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Ann Thorac Surg 2000;70:1761-1762
© 2000 The Society of Thoracic Surgeons

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Correspondence

Prevention of recurrent osteomyelitis using cyanoacrylate gluing in mediastinitis

^a Maltepe University Medical Faculty, Department of Cardiovascular Surgery, Maltepe Istanbul, Turkey

To the Editor

Mediastinitis accompanied by sternal dehiscence after open heart operation still has a high morbidity and mortality. In our experience, mediastinitis and sternal dehiscence were usually seen with multiple sternal fractures, mostly on the same side as the harvested internal thoracic artery. Refixation can be difficult and sometimes leads to recurrent dehiscence and chronic osteomyelitis localized around the wires. We suggest that excessive wire usage may also have a role in the recurrence of sternal infection. Although we agree with Opie [1] that increasing the number of wires could decrease the incidence of sternal nonunion, the close relation of the fistulas with the wires in sternal infections urged us to minimize the number of wires used. Sternal osteomyelitis necessitates long-term antibiotic treatment, hospitalization, and reoperations, which all considerably increase the cost.

We performed wide debridement of necrotic tissues including sternal edges and sternal refixation as routine treatment modality in 17 patients with mediastinitis between 1996 and 1998. There was no mortality using this protocol in patients who did not have sepsis. However, chronic suppurative fistula due to osteomyelitis developed in 6 patients (40%), 4 of which were treated with simple wire extirpation and simple local debridement; the other 2 patients needed wide sternal resection and bilateral pectoral muscle flaps due to resistant osteomyelitis. Hospital stay after the first revision was 24 ± 5 days (range, 17 to 33 days). However, treatment periods lasted up to 99.8 ± 26.7 days due to rehospitalizations of 6 patients with osteomyelitis fistulas for multiple revision procedures.

Application of cyanoacrylate glue in sternal infections and dehiscence is a new procedure [2]. The cyanoacrylate derivatives were found to have antibacterial effect on most microorganisms [3]. Referring to an interesting correspondence published in July 1998 [2], we added cyanoacrylate adhesive to our standard treatment protocol in 6 patients with mediastinitis to decrease the number of wires used and the incidence of recurrent osteomyelitis. Cyanoacrylate glue (cyanoacrylacidethylester; Lely Turbo Ltd, Istanbul, Turkey) was applied to the fractures and along the two sides of the sternum, and fixation with three or four steel 7F wires; one or two wires in the body were used. Skin and subcutaneous tissue were closed en-block with heavy polypropylene sutures. A sternal harness was routinely used for 1 month postoperatively. Hospital stay after revision is 10 to 24 days (mean, 15.3 ± 5.3 days). We have not encountered wound healing problems or sternal dehiscence during the follow-up period of 4 to 16 months (mean, 9.3 ± 5.1 months). The effect of cyanoacrylate on Staphylococcus aureus and Klebsiella growth was investigated in the blood agar cultures by adding 3 drops of cyanoacrylate to the culture media. Cultures were checked after 48 hours and the eighth day. The effect of cyanoacrylate due to vaporization [4] on cultures was seen as a circular zone without growth lasting even to the eighth day; therefore, it has bacteriosytic properties.

Although the number of patients is small, the absence of osteomyelitis and sternal dehiscence with this technique encouraged us to use cyanoacrylate glue in these patients. We also routinely used cyanoacrylate glue as an adjunct to sternal wiring in patients with mediastinitis and in osteoporotic, obese patients and those having chronic obstructive pulmonary disease, with no adverse effects.

References

1. Opie J.C. Avoidance of sternal nonunion. Ann Thorac Surg 1997;64:888-889.[Free Full Text]
2. Demirtas M., Akcar M., Sarýkaya S. Avoidance of sternal nonunion with cyanoacrylate gluing. Ann Thorac Surg 1998;66:304-306.[Free Full Text]
3. Robicsek F., Rielly J.P., Marroum M.C. The use of cyanoacrylate adhesive (crazy glue) in cardiac surgery. J Card Surg 1994;9:353-360.[Medline]
4. Blum G.N., Nolte N.A., Robertson P. In vitro determination of antimicrobial properties of two cyanoacrylate preparations. J Dent Res 1975;54:500-503.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sertaç Cicek Omer Isik Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ogus, N. T. Articles by Isik, O. Search for Related Content PubMed Articles by Ogus, N. T. Articles by Isik, O.