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. 2019 Jul;46(4):291-302.
doi: 10.5999/aps.2018.01151. Epub 2019 Jul 15.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Luigi Schiraldi  1   2 , Gaby Jabbour  2   3 , Paolo Centofanti  4 , Salvatore Giordano  5 , Etienne Abdelnour  6 , Michel Gonzalez  6 , Wassim Raffoul  2 , Pietro Giovanni di Summa  2
Affiliations

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Luigi Schiraldi et al. Arch Plast Surg. 2019 Jul.

Abstract

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Keywords: Infection; Reconstructive surgical procedure; Sternotomy; Sternum.

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Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1.
Fig. 1.. Flowchart according to the PRIMA criteria
PRIMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Fig. 2.
Fig. 2.. DSWI acute treatment algorithm
Acute treatment and surgical debridement algorithm for postoperative sternal wound infection complications. DSWI, deep sternal wound infection.
Fig. 3.
Fig. 3.. Clinical presentation of a DSWI
(A) Post-sternotomy wound infection. The wound involved skin and deep soft tissues, including bone with chronic osteomyelitis. Dehiscence appeared 3 months after the last surgical procedure (classified as Pairolero type III and El Oakley type V) [10,11]. (B) Intraoperative debridement. The defect partially involved the sternum, including the sternal notch. (C) Intraoperative phase of flap coverage surgery. The presence of one spared internal mammary artery, the width of the wound, and the necessity of reaching the sternal notch led the surgeon to choose a vertical rectus abdominis musculocutaneous flap based on the contralateral superior epigastric artery. (D) Surgical results at 3 weeks postoperatively. The patient fully recovered, with full working activity and no infectious complications at 2 years of follow-up.
Fig. 4.
Fig. 4.. Anatomical flap location for sternal coverage
A: Latissimus dorsi, B: pectoralis major, C: omentum, D: vertical rectus abdominis, E: superior epigastric artery perforator.
Fig. 5.
Fig. 5.. Proposed reconstruction algorithm according to the literature
IMA, internal mammary artery; VRAM, vertical rectus abdominis musculocutaneous.
See this image and copyright information in PMC

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