gms | German Medical Science

GMS German Plastic, Reconstructive and Aesthetic Surgery – Burn and Hand Surgery

Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC)
Deutsche Gesellschaft für Verbrennungsmedizin (DGV)

ISSN 2193-7052

Results and complications of plastic reconstruction in postoperative wound healing disorders in the sternum region

Ergebnisse und Komplikationen der plastisch-chirurgischen Deckung bei postoperativen Wundheilungsstörungen im Sternumbereich

Review Article

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  • corresponding author Ina Carolin Ennker - Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
  • author Francis Robicsek - Department of Thoracic and Cardiovascular Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
  • author Peter M. Vogt - Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany

GMS Ger Plast Reconstr Aesthet Surg 2012;2:Doc08

DOI: 10.3205/gpras000010, URN: urn:nbn:de:0183-gpras0000105

Veröffentlicht: 5. November 2012

© 2012 Ennker et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.de). Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.


Abstract

With an incidence rate of 1–4%, mediastinitis following cardiac surgery is a rarely occurring complication, but may show a mortality rate of up to 50%.

Since there are currently no standardized treatment recommendations, the available procedures are managed differently.

The aim of this paper is to show an overview of this clinical picture, present the risk factors and elucidate the therapy options chronologically.

As a result of interdisciplinary cooperation, a therapy concept has developed, which is adapted to the patient individually. Therapy is begun with the simplest measures and, if deemed necessary, this is then escalated step by step.

A combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage has proved itself and can be carried out with a high standard of safety.

Keywords: sternotomy, sternal infection, therapeutic options, interdisciplinary cooperation

Zusammenfassung

Die Mediastinitis nach herzchirurgischen Eingriffen ist, mit einer Inzidenz von 1–4% eine selten auftretende Komplikation, die jedoch eine Letalität von bis zu 50% aufweisen kann.

Da es derzeit keine standardisierten Behandlungsempfehlungen gibt, werden die Verfahren unterschiedlich gehandhabt.

Ziel der Arbeit ist es einen Überblick über dieses Krankheitsbild aufzuzeigen, die Risikofaktoren darzustellen und die Therapieoptionen chronologisch zu erläutern.

Durch interdisziplinäres Zusammenwirken ist ein Therapiekonzept entstanden, welches sich individuell dem Patienten anpasst. Mit der einfachsten Therapiemaßnahme wird begonnen und diese dann Schritt für Schritt bei Bedarf eskaliert.

Ein kombiniertes Vorgehen aus chirurgischen Debridement, kurzfristiger Vakuumtherapie und anschließender myoplastischer Deckung hat sich bewährt und ist mit hohem Sicherheitsstandard durchführbar.


Historical overview

In the early years of cardiac surgery, the heart and the vessels in close proximity to the heart were exposed by antero- or posterolateral thoracotomy. In more complex interventions, these routes of access were then extended transsternally onto the opposite side resulting in bilateral thoracotomy. This very lengthy operation, full of complications and painful for the patient, was abandoned in the 1950s in favor of median sternotomies. Median sternotomy was first described by Milton in 1897 and performed for decompression of the anterior mediastinum [15]. In 1953, Shoemaker was then the first surgeon to employ median sternotomy for an elective heart operation. Today sternotomies have become an integral part of cardiac surgery and is performed in Germany approximately 100,000 times per year.

Despite the years of experience and incontestable advantages this route of access offers, serious complications may occur, which represent the cause of considerable postoperative morbidity and mortality for the patients.

In consequence, further operations with prolonged hospitalization and increased costs for the healthcare system become unavoidable [8], [19], [27]. The complications are principally divided into those resulting from infections and those from other causes and then in each case into stable and unstable conditions. The severest complication for the patient is mediastinitis associated with sternal instability. An initially uncomplicated instability may cause an infection with a subsequent mediastinitis. Mediastinitis with initially stabile sternal conditions, however, sooner or later inevitably leads to instability [24].


Classification, incidence and diagnosis

Classification of mediastinitis is made either according to El Oakley or according to the CDC definitions [5], [13]. The incidence rate of mediastinitis following sternotomy is relatively small and estimated in the literature to be 1–4%; however, with a high mortality rate of over 50% [5], [8], on average 10–25% [26]. Risk factors to be considered are obesity, immunosuppression, COPD, insulin-dependent diabetes, irradiation of the surgical area, sternal osteoporosis, use of the internal thoracic arteries as connecting arteries, body height, renal failure, emergency interventions and inadequate surgical technique [6], [12], [18], [24], [29].

The diagnosis of mediastinitis is usually made clinically. As a general rule, the patients show the typical signs of an infection such as fever, leukocytosis and CRP elevation, swelling and pain in the operative area occur commonly in addition. Many patients show active secretion from the sternal wound, some already arrive for admission with a sternum apertum and ripped out cerclages (Figure 1 [Fig. 1]). In occasional unclear cases, an MRT or CT examination may be necessary [24].


Preparation

Provided there is still sufficient time available, before reconstructive surgery pretreatment with intensive respiratory therapy should be performed to prevent postoperative ventilation disorders. In reconstruction measures involving muscles, attention must be paid as to which auxiliary respiratory muscles may need to be sacrificed. The least restriction to pulmonary function is shown after using the pectoral muscles. Also when using the latissimus dorsi no major functional failures are to be expected, as opposed with the rectus abdominis [2], [11], [21], [23]. To avoid pulmonary function disorders, however, paradoxical mobility of the thorax should be avoided.

Postoperative ventilation disorders occur notably in patients who have already suffered preoperatively from a COPD [23].


Execution

In principal, surgical reconstruction may be performed using autologous tissue such as free and pedicled muscle flaps, free or vascularized rib grafts or by using synthetic material such as Teflon, acrylic and prolene meshes, Gore-Tex transplants or composite meshes in the form of Marlex nets. The greatest number of chest wall defects in sternotomy can, however, be treated with local musculocutaneous tissue, especially by using the major pectoral muscle.


Objectives of reconstruction

The objective of surgical therapy includes radical resolution of the local infection situation. This comprises radical excision of all non-vital, infected and necrotic tissue components. Foreign materials such as wire cerclages or pacer cables, for example, have to be removed. A persistent infection maintains necrosis, which then in turn leads to tissue death. Subsequent reconstruction measures are then doomed to failure, it thus being imperative to search for residues in the canals next to the wire. This is often the origin of recurrent suppurations. Moreover, the coverage of vital structures is required as well as reestablishing functionality and, if deemed necessary, the filling of body cavities, naturally taking the esthetic aspects into consideration. After partial chest wall resection it is often unnecessary to reestablish a rigid reconstruction of the chest wall. Local reconstruction using local muscles or using autologous material with the remaining skeleton fractions usually ensures adequate stability. It is therefore important to preserve still useful bony material and leave non-infected parts of the sternum as they are. As a general rule, only the chondral sternocostal parts are affected. However, paradoxal mobility of the thorax should if possible be avoided to avoid possible postoperative pulmonary function disorders [10], [11].

There is currently no general consensus concerning the appropriate surgical therapy of mediastinitis following open heart operations. A greater spectrum of wound healing strategies have been established and to some extent been used concomitantly [26]. The aim of surgical management of mediastinitis is to control the infection and to achieve prompt sternal stability with adequate soft tissue coverage [11].


Chronological development of the therapies

In the earlier era of cardiac surgery, open wound treatment was conducted. Due to the high complication rate, this is no longer performed [24].

Suction and irrigation drainage following this from 1969 on [8], [20] did not always lead to the desired success and exhibits a relatively high complication rate [7], [17], [24]. A publication by Schimmer et al. in 2008 shows that this method was at the time still being used in 28% of heart centers [26].

For full-layer tissue defects, flap-plasties are required. These were introduced by Jurkiewicz et al. and are an integral part of adequate care of these patients. Transposition of the greater omentum, which was performed more frequently earlier, is excellently suited for the treatment of this severe condition and is once again being performed increasingly. The patient’s own local tissues are optimally suited to cover the surfaces with well-vascularized tissue and, if deemed necessary, to fill out irrigation canals and cover exposed parts of the sternum [7], [11], [16], [24].


Paradigm shift

In the therapy of mediastinitis and sternum osteomyelitis, there has been a shift away from open as well as suction and irrigation procedures to combination procedures. Proving helpful here is the vacuum therapy used for about the last ten years in the treatment of sternum osteomyelitis. This measure was introduced by Argenta and Morykwas in 1997 in the field of extremity surgery [1], [4], [20]. The vacuum system comprises an open-cell polyurethane sponge, which is applied airtight with foil to the wound which closes it. The sponge includes a drainage discharge tube and a fluid reservoir with a vacuum pump. The system is based on the application of a uniform local vacuum up to 120 mm Hg in the wound area. The idea behind this is that chronic and sometimes acute or subacute wounds as well are characterized by a peripheral edema, thereby compromising microcirculation and lymph drainage. As a result of the vacuum now acting uniformly on the wound, increased removal of fluids and reduction of pressure in the local tissue occurs. Among other things, this leads to capillary vasodilatation with more favorable blood flow characteristics and therefore to improved arterial blood circulation and hence more favorable proliferation of the granulation tissue and to neoangiogenesis. The secretion and debris are continuously removed and the bacterial count reduced [1]. The overall complexity of the underlying healing mechanisms is, however, still unknown [4], [28]. VAC therapy should be used as briefly as possible as an interim measure until the final soft tissue reconstruction is carried out [14].

During vacuum therapy, in the case of recent cardiac surgery and hence inadequate formation of a connective tissue plate between the heart and the sternum, partial restabilization of the sternum is performed with cerclages or PDS-cords to prevent injury to the heart, especially to the right ventricle by sharp sternum edges or other osseous fragments. There have been repeated reports on ventricular ruptures during vacuum therapy, which may be evoked by a progressive infection, the loss of the vacuum by detachment of the foil, and by increased intrathoracic pressure (coughing).

Injury to the heart can, however, result from adhesions between the sternum and the heart [9], [24], [25] (Figure 2 [Fig. 2]).

It is sometimes not possible to achieve absolute sterility, and the question arises as to how many debridements are purposeful with a change of the VAC system. As a general rule, three to five VAC changes are sufficient. The following flap-plasty should be performed as soon as possible.


Surgical techniques with flap-plasties

In the following, the surgical procedures used most often are described in more detail.

1. Pectoralis major flaps

These flaps are best suited for closing ventral wall defects of the chest wall. Vascularization is achieved via the thoraco-acromial artery and vein; additionally, by thoracodorsal artery perforators and the internal thoracic artery (Figure 3 [Fig. 3]). There are different techniques for flap lifting available.

  • Uni- or bilateral flap lifting with or without disinsertion of the insertion on the humerus (with and without subcutaneous mobilization). Disinsertion should preferably not be implemented on the dominant arm and can be facilitated by a second incision over the deltoid-pectoral sulcus.
  • Flap lifting with complete excision of the insertion and origin as well as subcutaneous elevation and retention on the thoraco-acromial vessel pedicle alone. Although the clavicle part of the pectoralis major remains on the clavicle, this is in situ. The flap is then very mobile and can be displaced into the defect.
  • Turnover flap: In this case, the muscle at the humeral insertion as well as the vessel pedicle are excised completely, blood circulation then being provided exclusively via perforators of the internal thoracic artery. The lifted flap can then be displaced from laterally to medially directly into the defect. The disadvantage is the bulge emerging as a result, which may sometimes be considered disturbing from an esthetic point of view. When using the ipsilateral internal thoracic artery as a bypass graft, this measure should not be performed.

The caudal third of the sternum is sometimes difficult to cover by a pectoral muscle flap plasty alone as the lower section only has a rudimentary form in many patients and only exists as fascia. In such cases, the so-called bridging flap technique is recommended, i.e., the caudal pectoral muscle is lifted in continuity with the cranial section of the rectus abdominis and then displaced into the defect [2], [7], [11]. This area in particular, the distal third of the sternum, has been proven to be most vulnerable to developing instability. Soft tissue coverage in this area is marginal, whereas thorax mobility is much more pronounced.

The forces acting on the sternum are, on the one hand, the pectoralis major and the abdominal rectus muscle as well as the expansion during inspiration, whereas the sternum cerclages represent the cohesive forces [3].

2. Latissimus dorsi flap

This flap plasty represents a versatile and safe measure. The flap is supplied with blood from the thoracodorsal artery and further secondary lumbar and intercostal arteries. The latissimus dorsi is an extensive muscle and is well suited for extensive defects, above all, as pedicled flap plasty. It is thus well suited for the reconstruction of the ipsilateral chest wall. As a free microvascular flap, it can be used to cover almost the complete ventrolateral and dorsal chest wall. Unfavorable, however, is an intraoperative rearrangement as flap lifting must be performed in the lateral position [11], [24].

3. Greater omentum flap

The blood supply is via the left and right gastro-epiploic arteries and veins. Its course runs along the large curvature of the stomach. The special feature of the greater omentum is the immunological activity. It contains a great number of immunologically active cells (macrophages, monocytes, B- and T-lymphocytes as well as plasma cells) and shows anti-infective activity [3], [11], [17], [24]. The greater omentum can either be pedicled via the left or right gastro-epiploic artery and detached from the large curvature and from the transverse colon. As a general rule, the right gastro-epiploic artery, as this has a somewhat greater diameter, is left as it is and pedicled accordingly via the left one. The greater omentum extends over a large distance and it can be used effectively to fill distal and proximal thoracic defects, especially irrigation canals and dead spaces (Figure 4 [Fig. 4]).

However, there is the disadvantage for patients using this procedure of a two-cavity operation. Longer-term secretions sometimes occur and are associated with the possible necessity of revision surgery.

At the penetration site of the flap between the abdominal cavity and thorax, abdominal wall hernias may arise. If the wound cannot be closed primarily, skin transplants are necessary. Transpositioning the omentum can in extreme cases be performed concomitantly in combination with myoplastic coverage [3], [7], [11].

4. Rectus abdominis flap

The blood supply is via the superior and inferior epigastric vessels and intercostal vessels. This muscle might be favorable if the distal part of the sternum has to be reconstructed. It might be used as a cranial pedicled, vertical or transverse rectus abdominis musculocutaneous (VRAM, TRAM) flap, or as a muscle flap alone.

The pedicled M. rectus abdominis flap should only be used with an intact ipsilateral A. mammaria interna. Using the mammarian arteries impairs blood flow for the muscle resulting in an increased flap necrosis risk.

If the mammarian vessels were already used or damaged the reconstruction via the rectus abdominis muscle should be performed as a free flap plasty. This shpuld be a last resort. Herniation of abdominal organs is possible and the implantation of synthetic material might be necessary. This procedure should be avoided in a contaminated environment. Furthermore a bulging can occur by using the pedicled version, which might be troubling for the patient [11], [24].

5. Free flap-plasty

If the first choice muscles, as mentioned above were already used unsuccessfully, free tissue transfer might be indicated. First choice of recipient vessels are the internal mammarian-, the thoracodorsal- and the thoracoacrominal vessels. In case these vessels are damaged or have already been used as graft material in bypass surgery (mammarian vessels), an alternative approach is called for, in this case, AV-loops (cephalic vein/A. axillaris or A. thoracodorsalis) [11]. As described by Reichenberger, Germann at al., an arteriovenous loop between the cephalic vein and the thoracoacrominal artery can be used to create a new recipient vessel. In most cases a tensor fascia lata free (TFL) flap was employed successfully to treat deep sternal infection. The donor side morbidity using the TFL is low without further compromising the respiratory function of a critically ill patient. The workgroup reports reliable results with a 30-day mortality of 13.7% [22] (Figure 5 [Fig. 5]).

In addition to the increased logistic challenge for some hospitals, the following complications after muscle flap-plasties have to be taken into consideration.

1.
Necroses and wound healing disorders,
2.
formation of hematomas and seromas,
3.
discomfort at the operation site also long after surgery,
4.
abnormal sternum mobility under duress such as coughing or lateral position (sternal dehiscence/nonunion),
5.
reduction of strength in the shoulder girdle,
6.
tension and overstretching in the distal scar areas in patients with mammary hyperplasia [24],
7.
recurrent abscesses.

Avoidance strategies

The optimal surgical technique must be found for each patient on an individual basis. In high-risk patients, it must be weighed up whether using both internal thoracic arteries is absolutely essential as revascularization measure. Although this vessel transplant is still the gold standard, the reduced perfusion of the sternum resulting from dissection of the internal thoracic arteries may represent a blatant disadvantage to the healing process [24], [29].

The skeletonized vs. semi-skeletonized preparation technique is also important. The skeletonized method should be given preference. The use of bone wax also repeatedly gives cause for discussion and should only be used sparingly [24].

The surgical procedure applied when opening the thorax and closing it is definitely of elementary importance, making absolutely certain of proceeding in a tissue-conserving manner. Scrupulous care must be taken not to destroy the origin of the pectoralis major at the sternum, neither by intensified cautery nor by bold insertion of wires through soft tissues. It is better to then carefully transposition the muscle. Furthermore, when wiring the sternum attention should be paid not to generate the formation of steps and when tightening the cerclages to keep the two halves of the sternum under tension or by using an approximator.

With regard to the wiring technique, the following should be taken into consideration:

1 clerclage/10 kg BW is a reasonable proxy. Preference should be given to peristernal vs. transsternal application. The individual cerclages appear to be better than the ‘figure of 8’.

In very obese patients, it may be useful to use double wires or sternal bands.

If in a sternotomy the midline was missed or injury inflicted to the surrounding tissues by too vigorous application of the retractor, the heads of the ribs or transverse fractures, in this area according to Robicsek, reconstruction with parasternal weaving should be considered. Coverage of the sternum with soft tissues with an appropriate blood supply should also be given a high priority. Even if sternal osteosynthesis through wire cerclages is not in accordance with the AO criteria, it is nevertheless definitively the most commonly performed method to close the sternum following cardiac surgery. There are currently numerous methods using plate osteosyntheses, thermolabile clip procedures, screws and other orthopedic paraphernalia to optimize closure of the sternum. There are, however, no randomized controlled studies available and all offers currently on the market have up until now not provided proof that they are superior to the traditional sternal closure method using cerclages [24].

The methods also take considerably longer and the risk exists of injuring the structures in the sternal area.

Moreover, consideration must certainly be given to a cost factor, especially as all osteosynthetic procedures apart from cerclages have a considerably higher price.

“The objective is to stabilize the sternum, not the introduction of new methods.” (Francis Robicsek).

A prophylactic dosage of antibiotics is a matter of continued debate. In cardiac surgery it is considered to be mandatory. We recommend to administer prophylactic antibiotics, first generation cephalosporin. The first dose is given 1 hour before operation, the second on the ICU 8 hours postoperatively. The application of Mupirocin ointment is recommended in our center, the evening before and the morning before operation and the following morning.

Should antibiotic treatment be necessary the treatment should be individualized in accordance to the microbiological findings.


Conclusions

Despite all the available measures, for a patient mediastinitis remains a considerable complication following cardiac surgery with far-reaching consequences, in particular high mortality.

Complications must on average be expected in 10% of patients. An unsuccessful reconstruction measure also lies approximately in this range. In-hospital mortality after treating mediastinitis/sternal osteomyelitis has also been described with a figure of about 10% [2], [7].

All the aforementioned measures harbor morbidity and mortality risks. The necessity therefore continues to develop safe therapeutic procedures. Every procedure is adapted to the patient individually. It is our philosophy to begin with the simplest therapy measures and then to escalate these step by step.

Accordingly, preference should always be given to simple therapy options. Nevertheless, in the event of failure however, no time should not be wasted with frustrating “small” solutions, but an unequivocally safe solution also with larger reconstruction measures should be chosen.

A therapeutic scale thus includes:

1.
Conservative approach, secondary wound healing in the absence of an infected area,
2.
hydrotherapy, vacuum therapy,
3.
direct wound closure,
4.
local smaller displacement plastic surgery, split-skin plasty,
5.
local regional flap-plasties,
6.
free microvascular flap-plasties.

It is of importance to identify the patients suffering postoperatively from a complication in the form of sternal osteomyelitis and mediastinitis. Preoperatively, such patients show a similar risk. Matched-pair analyses also show that with the same risk adjustment only a small proportion (1–4%) of these patients suffer from these postoperative complications [6].

On 15th of June 2011 a mediastinitis register was founded by the DGTHG. Participation however is optional. Its aim is to track the developing of mediastinitis/osteomyelitis occurrences in Germany. With this institution clinicians have the opportunity to receive statistical analyses of risk factors, treatments and outcomes of an increased number of patients. It is the register’s intent to develop and provide differentiated and improved treatment options.

Additionally an 11-point pre-operative checklist was advanced by the DGTHG and the BQS containing recommendations on the prevention of postoperative wound healing disorders (http://www.dgthg.de/Dateien/checkliste.pdf).

The checklist serves as a benchmark for detecting high risk patients in turn allows the surgeon to proceed in a manner better suited for the patient.

Up until then we recommend a combined approach comprising surgical debridement, short-term vacuum therapy and subsequent myoplastic coverage.


Notes

Competing interests

The authors declare that they have no competing interests.


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