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. 2022 Oct 29:21:519-526.
doi: 10.1016/j.reth.2022.10.007. eCollection 2022 Dec.

A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection

Daiki Kitano  1 , Hiroaki Takahashi  2 , Tadashi Nomura  1 , Kenji Okada  2 , Hiroto Terashi  1 , Shunsuke Sakakibara  1
Affiliations

A new clinical classification and reconstructive strategy for post-sternotomy surgical site infection

Daiki Kitano et al. Regen Ther. .

Abstract

Introduction: Post-sternotomy surgical site infection (SSI) is a serious complication of cardiovascular surgery. Here, we proposed a new clinical classification and reconstructive strategy for this condition.

Methods: A retrospective study based on medical records was performed on 100 consecutive cases requiring wound management by plastic surgeons for post-sternotomy SSI at Kobe University Hospital between January 2009 and December 2021. We classified 100 cases into four categories according to the anatomical invasiveness of the infection (type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, aortic graft infection). The standard treatment plan comprised initial debridement, negative pressure wound therapy with continuous irrigation, and reconstructive surgery. Reconstructive methods and their outcomes (in-hospital mortality rate, follow-up period, and infection recurrence rate) were investigated for each SSI category.

Results: There were nine SSI cases in type 1, 28 in type 2, 25 in type 3, and 38 in type 4. The pectoralis major (PM) muscle advancement flap was mainly selected in types 1 and 2 (100 and 70.4%, respectively), while the omental flap or latissimus dorsi (LD) myocutaneous flaps were mainly selected in types 3 and 4 (77.3 and 81.8%, respectively) for reconstructive surgery. The in-hospital mortality rates for types 1, 2, 3, 4 were 44.4, 3.6, 12.0, and 15.8%, respectively. The mean follow-up periods for types 1, 2, 3, 4 were 542.8, 1514.5, 1154.5, and 831.1 days, respectively. Infection recurrence rates for types 1, 2, 3, 4 were 0, 11.5, 13.3, and 19.2%, respectively. All of these recurrent cases, except for 4 cases of type 4 that required surgical intervention, were treated with conservative wound management.

Conclusion: A volume-rich flap (omental or LD flap) was required to fill the dead space after debridement in mediastinitis (type 3) or aortic graft infection (type 4), whereas superficial SSI (type 1) or sternal osteomyelitis (type 2) received a less-invasive flap (PM muscle advancement flap). Our new classification method was based on the anatomical invasiveness of the infection, providing both a simple and easy diagnosis and definitive treatment strategy.

Keywords: AGI, aortic graft infection; CT, computed tomography; Cardiovascular surgery; Classification; LD, latissimus dorsi; Mediastinitis; NPWTci, negative-pressure wound therapy with continuous irrigation; PM, pectoralis major; SSI, surgical site infection; Surgical site infection.

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Figures

Fig. 1
Fig. 1
Our classification of post-sternotomy SSI. We classified post-sternotomy SSI cases into four categories according to the anatomical invasiveness of the infection. Type 1, superficial SSI; type 2, sternal osteomyelitis; type 3, mediastinitis; and type 4, AGI. Abbreviations: AGI, aortic graft infection; SSI, surgical site infection
Fig. 2
Fig. 2
Type 1: superficial SSI. (a) A 70-year-old man after total arch replacement for aortic dissection presented with fever and wound discharge. (b), (c) Subcutaneous abscess was confirmed, but there was no sternal instability. (d), (e), (f) The wound was reconstructed with the PM muscle advancement flap after NPWTci. (g), (h) CT before and after reconstruction. Abbreviations: AGI, aortic graft infection; CT, computed tomography; NPWTci, negative-pressure wound therapy with continuous irrigation; PM, pectoralis major; SSI, surgical site infection.
Fig. 3
Fig. 3
Type 2: sternal osteomyelitis. (a) A 82-year-old man after aortic valve replacement presented with fever and wound discharge. (b), (c) The exposed sternal wire and necrotic bone were removed. (d), (e) Favorable granulation tissue was formed after NPWTci. (f) The bone defect was filled with the PM muscle advancement flap. (g), (h) CT before and after reconstruction. The PM muscle was placed within the bone defect (arrow). Abbreviations: CT, computed tomography; NPWTci, negative-pressure wound therapy with continuous irrigation; PM, pectoralis major.
Fig. 4
Fig. 4
Subtypes of sternal osteomyelitis. (a) Type 2-a: wire-hole infection. (b) Wire removal and curettage of wire-hole. (c), (d) Postoperative CT and schema. The wire-hole tissue was calcified. (e) Type 2-b: partial sternal osteomyelitis. (f) The infection spread along the wire-hole. The anterior plate and bone marrow were destructed, but the posterior plate was intact. (g), (h) Postoperative CT and schema. The debrided sternal cavity was filled with PM muscle advancement flap. (i) Type 2-c: total sternal osteomyelitis. The infection extended to the posterior plate, but the mediastinum was intact. Granulation tissue was formed on the preserved periosteum. (j) The defect was reconstructed with LD myocutaneous flap (k), (l) Postoperative CT and schema. The sternum was totally removed. Abbreviations: CT, computed tomography; LD, latissimus dorsi; PM, pectoralis major.
Fig. 5
Fig. 5
Type 3: mediastinitis. (a) A 74-year-old man after coronary artery bypass grafting presented with sepsis and subcutaneous swelling. (b) Purulent discharge was accumulated in the mediastinum. (c) The wire-cutting through the sternum was confirmed. (d), (e) Wound bed preparation was achieved by NPWTci. (f) The mediastinum was reconstructed with the omental flap. (g), (h) CT before and after reconstruction. The retrosternal abscess (arrow) was debrided. The defect was filled with the omental flap. Abbreviations: CT, computed tomography; NPWTci, negative-pressure wound therapy with continuous irrigation.
Fig. 6
Fig. 6
Type 4: AGI. (a) A 78-year-old man after total arch replacement for arch aortic dissection presented with sepsis and wound discharge. (b) The aortic graft was exposed after re-sternotomy. (c) The wire and necrotic bone were removed. (d), (e) The wound was managed by NPWTci. (f) The omental flap was placed into the mediastinum so as to fill the dead space around the graft. (g), (h) CT before and after reconstruction. The abscess around the graft was removed. The perivascular space was filled with the omental flap. Abbreviations: AGI, aortic graft infection; CT, computed tomography; NPWTci, negative-pressure wound therapy with continuous irrigation.
Fig. 7
Fig. 7
Case and classification. Abbreviations: SSI, surgical site information.
Fig. 8
Fig. 8
Reconstructive method. Abbreviations: LD, latissimus dorsi; PM, pectoralis major.
Fig. 9
Fig. 9
In-hospital mortality rate.
Fig. 10
Fig. 10
Mean postoperative follow-up period.
Fig. 11
Fig. 11
Infection recurrence rate. The major recurrence was referred as serious case which required surgical intervention, while the minor recurrence received conservative treatment.
Fig. 12
Fig. 12
Our diagnostic and reconstructive algorithm. Abbreviations: AGI, aortic graft information; LD, latissimus dorsi; PM, pectoralis major; SSI, surgical site infection.
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References

    1. Berrios-Torress S.I., Umscheid C.A., Bratzler D.W., Leas B., Stone E.C., Kelz R.R., et al. Centers for disease control and prevention guideline for the prevention of surgical site infection. JAMA Surg. 2017;152(8):784–791. - PubMed
    1. Sainz de la Cuesta R., Mohedano R., Sainz de la Cuesta S., Guzma B., Serrera A., Paulos S., et al. Intraoperative subcutaneous culture as a predictor of surgical site infection in open gynecological surgery. PLoS One. 2021;16(1) - PMC - PubMed
    1. Kuhme T., Isaksson B., Dahlin L.G. Wound contamination in cardiac surgery: a systematic quantitative and qualitative study of the bacterial growth in sternal wounds in cardiac surgery patients. APMIS. 2007;115(9):1001–1007. - PubMed
    1. Surgical Site Infection (SSI) Events – January 2022. Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf (accessed 2022-3-8).
    1. Bustamante-Munguira J., Herrera-Gómez F., Ruiz-Álvarez M., Figuerola-Tejerina A., Hernández-Aceituno A. A new surgical site infection risk score: infection risk index in cardiac surgery. J Clin Med. 2019;8(4):480. - PMC - PubMed

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