• Cardiac surgery
• Mortality registries
• Neural network model
• Thoracic surgery
• Wound infection

• BMI
• MICLAT-S
• aortic valve replacement
• minimally invasive surgery
• obesity
• sternum-sparing
• transaxillary

• 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)

• conventional treatment
• negative pressure wound therapy
• poststernotomy mediastinitis

• DSWI
• Postoperative infection
• deep sternal wound infection
• mediastinitis
• mortality

Deep sternal wound infection (DSWI) is one of the most complex and devastating complications post cardiac surgery. We present here the modified sternoplasty, a novel surgical technique for treating DSWI post cardiac surgery. The modified sternoplasty includes debridement and sternal refixation via bilateral longitudinal stainless-steel wires that are placed parasternally along the ribs at the midclavicular or anterior axillary line, followed by six to eight horizontal stainless-steel wires that are anchored laterally and directly into the ribs. On top of that solid structure, wound reconstruction is performed by the use of bilateral pectoralis muscle flaps followed by subcutaneous tissue and skin closure. We reported mortality rates and length of hospitalization of patients who underwent the modified sternoplasty. In total, 68 patients underwent the modified sternoplasty. Two of these critically ill patients died (2.9%). The average length of hospitalization from the diagnosis of DSWI was 24.63 ± 22.09 days. The modified sternoplasty for treating DSWI is a more complex surgery compared with other conventional sternoplasty techniques. However, this technique was demonstrated to be more effective, having a lower rate of mortality, and having a length of hospitalization lower than or comparable to other techniques previously reported in the literature.

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

• Health care–associated infection
• Outcome
• Prevention
• Risk
• Surgical site infection

• Negative pressure wound therapy
• cardiac surgery
• mediastinitis
• sternotomy
• surgical flaps

• median thoracotomy
• nomogram
• prediction model
• sternal incision problems

• aortic valve replacement
• minimally invasive
• obesity

• D-PLEX technology
• antibiotics
• cardiac surgery
• sternal wound infections

• closed incision negative pressure therapy
• negative pressure wound therapy
• sternotomy
• wound healing

Morbidly obese patients (body mass index [BMI] ≥ 35 kg/m²) who undergo cardiac surgery involving median sternotomy have a higher-than-normal risk of sternal dehiscence. To explore a potential solution to this problem, we examined the utility of transverse sternal plating for primary sternal closure in morbidly obese cardiac surgical patients.

We retrospectively reviewed data from cardiac surgical patients who underwent single primary xiphoid transverse titanium plate reinforcement for primary sternal closure from August 2009 to July 2010 (n = 8), and we compared their outcomes with those of patients with BMI ≥35 kg/m² who underwent cardiac surgery without sternal plate reinforcement from April 2008 to July 2009 (n = 14). All cases were performed by the same surgeon.

The 2 groups of patients had similar demographics and comorbidities (P > 0.05 for all). All patients with sternal plate reinforcement reported sternal stability at last follow-up (at a median of 27 months postoperatively; range, 8.4–49.3 months), whereas 1 patient (7.1%) who underwent standard closure developed sterile sternal dehiscence (P = 0.4). Postoperative patient-controlled analgesia (PCA) morphine usage was significantly higher for patients without sternal plate reinforcement than for patients who had sternal plate reinforcement (3.6 mg/h vs 1.3 mg/h, P = 0.008). No patient in the sternal plate group had wound seroma or perioperative complications attributable to sternal closure technique.

Single xiphoid transverse plate reinforcement for primary sternal closure is a feasible option for morbidly obese patients, who are otherwise at high risk of developing sternal dehiscence. Using this technique may decrease postoperative narcotics usage.

Morbidly obese patients (body mass index ≥35 kg/m²) have a higher-than-normal risk of sternal dehiscence after cardiac surgery. In a pilot study, we found that those who underwent transverse sternal plating (n = 8) had no sternal dehiscence and required less postoperative analgesia than patients who underwent standard wire closure (n = 14).

• Cardiac surgery
• Obesity
• Sternal plating
• Sternal wound dehiscence

• Negative pressure therapy
• Postoperative treatment
• Surgical wounds
• Wound dehiscence
• Wound rupture

• Arterial grafts
• Coronary artery bypass grafting
• Prevention
• Quality of care improvement
• Sternal wound infection

• Health care–acquired infection
• Outcome
• Prevention
• Risk
• Surgical site infection

• Anti-Bacterial Agents
• Antibiotic Prophylaxis
• Cross Infection
• Humans
• Risk Factors
• Surgical Wound Infection
• Treatment Outcome

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
• Negative pressure wound therapy
• Post-operative mediastinitis
• Sternal osteomyelitis
• Sternotomy

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

• poststernotomy mediastinitis
• mortality
• methicillin-resistant staphylococcus aureus

• Aged
• Cardiac Surgical Procedures/methods
• Female
• Humans
• Intensive Care Units
• Male
• Mediastinitis/microbiology
• Mediastinitis/mortality
• Methicillin-Resistant Staphylococcus aureus
• Middle Aged
• Risk Factors
• Staphylococcal Infections/microbiology
• Staphylococcal Infections/mortality
• Sternotomy
• Surgical Wound Infection/microbiology
• Surgical Wound Infection/mortality
• United States

The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT).

We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail.

A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action.

There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement.

Cite this article: Bone Joint Res 2013;2:276–84.

• Incisional NPWT
• Mechanism of action
• NPWT
• Negative pressure wound therapy
• Single-use NPWT
• Surgical site infection

Management of difficult wounds can be a complex, challenging and expensive task, especially for wounds showing a slow healing process. Topical negative pressure (TNP) therapy has greatly improved difficult wounds treatment. It allows to treat patient on an outpatient management, to reduce the complication rate with shorter hospital stay, to avoid frequent dressings with expensive advanced materials and allow a lower commitment of health professionals. Vacuum Assisted Closure^® (VAC^®) system is a therapeutic device based on the administration of a controlled TNP introduced by Morykwas and Argenta in 1997. It is indicated in different kinds of wound, but clinical evidences are present only for few of them. In this work we summarize indications and recommendations for VAC^® therapy and we analyze the actual better choice of treatment based on evidences and personal experience in order to stimulate further studies. Finally we introduce recent applications of VAC^® system such as Prevena^®, VAC Instill^® and VAC Via^®. Prevena^® is a system based on TNP indicated in the management of closed wounds that present risk factors for dehiscence. VAC Instill^® is a system that allows to associate TNP and topical administration of solutions, such as antibiotics or disinfectants, to treat specific type of wounds. VAC Via^® is a device based on TNP, characterized by little dimension and a preset system that allow the treatment of little wounds for 7 d, with no impairment for the patient. The aim of our paper is to describe a report of VAC^® therapy use in order to stimulate further studies and to define the level of evidence of VAC^® therapy.

• Topical negative pressure
• Wound
• Vacuum Assisted Closure^®
• Diabetic foot
• Pressure ulcers

Preoperative screening for nasal S. aureus carriage, followed by eradication treatment of identified carriers with nasal mupirocine ointment and chlorhexidine soap was highly effective in preventing deep-seated S. aureus infections. It is unknown how cost-effectiveness of this intervention is affected by suboptimal S. aureus screening. We determined cost-effectiveness of different preoperative S. aureus screening regimes.

We compared different screening scenarios (ranging from treating all patients without screening to treating only identified S. aureus carriers) to the base case scenario without any screening and treatment. Screening and treatment costs as well as costs and mortality due to deep-seated S. aureus infection were derived from hospital databases and prospectively collected data, respectively.

As compared to the base case scenario, all scenarios are associated with improved health care outcomes at reduced costs. Treating all patients without screening is most cost-beneficial, saving €7339 per life year gained, as compared to €3330 when only identified carriers are treated. In sensitivity analysis, outcomes are susceptible to the sensitivity of the screening test and the efficacy of treatment. Reductions in these parameters would reduce the cost-effectiveness of scenarios in which treatment is based on screening. When only identified S. aureus carriers are treated costs of screening should be less than €6.23 to become the dominant strategy.

Preoperative screening and eradication of S. aureus carriage to prevent deep-seated S. aureus infections saves both life years and medical costs at the same time, although treating all patients without screening is the dominant strategy, resulting in most health gains and largest savings.

• Aged
• Carrier State/diagnosis
• Carrier State/drug therapy
• Carrier State/microbiology
• Cost-Benefit Analysis
• Female
• Health Care Costs
• Humans
• Life Expectancy
• Male
• Mass Screening/economics
• Middle Aged
• Patient Admission
• Postoperative Complications/diagnosis
• Postoperative Complications/economics
• Postoperative Complications/prevention & control
• Preoperative Care/economics
• Sensitivity and Specificity
• Soaps
• Staphylococcal Infections/diagnosis
• Staphylococcal Infections/drug therapy
• Staphylococcal Infections/economics
• Staphylococcal Infections/prevention & control
• Staphylococcus aureus/physiology
• Treatment Outcome

• Adult
• Cardiac Surgical Procedures/adverse effects
• Cardiac Surgical Procedures/mortality
• Cross Infection/microbiology
• Cross Infection/mortality
• Hospital Mortality
• Humans
• Kaplan-Meier Estimate
• Logistic Models
• Mediastinitis/microbiology
• Mediastinitis/mortality
• Pneumonia, Ventilator-Associated/microbiology
• Pneumonia, Ventilator-Associated/mortality
• Retrospective Studies
• Risk Assessment
• Risk Factors
• Time Factors