive Care Unit (ICU) and on a ventilator for a mean of 1.5 and 0.75 days, respectively. Patients treated without ORIF spent significantly more days in the ICU (mean of 7.5 days, P < 0.05) and on a ventilator (mean of 2.15 days, P = 0.1). Furthermore, it was found that none of the patients (0%) who underwent ORIF complained of any postoperative sternal instability or pain. Preoperatively, however, these rates were as high as 72%. Conclusions. In the select patient, ORIF can be a safe option in the management of mediastinitis, which we have shown to significantly decrease morbidity and mortality by providing anatomic reduction as well as physiologic stabilization. We have shown that ORIF will improve the quality of life of the patient by minimizing abnormal sternal mobility and pain and will also decrease inpatient costs by decreasing days spent in the ICU and ventilator dependence.

Negative-pressure wound therapy, commercially known as vacuum-assisted closure (V.A.C.^®) therapy, has become one of the most popular (and efficacious) interim (prior to flap reconstruction) or definite methods of managing deep sternal wound infection. Complications such as profuse bleeding, which may occur during negative-pressure therapy but not necessarily due to it, are often attributed to a single factor and reported as such. However, despite the wealth of clinical experience internationally available, information regarding certain simple considerations is still lacking. Garnering information on all the factors that could possibly influence the outcome has become more difficult due to a (fortunate) decrease in the incidence of deep sternal wound infection. If more insight is to be gained from fewer clinical cases, then various potentially confounding factors should be fully disclosed before complications can be attributed to the technique itself or improvements to negative-pressure wound therapy for deep sternal wound infection can be accepted as evidence-based and the guidelines for its use adapted. The authors propose the adoption of a simple checklist in such cases.

Redo open-heart surgery and sternal reentry in patients with previous deep sternal wound infection (DSWI) and absence of sternal integrity can be a delicate and morbid task due the lack of a dissection plane between the heart and the surrounding soft tissues. Delayed sternal reconstruction and osteosynthesis with horizontal titanium plating fixation (Synthes) following vacuum assisted therapy (KCI) has recently been proposed and adopted for the treatment of DSWI. We present such a case of a patient who was successfully reoperated for valve replacement three years after coronary artery bypass grafting complicated by DSWI and initially treated with titanium plate fixation.