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Sternectomy and Sternum Reconstruction for Infection After Cardiac Surgery

2008; Elsevier BV; Volume: 86; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2008.04.084

1552-6259

T Iarussi, Alessandro Marolla, Alessandro Pardolesi, Rosa Lucia Patea, Pierpaolo Camplese, Rocco Sacco,

Pleural and Pulmonary Diseases

Sternum infection after cardiac surgery represents a severe complication with a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection. We report a case of sternum reconstruction using a titanium patch covered with bone-powder. Sternum infection after cardiac surgery represents a severe complication with a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection. We report a case of sternum reconstruction using a titanium patch covered with bone-powder. Sternum resection is still characterized by a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection with mortality rate respectively nearly 50% and less than 10% [1Jones G. Jurkiewicz M.J. Bostwick J. et al.Management of the infected median sternotomy wound with muscle flaps The emory 20-year experience.Ann Surg. 1997; 225: 766-776Crossref PubMed Scopus (257) Google Scholar]. According to the literature the main preoperative factors implicated in the pathogenesis of the sternum infection are obesity, significant smoking history, diabetes, vasculopathy, and a high New York Heart Association functional class, whereas the intraoperative factors are represented by the use of both internal mammary arteries for myocardial revascularization, intra-aortic balloon pumps, and acute myocardial infarctions. Prolonged mechanical ventilation in the postoperative period seems to be an important risk factor [1Jones G. Jurkiewicz M.J. Bostwick J. et al.Management of the infected median sternotomy wound with muscle flaps The emory 20-year experience.Ann Surg. 1997; 225: 766-776Crossref PubMed Scopus (257) Google Scholar, 2Ridderstolpe L. Gill H. Granfeldt H. Ahlfeldt H. Rutberg H. Superficial and deep sternal wound complications: incidence, risk factor and mortality.Eur J Cardiothorac Surg. 2001; 20: 1168-1175Crossref PubMed Scopus (349) Google Scholar, 3Lu J.C. Grayson A.D. Jha P. Srinivasan A.K. Fabri B.M. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery.Eur J Cardiothorac Surg. 2003; 23: 943-949Crossref PubMed Scopus (213) Google Scholar].A 63-year-old man with diabetes, hypertension, chronic atrial fibrillation, and chronic peripheral arteriopathy underwent mitral ring annuloplasty and myocardial revascularization with a right internal mammary artery complicated with a moderate to severe pericardial effusion with cardiac tamponade surgically drained through sternotomy. Sternum inflammation and surgical wound effusion with no temperature increase but pain exacerbated in the supine position was complicated during the postoperative period after approximately 1 month. After a positive cultural examination was found in the wound for Corynebacterium species, a wound revision was performed with an antibiotic treatment with vancomycin (500 mg every 6 hours for 14 days). After approximately 1 month the wound effusion appeared again, and without temperature this time. The patient underwent surgical removal of some sternal steel wires. Cultured wires were negative for infection. After another month, wound effusion appeared again. The wound was again cultured, and it resulted in a sterile finding; therefore, we decided to perform a sternectomy with sternum reconstruction. On admission, there was no temperature increase, but a mild leukocytosis (14,000 white blood cell count). The multi-slide computed tomographic scan of the thorax displayed sternum osteolysis (Fig 1). For these reasons the patient underwent en-bloc resection of the sternum with internal mammary artery preservation. After accurate anterior mediastinum toilette and bilateral mobilization of the pectoralis major muscle, four titanium plates (Titanium Sternal Fixation System; Synthes Inc, West Chester, PA) were fixed with four tapping screws (diameter, 2.4 mm) to the clavicle and to the second, fourth, and fifth rib on each side. A titanium patch was applied to the plates, which was then covered with bone powder to stimulate osteoblastic activity and promote living bone growth (Fig 2, Fig 3). Finally, each pectoralis major muscle was positioned over the titanium net.Fig 2Sternum with fistulas.View Large Image Figure ViewerDownload (PPT)Fig 3Sternum reconstruction with titanium plates and bone-powder.View Large Image Figure ViewerDownload (PPT)Culture examinations in the removed sternum were found negative of bacterial infection.Patient intensive care unit stay was less than 48 hours, and 10 days after surgery he was discharged. Follow-up at 40 days showed rib cage stability as documented by the multi-slide computed tomographic scan of the thorax (Fig 4). Six months after surgery, a bone scintigraphy showed the presence of osteoblastic activity where the plates were fixed, without living bone growth.Fig 4Postoperative computed tomographic scan.View Large Image Figure ViewerDownload (PPT)CommentUse of an en-bloc sternum surgical resection procedure is not infrequent [4Voss B. Bauernschmitt R. Brockmann G. Lange R. Osteosynthetic thoracic stabilization after complete resection of the sternum.Eur J Cardiothorac Surg. 2007; 32: 391-393Crossref PubMed Scopus (16) Google Scholar]. The use of titanium plates fixed with tapping screws offers an optimum and prompt stabilization of the thoracic wall. Prosthesis coverage with muscles outdistances the cutaneous surface preventing the risk of infection. Pectoralis major muscle mobilization represents a valid choice because of its feasibility and because it is an optimum coverage of the replacement device with slight tension. An increased osteoblastic activity without bone tissue regeneration seems to be induced by bone powder applied on the titanium net. Even if there were not any bone tissue regeneration, we assessed good rib cage stability, with complete pain resolution leading to a good quality of life. For these reasons, we prefer this technique for sternum reconstruction to the others based only on the use of muscle flap. Sternum resection is still characterized by a high mortality rate. Therapeutic possibilities consist in "open packing" with specific antibiotic irrigation or in "en-block" resection with mortality rate respectively nearly 50% and less than 10% [1Jones G. Jurkiewicz M.J. Bostwick J. et al.Management of the infected median sternotomy wound with muscle flaps The emory 20-year experience.Ann Surg. 1997; 225: 766-776Crossref PubMed Scopus (257) Google Scholar]. According to the literature the main preoperative factors implicated in the pathogenesis of the sternum infection are obesity, significant smoking history, diabetes, vasculopathy, and a high New York Heart Association functional class, whereas the intraoperative factors are represented by the use of both internal mammary arteries for myocardial revascularization, intra-aortic balloon pumps, and acute myocardial infarctions. Prolonged mechanical ventilation in the postoperative period seems to be an important risk factor [1Jones G. Jurkiewicz M.J. Bostwick J. et al.Management of the infected median sternotomy wound with muscle flaps The emory 20-year experience.Ann Surg. 1997; 225: 766-776Crossref PubMed Scopus (257) Google Scholar, 2Ridderstolpe L. Gill H. Granfeldt H. Ahlfeldt H. Rutberg H. Superficial and deep sternal wound complications: incidence, risk factor and mortality.Eur J Cardiothorac Surg. 2001; 20: 1168-1175Crossref PubMed Scopus (349) Google Scholar, 3Lu J.C. Grayson A.D. Jha P. Srinivasan A.K. Fabri B.M. Risk factors for sternal wound infection and mid-term survival following coronary artery bypass surgery.Eur J Cardiothorac Surg. 2003; 23: 943-949Crossref PubMed Scopus (213) Google Scholar]. A 63-year-old man with diabetes, hypertension, chronic atrial fibrillation, and chronic peripheral arteriopathy underwent mitral ring annuloplasty and myocardial revascularization with a right internal mammary artery complicated with a moderate to severe pericardial effusion with cardiac tamponade surgically drained through sternotomy. Sternum inflammation and surgical wound effusion with no temperature increase but pain exacerbated in the supine position was complicated during the postoperative period after approximately 1 month. After a positive cultural examination was found in the wound for Corynebacterium species, a wound revision was performed with an antibiotic treatment with vancomycin (500 mg every 6 hours for 14 days). After approximately 1 month the wound effusion appeared again, and without temperature this time. The patient underwent surgical removal of some sternal steel wires. Cultured wires were negative for infection. After another month, wound effusion appeared again. The wound was again cultured, and it resulted in a sterile finding; therefore, we decided to perform a sternectomy with sternum reconstruction. On admission, there was no temperature increase, but a mild leukocytosis (14,000 white blood cell count). The multi-slide computed tomographic scan of the thorax displayed sternum osteolysis (Fig 1). For these reasons the patient underwent en-bloc resection of the sternum with internal mammary artery preservation. After accurate anterior mediastinum toilette and bilateral mobilization of the pectoralis major muscle, four titanium plates (Titanium Sternal Fixation System; Synthes Inc, West Chester, PA) were fixed with four tapping screws (diameter, 2.4 mm) to the clavicle and to the second, fourth, and fifth rib on each side. A titanium patch was applied to the plates, which was then covered with bone powder to stimulate osteoblastic activity and promote living bone growth (Fig 2, Fig 3). Finally, each pectoralis major muscle was positioned over the titanium net. Culture examinations in the removed sternum were found negative of bacterial infection. Patient intensive care unit stay was less than 48 hours, and 10 days after surgery he was discharged. Follow-up at 40 days showed rib cage stability as documented by the multi-slide computed tomographic scan of the thorax (Fig 4). Six months after surgery, a bone scintigraphy showed the presence of osteoblastic activity where the plates were fixed, without living bone growth. CommentUse of an en-bloc sternum surgical resection procedure is not infrequent [4Voss B. Bauernschmitt R. Brockmann G. Lange R. Osteosynthetic thoracic stabilization after complete resection of the sternum.Eur J Cardiothorac Surg. 2007; 32: 391-393Crossref PubMed Scopus (16) Google Scholar]. The use of titanium plates fixed with tapping screws offers an optimum and prompt stabilization of the thoracic wall. Prosthesis coverage with muscles outdistances the cutaneous surface preventing the risk of infection. Pectoralis major muscle mobilization represents a valid choice because of its feasibility and because it is an optimum coverage of the replacement device with slight tension. An increased osteoblastic activity without bone tissue regeneration seems to be induced by bone powder applied on the titanium net. Even if there were not any bone tissue regeneration, we assessed good rib cage stability, with complete pain resolution leading to a good quality of life. For these reasons, we prefer this technique for sternum reconstruction to the others based only on the use of muscle flap. Use of an en-bloc sternum surgical resection procedure is not infrequent [4Voss B. Bauernschmitt R. Brockmann G. Lange R. Osteosynthetic thoracic stabilization after complete resection of the sternum.Eur J Cardiothorac Surg. 2007; 32: 391-393Crossref PubMed Scopus (16) Google Scholar]. The use of titanium plates fixed with tapping screws offers an optimum and prompt stabilization of the thoracic wall. Prosthesis coverage with muscles outdistances the cutaneous surface preventing the risk of infection. Pectoralis major muscle mobilization represents a valid choice because of its feasibility and because it is an optimum coverage of the replacement device with slight tension. An increased osteoblastic activity without bone tissue regeneration seems to be induced by bone powder applied on the titanium net. Even if there were not any bone tissue regeneration, we assessed good rib cage stability, with complete pain resolution leading to a good quality of life. For these reasons, we prefer this technique for sternum reconstruction to the others based only on the use of muscle flap.