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Surgical management of sternal wound complications

Surgical management of sternal wound complications
Literature review current through: Jan 2024.
This topic last updated: Nov 14, 2023.

INTRODUCTION — Separation of the sternal bones previously divided during sternotomy and reapproximated is an infrequent but serious complication that is often a precursor to mediastinitis [1]. Median sternotomy, which provides excellent access to the heart and surrounding structures, is the most commonly used incision for open cardiac surgery but may also be used for treating traumatic injuries in the chest or for revascularization of the aortic arch branch vessels. Transverse sternotomy in association with bilateral thoracotomy (ie, clamshell incision) is used less often but may be needed to manage large tumors, chest trauma, or to perform bilateral lung transplantation.

Median sternotomy complications occur in 0.5 to 5 percent of patients, with 0.2 to 3 percent of patients developing mediastinitis [2]. For transverse sternotomy, the rate of wound complications appears to be similar [3,4]. The risk of sternal wound complications may be higher in adults undergoing open heart surgery due to multiple medical comorbidities compared with other populations (eg, trauma, children). Patients who develop deep sternal wound infections have increased short- and long-term mortality [5].

The diagnosis, management, and measures to prevent sternal wound complications will be reviewed here. The diagnosis and medical management of mediastinitis is discussed elsewhere. (See "Postoperative mediastinitis after cardiac surgery".)

RISK FACTORS FOR STERNAL WOUND COMPLICATIONS — The etiology of sternal wound complications is multifactorial [6-12]. Any factor that contributes to poor wound or bone healing (eg, osteopenia, malnutrition) or increases the risk for surgical site infection (eg, diabetes, immunosuppression) may be clinically important, especially if two or more factors are present [13]. Sternal dehiscence is defined as separation of the bones (sternum, manubrium, xiphoid) previously divided during sternotomy, either partially or completely. (See 'Sternal closure' below.)

Although postoperative sternal wound infection is clearly associated with sternal dehiscence, whether the sternal wound infection has caused the sternal dehiscence or the sternal dehiscence has caused the sternal wound infection is usually not known. Thus, it is essential to follow measures that can help prevent surgical site infection [14]. (See 'Prevention' below.)

Sternal wound healing is impaired if the edges of the sternum are not aligned properly, the sternum is ischemic, or the bone is abnormal.

Technical factors that contribute to poor sternal union include the creation of an asymmetric sternotomy incision that is difficult to realign, residual separation of the sternal edges after closure, and bone ischemia due to excessive use of electrocautery or possibly internal thoracic artery harvesting (especially if bilateral). (See 'Internal thoracic (mammary) artery harvest' below.)

Perioperative factors that increase the risk for sternal dehiscence include prolonged operative time, the need for chest compressions before or after sternotomy, postoperative bleeding, transfusion, and reoperation [15]. (See 'Sternal closure' below.)

Certain patient populations have risk factors that increase the risk for surgical site infection or poor wound healing [16]. These include the following:

Patients undergoing cardiac surgery have multiple risk factors for infection, including cardiopulmonary bypass, which leads to a relatively immunosuppressed state [17]; the presence of multiple drains and thoracostomy tubes, which are portals for the entry of bacteria; and a higher prevalence of other postoperative risk factors for wound infection (eg, respiratory infection) [18,19]. Patients with coronary artery disease are often older and have an increased incidence of diabetes, obesity, and tobacco use, which, in addition to being risk factors for atherosclerosis, are risk factors for postoperative infection following cardiac surgery [20]. (See "Overview of established risk factors for cardiovascular disease" and "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Infection'.)

Patients with obesity are at a particularly high risk for sternal dehiscence [2,21-26]. The excess weight of the chest wall places high tensile stress on the sternal closure, which is exacerbated by upper body movement or coughing. Similarly, women with macromastia have a higher risk of sternal wound complications compared with women who have smaller breasts [27]. Even small amounts of additional stress on the sternum can lead to sternal wire fracture or cutting of sternal wires through the sternum, resulting in sternal separation [28]. Prophylactic sternal reinforcement may decrease the incidence of sternal dehiscence in patients with obesity. (See 'Sternal wiring' below and 'Prevention' below.)

Patients with chronic pulmonary disease have multiple risk factors for sternal wound complications. Preoperative chest deformities such as barrel chest or pectus excavatum can increase the difficulty in maintaining proper alignment of the sternal edges during closure [29]. These deformities also exert additional stress on the sternal closure, and coughing exacerbates the stress. Continued smoking in patients with obstructive pulmonary disease also adversely affects wound healing. (See 'Prevention' below.)

Patients with diabetes exhibit poor wound healing and have a higher incidence of surgical site infection [30]. They may also be more susceptible to sternal ischemia with harvest of the internal thoracic artery, particularly if bilateral [18]. Improved perioperative glycemic control decreases wound infection rates in patients with diabetes [30-34]. (See 'Prevention' below and 'Internal thoracic (mammary) artery harvest' below.)

STERNAL CLOSURE — To access the mediastinum, the sternum is divided with a surgical saw longitudinally in the midline (eg, coronary artery bypass) or transversely (eg, clamshell incision for bilateral thoracotomy). At the completion of the procedure, the sternal edges are reapproximated, usually with sternal wires, although other permanent suture materials have been described [35]. Sternal closure in low-risk patients is generally accomplished with simple (transsternal or peristernal) surgical wire closure; however, prophylactic sternal reinforcement techniques (wiring or rigid surgical plate fixation) may decrease the risk for sternal dehiscence in patients with risk factors. Topical antimicrobial agents (eg, vancomycin paste) may be used as an adjunct as it is inexpensive and easy to make in the operating room, with reasonable evidence that it reduces sternal wound infections [36]. The subcutaneous tissues are typically closed with absorbable sutures and the skin closed in a subcuticular fashion [37]. Other methods of sternal closure including advanced wire design, tapes, and cables have also been used. In a review of the use of rigid plates, thermoreactive clips, cables, or flat wires, no superiority was noted compared with sternal wires [38]. (See 'Risk factors for sternal wound complications' above.)

Sternal wiring — The most common wiring technique passes stainless steel wires through the sternum (transsternal) approximately 2 to 3 cm from the sternal edge. The ends of the wires are twisted anteriorly to draw the sternal edges together. Various wire sizes, numbers, and configurations (eg, simple, figure of eight) have been used [39-41]. Comparative prospective trials have not been performed to determine the optimal closure methods for specific sternal wound types.

A wire cerclage technique passes wires around the sternum (peristernal) instead of through it (transsternal) (figure 1). Several variations of wire cerclage have been described [22,42-44]. As an example, with the Robicsek technique, the wires are weaved through the intercostal spaces parasternally with cerclage wires that are placed lateral to the woven wire (figure 2). Based upon observational studies, cerclage techniques appear to increase the strength and stability of sternal closure, but a clear benefit for more complicated wiring schemes over simple wire cerclage has not been established in randomized trials. Nevertheless, high-risk patients may benefit from prophylactic sternal reinforcement.

A retrospective review comparing sternal dehiscence rates in heart surgery patients who were and were not obese (body mass index [BMI] >30 kg/m2) used routine wire closure, figure-of-eight wiring, or the Robicsek technique [45]. The rates of sternal dehiscence were 6.5, 1.6, and 0 percent, respectively.

In a prospective study of 200 patients, Robicsek closure significantly decreased the incidence of sternal dehiscence compared with standard wire closure (2.5 versus 12.5 percent) for patients with two or more risk factors [42].

In a randomized trial, 700 patients were assigned to transsternal wiring or cerclage wiring with a double criss-cross technique; the double criss-cross technique was associated with a small but significantly decreased incidence of superficial and deep sternal wound infection (superficial: 0 versus 2 percent; deep: 0 versus 1.7 percent) [43].

A second trial randomly assigned 815 high-risk patients to Robicsek closure or conventional wiring; there was no significant difference in the incidence of sternal dehiscence (3.7 versus 2.5 percent) [22].

Rigid sternal fixation — Rigid sternal fixation can be accomplished with sternal bands or sternal plates. Steel bands are composed of thin, wide pieces of steel that are placed below the manubrium in the intercostal spaces. Small trials have found decreased postoperative pain and decreased length of stay, but sternal banding does not appear to alter the risk for sternal wound complications and sternal wound infection [13,46-52].

Alternatively, one to four rigid anterior plates can be attached with screws across the sternum (figure 3). Some systems will extend plates to the ribs [53]. In a cadaver model, sternal plating increased sternal stability compared with wire cerclage [54]. Small retrospective reviews comparing sternal plating with wire closure suggest that plating may decrease the incidence of wound complications and mediastinitis [55-57]. However, sternal plating systems are expensive and may be justified for primary closure only in high-risk patients following longitudinal sternotomy [54]. One study using a particular sternal closure system using plates, cables, and cannulated screws to manage complicated sternal dehiscence showed an increased risk for subsequent sternal wound infection [58].

For transverse sternotomy, the use of sternal plating for primary closure has been associated with decreased rates of dehiscence compared with historical controls [3,59]. (See 'Risk factors for sternal wound complications' above.)

Technical considerations

Hemostasis — Bleeding from sternal edges during surgery is controlled by a variety of hemostatic agents. Electrocautery is commonly used to control bleeding from the subcutaneous tissues and bone edges. Minimization of electrocautery during sternotomy may improve wound perfusion and decrease wound infection [29].

Bone wax was commonly used in the past to control sternal bleeding, but it does not degrade over time and may inhibit bone growth. Excessive use of bone wax has been speculated to contribute to sternal nonhealing; however, the only randomized trial evaluating bone wax reported no increase in sternal infection rates [60]. Nevertheless, the availability of alternative hemostatic agents (eg, thrombin) has diminished the use of bone wax [61]. (See "Overview of topical hemostatic agents and tissue adhesives".)

Internal thoracic (mammary) artery harvest — The internal thoracic artery is a superior conduit for coronary artery bypass grafting because of a higher rate of graft patency compared with a saphenous vein. Bilateral internal thoracic artery grafts are used, when indicated, in patients who do not have an excessive risk of sternal complications [62].

In a primate model, harvesting the internal thoracic artery decreased sternal blood flow by 90 percent [63]. In the clinical setting, this degree of blood flow reduction is probably not sustained. Even so, parasternal ischemia from internal thoracic artery harvest (especially bilateral harvest) is felt to diminish wound healing, potentially contributing to sternal wound complications, particularly in high-risk patients [30,64-66]. However, some clinicians feel that using "skeletonized internal mammary arteries" may decrease the risk for ischemia [67-69]. In one retrospective review of 560 patients undergoing bilateral skeletonized mammary artery grafts, the incidence of postoperative sternal wound complication was low at 1.1 percent [68]. (See "Coronary artery bypass graft surgery: Graft choices", section on 'Two arterial grafts'.)

A retrospective review of 6504 patients found no difference in the risk of sternal wound complications (eg, mediastinitis) in patients without diabetes who underwent bilateral internal thoracic artery harvest compared with either unilateral harvest or no harvest (eg, valve surgery) [30]. However, those with diabetes who underwent bilateral internal thoracic artery harvesting had a significantly increased risk (relative risk 5.0, 95% CI 2.4-10.5).

In the Arterial Revascularization Trial (ART), which randomly assigned 3102 patients to single or bilateral internal mammary artery harvest (SIMA, BIMA, respectively), the risk for wound infection was increased in the BIMA group (3.5 versus 1.9 percent; hazard ratio [HR] 1.87, 95% CI 1.20–2.92), as was the rate of sternal reconstruction (1.9 versus 0.6 percent; HR 2.91, 95% CI 1.42–5.95) [70,71]. There were no significant differences in mortality or cardiovascular event rates at five-year follow-up. The results were no different after adjusting for age, sex, diabetes, and ejection fraction. Of note, the percentage of patients who did not receive the allocated treatment was 3.4 percent in the SIMA group and 15.5 percent in the BIMA group. In the BIMA group, vessel unsuitability due to size or condition, patient status, surgeon preference, unsuitable coronary anatomy, or other reasons were cited as reasons not to perform BIMA. Whether patient obesity or diabetes factored into these reasons was not given.

Other retrospective studies have not identified bilateral internal thoracic harvesting as an independent risk factor for sternal wound complications in patients with diabetes [6,72,73]. Nevertheless, bilateral internal thoracic harvesting is often reserved for younger patients (<55 years) without diabetes in many institutions. (See "Postoperative mediastinitis after cardiac surgery", section on 'Risk factors'.)

WOUND ASSESSMENT — Early detection and treatment of sternal wound breakdown or sternal instability may prevent subsequent complications, such as infection or nonunion. When a sternal wound complication is identified, plain chest radiographs of the sternum (eg, lateral view) should be obtained to evaluate the integrity of the sternal closure. Findings of sternal separation, fractured or malpositioned wires, sternal fracture, or pseudoarthrosis are indicative of sternal dehiscence. Wound cultures are obtained for most sternal wound complications. (See "Postoperative mediastinitis after cardiac surgery", section on 'Microbiology'.)

As with any surgical site, sternal wound failure can be limited to the superficial tissues or extend deeply through all layers of the closure (table 1). (See "Overview of the evaluation and management of surgical site infection".)

Soft tissue dehiscence – Soft tissue dehiscence refers to separation of the superficial tissues (ie, skin, subcutaneous fat, muscle) and occurs in 6 to 8 percent of patients undergoing cardiac surgery [74]. The sternum is stable to palpation. Although soft tissue dehiscence is considered a minor complication, sternal wires can become exposed, and proper management is important to prevent further complications. If significant wound drainage is present or the patient has systemic symptoms (eg, fever, chills), deep sternal wound infection must be presumed even in the absence of sternal instability [75].

Sternal dehiscence – Sternal dehiscence refers to the separation of the edges of the sternum from one another and can occur in the absence of soft tissue dehiscence; this can be caused by wire fracture, loosening, or "pulling through" the sternal edge. Patients may complain of a painful chest motion and "clicking" [76]. The diagnosis is made on physical examination by placing each hand on either side of the sternum and having the patient cough; this will cause a click, or "rocking" of the sternum. Sternal dehiscence is considered a surgical emergency, since affected patients have an increased risk of ventricular rupture due to sharp wires or bone fragments rubbing against the heart. When sternal dehiscence occurs in the early postoperative period, the patient is taken to the operating room for exploration. (See 'Surgical management' below.)

Deep sternal wound infection – Deep sternal wound infection, also known as mediastinitis, is a surgical emergency and can result from of an overlying soft tissue dehiscence, or due to intraoperative contamination of the deeper tissues. The patient typically presents with fever and systemic symptoms within several weeks of the surgery with or without local symptoms or signs of superficial soft tissue dehiscence, sternal dehiscence, or wound infection [77]. A guideline from the United States Centers for Disease Control (CDC) provides criteria to define mediastinitis, primarily for the purpose of surveillance and reporting (table 2) [78].

If deep sternal wound infection is suspected but not clinically apparent, computed tomography (CT) of the chest may show changes in the configuration of the bone, or the presence of fluid or abscess, which can be aspirated for culture [79]. The microbiologic diagnosis of mediastinitis is discussed elsewhere. (See "Postoperative mediastinitis after cardiac surgery", section on 'Clinical features'.)

SURGICAL MANAGEMENT — Superficial sternal wound infections without involvement of the sternum can be treated with local wound care or operative debridement and readvancement of the skin. Sternal dehiscence without infection can often be treated with rewiring or plating. Patients suspected of having deep sternal wound infection (DSWI, also known as mediastinitis) should be taken to the operating room for emergency exploration; intravenous antibiotics are also initiated. Mediastinitis is a clinical diagnosis based on factors that include wound separation, wound drainage, sternal instability, systemic toxicity, chest radiography, computed tomography (CT) findings, and positive results from wound cultures with subsequent coverage based upon the results of wound culture and sensitivity. Antibiotic management in the treatment of DSWI is discussed in detail elsewhere. (See "Postoperative mediastinitis after cardiac surgery", section on 'Treatment'.)

The surgical treatment of DSWI is individualized based upon basic wound care principles and sound surgical judgment. The variability in presentation and clinical course limits the ability to develop consensus guidelines for management. In our experience, debridement of all nonviable tissue is essential. The sternum can be rewired or plated if adequate bone stock is present and infection is absent. Flap closure is reserved for patients who have an inadequate amount of bone after debridement or if there is uncertainty whether the infectious process is controlled. A systematic review defined and used the Assiduous Mediastinal Sternal Debridement & Aimed Management (AMSTERDAM) classification, which is based on sternal stability and bone viability and stock, to classify and provide evidence-based support for various treatment options (eg, rewiring, plating or other bone fixation devices, negative pressure wound therapy, muscle flap, omental flap) (table 3) [80]. (See 'Sternal flap closure' below.)

Debridement — Surgical debridement, which is indicated in the presence of necrotic tissue or purulent drainage, is the mainstay of therapy for postoperative sternal wound complications. Exploration of the sternal wound should be performed once the diagnosis of dehiscence or infection is suspected. Early compared with later debridement was associated with shorter hospitalization in one review [81]. The exploration of a sternal wound in suspected dehiscence should be performed in an operating room equipped for complex cardiac surgical procedures with the availability of blood transfusion, defibrillation, and cardiopulmonary bypass. Sternal debridement and closure are often performed as a collaborative effort between the cardiac and plastic surgery services.

All devitalized tissue is thoroughly debrided, and foreign materials should be removed [17]. The endpoint of sternal debridement is the clinical appearance of well-vascularized healthy bone. In most cases, total sternectomy can be avoided. However, recurrent infection or a chronic draining sinus tract can develop in wounds with residual nonviable tissue, infected bone or cartilage, or foreign material. Sternal plates are not removed unless they can be palpated or are overtly exposed. Any sharp bone edges should be filed down to minimize the risk of damage to the heart. We use pulse lavage with antibiotics, although there are no randomized trials evaluating its effectiveness in sternal debridement.

In the past, some surgeons advocated total sternectomy for all patients. Although this procedure is effective in clearing the infection, it is associated with significant morbidity from chest wall instability. Sternectomy can usually be avoided by judicious debridement and management of the open sternal wound until subsequent closure can be performed. If the sternum requires complete resection, the chest defect can be managed with immediate or delayed flap closure [17]. (See 'Sternal flap closure' below.)

Deep wound culture — Deep wound gram stain and cultures should be taken, whenever possible, even if wound failure appears to be superficial. Staphylococcus aureus and coagulase-negative staphylococci are the most common bacteria isolated from deep surgical wound infections, and antibiotic therapy is initially targeted to cover these organisms [82]. Subsequent treatment is based upon the results of the wound cultures and sensitivity testing. The microbiologic diagnosis and antibiotic treatment of postoperative mediastinitis is discussed in detail elsewhere. (See "Postoperative mediastinitis after cardiac surgery", section on 'Microbiology' and "Postoperative mediastinitis after cardiac surgery", section on 'Treatment'.)

Reclosure versus delayed closure — Following debridement, the sternum can be closed immediately, or following an interval of open wound management. The choice of immediate or delayed closure is a matter of surgical judgment that is influenced by the operative findings and available surgical expertise. For example, a thin patient with intact sternal edges that readily come together would be more amenable to sternal closure than a patient with obesity and a highly fragmented sternum. Patients who are not candidates for immediate closure because of high anesthetic risk are treated with sternal wound dressing changes. (See 'Sternal dressings' below.)

Sternal reclosure, whether immediate or delayed, is accomplished with wire cerclage or rigid fixation (described above) or with flap closure provided infection is not present. For malunion of the bony edges with an intact sternum, simple rewiring with a figure-of-eight or cerclage technique is usually sufficient (figure 1). For sternal malunion with multiple wire fractures, additional stability can be achieved with the Robicsek technique (figure 2) [45]. Steel bands or titanium plates (figure 3) can be used to improve the strength and stability of the closure if the sternum is intact and the patient is high risk, multiple sternal fractures are present, or if the transsternal wires cut through the bone due to poor bone quality [4,49,55,83,84]. (See 'Sternal closure' above and 'Sternal flap closure' below.)

Management of the open sternum — For patients who are not candidates for immediate primary sternal or flap closure due to the need for repeat debridement for ongoing infection, the open sternum can be managed with conventional moist gauze dressings with or without closed, antibiotic irrigation, or alternatively using negative pressure wound therapy, also known as vacuum-assisted closure, while awaiting delayed closure [85]. (See 'Negative pressure wound therapy' below.)

Patients who are medically unstable or unwilling to undergo additional surgery can continue with sternal dressings, but this approach leads to prolonged hospitalization and increases the risk for chronic infection and ventricular rupture.

Sternal dressings — The sternum is dressed by placing moist saline-soaked gauze over a barrier dressing (eg, petrolatum gauze) that protects the beating heart. Soft suction drains may be placed into the wound in a position that minimizes contact with the heart. The entire wound is then covered with an elastic barrier dressing (eg, Steri-drape). For noninfected wounds, these dressings are changed in the operating room, usually every one to three days until delayed closure can be accomplished. Infected wounds require more frequent dressing changes (up to four times daily, depending upon the degree of purulence). When frequent dressing changes are needed, the dressing is often changed at the bedside.

An alternative method uses closed continuous wound irrigation via large irrigation tubes [86]. To our knowledge, there is no proven efficacy for irrigation with antibiotics or disinfectant solution, and these agents may be toxic to tissue, leading to delayed wound healing. Also, with longer-term iodine irrigation, patients may develop other complications that include iodine toxicity seizures, metabolic acidosis, or renal failure [87].

Negative pressure wound therapy — Negative pressure wound therapy (NPWT), also called vacuum-assisted wound closure, refers to a wound dressing system that continuously or intermittently applies subatmospheric pressure to the surface of a wound. NPWT stabilizes the chest wall, removes excess fluid, and facilitates wound healing [88-91]. A 12-year review published in 2015 showed the various advantages of NPWT, mostly in reducing the need to do flap reconstructions, hospital length of stay, and complications due to surgery [92]. The increased blood flow demonstrated for other wound models has been confirmed in a porcine sternotomy model [93]. Respiratory mechanics are not impaired as a result of the application of subatmospheric pressure to mediastinal structures [94,95]. The general mechanism of action of NPWT and placement and management of the NPWT device are discussed separately. (See "Negative pressure wound therapy".)

Although NPWT is associated with decreased times to delayed closure and may reduce overall patient mortality, a small number of deaths have been reported in association with this therapy, primarily due to cardiac rupture [96]. It is important to provide a barrier dressing between the gauze or foam and the heart to minimize the delivery of excessive negative pressure to the heart muscle.

NPWT has become a popular treatment modality for the management of many acute and chronic wounds, including sternal wounds [97]. In one questionnaire, nearly two-thirds of cardiac surgeons stated that they use NPWT to control the open sternal wound until primary closure or myocutaneous flap coverage can be performed [98]. Following debridement, NPWT dressings are typically needed for 2 to 10 days [15,88,99].

The optimal frequency and duration of NPWT dressings has not been determined. As with gauze dressing, most clinicians use NPWT as a bridge to surgical closure, discontinuing the dressing when the wound is clean and has started to granulate. In patients who are not candidates for surgical closure, NPWT has been used to completely heal the sternal wound.

There are no randomized trials comparing NPWT to standard therapy (eg, debridement with either immediate or delayed sternal closure over drains). The available evidence, consisting of retrospective reviews, suggests that NPWT is a reasonable option for managing open wounds following sternal debridement [15,90,91,100-108].

In one of the largest series, NPWT was compared with standard therapy in 68 patients [106]. Patients in the NPWT group had a significantly shorter time to bacteriologic cure, reduced in-hospital stay, and reduced percentage of patients discharged with an open sternum. A reduced need for myocutaneous flap coverage has not been consistently demonstrated; however, the time interval between debridement and closure (either primary or flap coverage) appears to be shorter [100].

The use of NPWT may reduce overall mortality in patients with deep sternal wound infection [102,106]. One retrospective analysis of 118 patients with post-sternotomy mediastinitis found that mortality with NPWT was 6 percent, compared with 25 percent in patients treated with conventional therapy [102]. The groups were similar with respect to the type of their initial surgical procedure (ie, coronary artery bypass, valve placement) and risk factors.

Sternal flap closure — Flap closure is reserved for patients with significant soft tissue deficits. Flap closure is usually accomplished without bony reapproximation. Bone grafts are rarely needed, and because of the elasticity of the chest skin, skin grafts are also uncommon [4]. For most patients, the resulting scar tissue leads to a stable anterior chest wall.

Several options for sternal flap closure are available, either for immediate or delayed closure. The most common flaps for chest wall closure and coverage are the pectoralis major, latissimus dorsi, and rectus abdominis flaps, which can be combined with an omental flap to fill the defect [109,110]. The use of a perforator artery flap has also been reported [111-113]. (See "Overview of flaps for soft tissue reconstruction".)

The pectoralis major muscle has become the preferred flap for the closure of anterior chest wall defects. A portion of the muscle, based upon the thoracoacromial artery, is detached from the sternum and advanced into the superior mediastinal defect. A larger portion of the muscle can be taken using perforators off the internal thoracic artery as a turnover flap. However, turnover flaps are unreliable in patients who have had the internal thoracic artery harvested as a bypass conduit. Bilateral pectoral flaps are frequently used for large defects (figure 4). In a series of 24 patients with sternal nonunion, the use of bilateral pectoralis flaps significantly improved patient symptoms [114].

Omental flaps are rich in blood supply and contour well to irregular defects [115-117]. They can be harvested laparoscopically with little morbidity [118]. The omentum is pulled up through an opening in the central diaphragm and placed into the mediastinal defect (figure 5). Potential complications unique to this technique include injury to abdominal organs and gastrointestinal obstruction due to diaphragmatic hernia, abdominal incisional hernia, or postoperative peritoneal adhesions. The omentum can usually be harvested without the need to extend the skin incision or, alternatively, through a laparoscopic approach [119]. (See "Overview of abdominal wall hernias in adults" and "Management of small bowel obstruction in adults".)

Omental and pectoralis flaps can be used together to fill larger defects (figure 4). Other muscles, including the latissimus dorsi and rectus abdominis muscle, have been used successfully as muscle or myocutaneous flaps when other flap options are not available. The rectus abdominis may be preferred when the defect is at the caudal margin of the sternum [120].

Complications associated with flap closure include hematoma, flap dehiscence, partial or complete flap necrosis, and recurrent wound infection [121]. However, the incidence of recurrent wound infection is lower for flap closure compared with other wound management strategies [88,121,122].

OUTCOMES — Most patients requiring flap surgery for sternal wound infection will stay in the hospital until they can get up and move around and chest tubes are removed, which typically occurs three to five days after surgery. Antibiotics are continued for six to eight weeks if there is residual bone involvement. It is uncommon to have a recurrent infection with adequate management consisting of thorough debridement and antibiotics. (See "Postoperative mediastinitis after cardiac surgery", section on 'Treatment'.)

Most patients regain their baseline quality of life. In a small percentage of patients with flaps, chest wall instability can be uncomfortable, particularly in certain positions such as lying on the side. In young muscular men, significant disfigurement and loss of arm strength can result when pectoralis major turnover flaps are used.

Long-term mortality is increased in patients with sternal wound infection as a complication of sternotomy. In one review, mortality at one year was 12.8 percent for those with sternal wound infection compared with 4.5 percent for those without a wound infection [5].

PREVENTION — Perioperative measures that can reduce the incidence of sternal wound dehiscence and infection include the following [1,8,123]:

Follow all recommendations for preventing surgical site infection. Prior to any cardiac or thoracic procedure, prophylactic antibiotics should be administered. Antibiotic choice and timing and other measures to prevent surgical site infection, such as topical antimicrobial agents, are discussed elsewhere. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)

Assess the patient's risk factors (anatomic and medical) for sternal wound complications and choose an appropriate technique for primary sternal closure. For high-risk patients, prophylactic sternal reinforcement or minimally invasive surgical methods that avoid sternotomy can be considered. Meticulous surgical technique is essential to minimize sternal asymmetry and provide adequate hemostasis without the excessive use of electrocautery. Avoid bilateral internal thoracic harvesting in high-risk patients, whenever possible. (See 'Sternal closure' above.)

Optimize glycemic control. The risk of sternal wound infection can be significantly reduced by improving perioperative glycemic control in patients with diabetes [10,124-126]. The management of glucose levels in patients with diabetes is discussed in detail elsewhere. (See "Management of cardiopulmonary bypass", section on 'Glucose' and "Susceptibility to infections in persons with diabetes mellitus" and "Perioperative management of blood glucose in adults with diabetes mellitus".)

Encourage smoking cessation prior to surgery, which may decrease the risk for wound complications [127]. Smoking should be discontinued at least six weeks before the planned surgery to achieve significant benefit. (See "Strategies to reduce postoperative pulmonary complications in adults", section on 'Smoking cessation' and "Risk factors for impaired wound healing and wound complications", section on 'Smoking and nicotine replacement therapy'.)

Optimize nutritional status. Malnutrition is associated with an increased susceptibility to infection and poor wound healing [77]. Preoperative hypoalbuminemia, which is often a reflection of impaired nutritional status, is associated with an increased risk for sternal wound complications [10,77]. The assessment of, and measures to improve, nutritional status in surgical patients are discussed elsewhere. (See "Overview of perioperative nutrition support".)

Consider prophylactic negative pressure wound therapy (NPWT) over the closed incision for high-risk patients [128]. In a retrospective review the incidence of surgical site infection decreased from 3.4 to 1.3 percent when NPWT was used [129]. (See "Negative pressure wound therapy", section on 'Prophylactic use'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Skin and soft tissue infections" and "Society guideline links: Deep sternal wound infection".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Flap surgery (The Basics)")

SUMMARY AND RECOMMENDATIONS

Sternal wound dehiscence – Sternal dehiscence is an infrequent but serious complication that is often a precursor to mediastinitis. Although the incidence of sternal wound complications has decreased, the mortality rate for deep sternal wound infection (ie, mediastinitis) remains high. (See 'Introduction' above.)

Risk factors – The etiology of sternal wound complications is multifactorial. Any factor that contributes to poor wound or bone healing (eg, osteopenia, malnutrition) or increases the risk for surgical site infection (eg, poorly controlled diabetes, immunosuppression) may be clinically important. Other risk factors include the need for cardiopulmonary bypass, obesity, preoperative chest wall deformity, and smoking. Technical factors that lead to poor sternal union or bone ischemia (eg, electrocautery, internal thoracic artery harvest) and perioperative factors such as prolonged operative time, the need for chest compressions, postoperative bleeding, transfusion, and reoperation also increase the risk. (See 'Risk factors for sternal wound complications' above.)

Sternal closure – For patients with one or more risk factors for sternal dehiscence, we suggest a peristernal (cerclage) wiring technique over simple transsternal wiring for initial sternal closure (Grade 2C). Other surgical options for sternal closure in high-risk patients include prophylactic sternal reinforcement with specialized wiring or plating techniques. (See 'Risk factors for sternal wound complications' above and 'Sternal closure' above.)

Prevention – Other surgical practices that decrease the risk for sternal wound complications include the appropriate administration of prophylactic antibiotics and other standard measures to control surgical site infection, and meticulous surgical technique with adequate hemostasis to minimize the need for transfusion or reoperation. Perioperative preventive measures that decrease wound complications include optimizing glycemic control in patients with diabetes, smoking cessation, and optimizing nutritional status. (See 'Prevention' above.)

Wound assessment – Sternal wound breakdown can be limited to the superficial tissues or extend deeply through all layers of the closure. Whenever sternal wound infection is suspected (eg, wound separation or drainage, sternal instability), broad-spectrum antibiotic therapy is initiated, and the wound is explored. Deep wound gram stain and cultures should be taken, whenever possible, even if wound failure appears to be superficial. (See 'Wound assessment' above and 'Surgical management' above.)

Surgical management – Surgical debridement and wound closure/coverage is the mainstay of therapy for postoperative sternal wound complications.

Following debridement, the sternum can be closed immediately, or following an interval of open wound management. The choice of immediate versus delayed closure depends on both patient and wound-related factors. The sternum can be rewired or plated if adequate-quality bone is present and infection is absent. (See 'Reclosure versus delayed closure' above.)

For patients who are not candidates for immediate sternal closure, traditional moist gauze dressings or negative pressure wound therapy (NPWT) systems can be used to manage the open sternal wound. Although NPWT is associated with decreased times to closure and may reduce overall patient mortality, a small number of deaths due to cardiac rupture have been reported as complications of this therapy. Clinicians should familiarize themselves with contraindications and proper use of NPWT systems prior to use in patients with sternal wounds. (See 'Management of the open sternum' above and "Negative pressure wound therapy".)

Flap closure using omental or myocutaneous (pectoralis major, rectus, latissimus dorsi) flaps can be performed immediately following sternal debridement or after an interval of open wound management. Flap closure is reserved for patients who have an inadequate amount of bone after debridement or if there is uncertainty whether the infectious process is controlled. The muscle flap chosen depends upon the location and extent of the chest wall defect. (See 'Sternal flap closure' above.)

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References

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