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Ann Thorac Surg 2004;77:1371-1375
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps

Kiick Sung, MDa, Tae-Gook Jun, MDa*, Pyo Won Park, MDa, Kay-Hyun Park, MDa, Young Tak Lee, MDa, Ji-Hyuk Yang, MDa

a Department of Thoracic and Cardiovascular Surgery, Samsung Seoul Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea

Accepted for publication June 6, 2003.

* Address reprint requests to Dr Jun, Department of Thoracic and Cardiovascular Surgery, Samsung Seoul Hospital, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-280, South Korea
e-mail: tgjun{at}smc.samsung.co.kr


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
BACKGROUND: Advanced pectoralis major muscle flaps can be used to treat deep sternal wound infections in children; however, the long-term outcomes have not been widely reported.

METHODS: We retrospectively reviewed 11 patients (median age, 3.8 months), who had developed deep sternal wound infections following median sternotomy, among 1380 consecutive pediatric cardiac procedures from January 1995 to July 2001.

RESULTS: Advanced pectoralis major muscle flaps were used in 10 patients bilaterally and in 1 patient unilaterally. All survived and were discharged without evidence of infection. During a mean ± standard deviation follow-up of 42.1 ± 20.9 months, there was no evidence of recurrent or chronic infection. All patients demonstrated normal development with no limitations to their upper trunk or limb movements. All of the 6 patients who had undergone a palliative operation initially had additional operations without difficulty through the existing sternotomy incision.

CONCLUSIONS: This technique proved to be easy and promoted wound healing that covered all of the sternal wound defects without tension and without requiring additional flaps. It produced minimal growth and developmental problems, and it might facilitate additional operations.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Deep sternal infection following a median sternotomy for cardiac surgery results in significant morbidity and mortality. Such complications in adults have been treated with a pectoralis major muscle flap [1–4], an omental flap [5, 6], a rectus abdominis muscle flap [3, 7], or by closed irrigation [8, 9] with good results. However, only a few reports are available concerning the treatment of deep sternal wound infection in infants and children [10–14].

We report on a series of 11 infants and children with deep sternal infection in whom there was no mortality and limited morbidity. Our current approach to the treatment of deep sternal infection consists of early debridement of all infected tissues and soft tissue reconstruction using advanced pectoralis major muscle flaps (APMF). Pectoralis muscle flaps have an excellent blood supply furnished by the thoracoacromial arteries and have sufficient muscle mass to fill the sternal defect even in neonates and children [1]. The pectoralis major flap with a turnover technique is particularly valuable for repairing the upper three fourths of the anterior sternum, but is limited for lower defects [13, 15, 16]. We developed an advanced flap technique using the pectoralis major muscle to fill the whole defect and report our experience, including immediate and midterm outcomes.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
We performed a retrospective review of 1380 consecutive pediatric cardiac procedures using median sternotomy from January 1995 to July 2001 at the Samsung Seoul Hospital. All patients were computer registered. Since the foundation of our hospital in 1995, early debridement and reconstruction with APMF has been our major treatment for deep sternal wound infections in pediatric patients, especially if the wound could not be closed directly. Deep sternal wound infections occurred in 14 of the patients (1.0%). Among them, 3 patients were treated by wound opening, early debridement, and delayed primary closure, after a median of 3 days, using open dressings. The other 11 patients were treated by wound opening, early debridement, and reconstruction with APMFs. Their preoperative characteristics are summarized in Table 1.


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  		Table 1. Preoperative Characteristics of Patients

 
Antibiotics were used as a part of the perioperative management (second-generation broad-spectrum cephalosporins 25 mg/kg four times per day for 2 to 3 days). The sternum had been opened and covered with silastic membrane for a few days to minimize cardiac compression after the initial operation in four patients. Previous median sternotomy had been performed in 2 patients, 4 and 6 months earlier. Repeated sternotomy had been performed in 1 patient during the same period of admission before developing a deep sternal wound infection. Pulmonary complications, including pneumonia, had been present in 4 patients and prolonged ventilator care ( > 5 days) was necessary in 7 patients. Palliative operations had been performed in 6 patients. Low cardiac output had been present in 1 patient.

Diagnosis
Patients were considered as having a deep sternal infection if pus or bacterial growth was identified in the mediastinal tissue obtained during surgical exploration. Wound discharge, fever, leukocytosis, and elevated C-reactive protein blood concentrations were initial symptoms. We did not include any patients with simple sternal dehiscence in this series. The median interval between the initial operation and diagnosis was 11 days (range 5 to 33 days). Cultures of pus or soft tissue from the mediastinum were positive in 9 of 11 patients. Staphylococcus aureus (including 4 patients with of methicillin-resistant S. aureus) was the most common pathogen and accounted for eight of the infections. One patient had gram-negative Enterobacter cloacae. No organisms were isolated in 2 patients.

Management and operative technique
If the wound infection was clinically suspicious, early wound exploration and drainage was done under local anesthesia and followed by packing with wet dressings for 2 to 3 days. Initially the patients were given vancomycin intravenously until wound tissue culture results, including sensitivity tests, were reported. Once the systemic signs of acute infection were under control (1 to 4 days after initial drainage) and if the deep sternal wound infections were suspicious, complete reopening of the sternotomy wound was performed with the patient under general anesthesia. All sternal wires were removed and the sternal edges were debrided until healthy solid bone with briskly bleeding margins was found. If the bone was obviously necrotic, soft and oozing pus, the entire sternum was resected. Subcutaneous tissue, mediastinal fluid, and sternal bones were sent for culture. The wound was irrigated with antibiotic solution (500 mg of vancomycin in 1 L of normal saline).

Advanced pectoralis major muscle flaps were raised from medial to lateral in the avascular plane above and beneath the pectoralis major muscles using minimal diathermy. Superiorly, the dissection was made to the level of the clavicles and laterally as far as the anterior axillary line. On the left side, the pectoralis muscle flap was made after splitting from the clavicular and external segments, dividing the sternocostal component of the insertion tendon from the humerus, and preserving the thoracoacromial pedicles of artery and nerve. On the right side, the flap was made after splitting the clavicular and external segments, but preserving the thoracoacromial pedicles. The flaps were easily advanced to the midline without tension. The left side pectoralis muscle flap was used to cover the lower mediastinum and the right flap was used to cover the upper part of the mediastinum (Fig 1).



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  		Fig 1. The bilateral pectoralis major muscle advancement flap technique. The dotted line is the muscle splitting incision (left). Through this technique, the whole mediastinum including the xiphoid process can be covered without tension and without requiring additional flaps (right).

 
Multiple nonabsorbable sutures with 4-0 polypropylene were used to fix the flaps on the edge of the defective chest wall and to approximate the pectoralis muscle flaps. After insertion of a closed suction drain (Barovac, Sewoon Medical Co, Hwaseong, Korea) above and under the muscle flaps, the skin was closed with interrupted nylon sutures. Postoperatively, we paralyzed and sedated the patients for about 48 hours to allow for stabilization of the sternal wound. We did not use any additional catheter irrigation. Culture results determined the choice of antibiotic therapy: vancomycin only in 8 patients; vancomycin plus gentamycin in 2; and piperacillin plus amikacin in 1. We used antibiotic therapy for 4 weeks if C-reactive protein concentrations and white blood cell normalized. In four patients with proven infections in blood cultures, we used antibiotics for 6 weeks.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Ten young patients with deep sternal wound infections were treated with bilateral APMFs, and 1 patient with a unilateral APMF. All of the sternal wounds healed successfully and all the patients survived and were discharged without any evidence of recurrence. The mean ± standard deviation (SD) operation time was 139 ± 42 minutes (range 80–215 minutes). A staged operation (initial debridement under general anesthesia and later staged reconstruction with APMF) was performed in 4 patients with a median interval of 5.5 days (range 3 to 24 days). Except for these patients, reconstruction with APMF was performed initially after a median of 2 days and by using open dressings. Overall, the median interval between recognition of mediastinitis and reconstruction using APMF was 3.5 days. Including three readmitted patients, the median length of hospitalization after the original operation was 41 days. The median length of hospitalization after reconstruction with APMF was 24 days (range 8 to 140 days). One patient (number 3 in Table 1) had to be admitted for 140 days because of combined bronchomalacia, and 1 patient (number 5) was discharged after 8 days, but continued receiving parenteral antibiotic treatment at an outpatient clinic.

The mean ± SD duration of follow-up was 41.7 ± 23.0 months (range 11 to 84 months) except for 1 foreign patient who could not be found for follow-up (number 5). During the follow-up, there were no signs of recurrent or chronic sternal infection. All patients were between the 25th and the 75th percentile for their weight and height nomograms and appropriately developed for their age. One patient who had undergone a reoperation had a mild protrusion of the lower sternum, which may have been related to repeated sternotomy (number 2). In 3 patients (numbers 1, 6, and 9), mild asymmetric chest wall deformity was developed. But, there were no limitations in upper trunk or limb movements in all patients (Fig 2). All 6 patients who had undergone a palliative operation had additional operations without difficulty (Table 2). Reentry through the previous incision and between the muscle flaps was not problematic. Preservation of the collateral blood vessels of the flaps was not necessary.



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  		Fig 2. Recent pictures of patient number 10, who had undergone soft tissue reconstruction using advanced pectoralis major muscle flaps because mediastinitis developed after a bidirectional cavopulmonary shunt at age 3.8 months. Fifteen months later, he underwent a modified Fontan operation through the previous sternotomy incision. He did not show any functional disability of his upper extremities or trunk.

 

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  		Table 2. Additional Staged Operations After Reconstruction With Advanced Pectoralis Major Muscle Flaps

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Deep sternal infection after cardiac surgery is a fatal complication associated with increased morbidity and mortality and has been reported to occur in 0.15% to 8% of patients, with a generally accepted rate of 1% to 2% [8, 17–19]. In adult patients, various techniques for deep sternal infection have evolved with good results and there has been extensive experience using vascularized muscle flaps [1–7] or omental flaps [5, 6]. The ability of muscle flaps and omental flaps to control and eliminate sepsis is well established [6, 20, 21]. However, there have been only a few reports about these techniques in infants and children, and the long-term results have not been evaluated adequately [10–14].

When compared with adults, the tissue planes are not as distinct in children, especially in infants. The muscles are very delicate, especially in critically ill neonates. Moreover, the vascular pedicle is obviously much smaller and less resilient to stretching. The patient's nutritional status should also be considered [11]. Furthermore, body size and ongoing development should be considered and debridement should be done conservatively with resection of only obviously infected nonviable tissue, to minimize future growth disturbances [10]. However, the sternum and ribs are small, highly cartilaginous, and offer a poor defense against contamination. In patients who have undergone palliative surgery, tissue hypoxia and resultant polycythemia may impair wound healing and graft viability. Also, reentry should be considered for staged or corrective operations. All of these points should be considered in infants or children with deep sternal wound infections when aiming to repair the defect with muscle flaps or omentum.

Initial management of deep sternal wound infection focuses on the control of sepsis. Therefore, early recognition of sternal infection and early and aggressive debridement of all infected and foreign material is essential, as well as systemic antibiotic treatment. If initial debridement is performed adequately, reconstruction should be followed contemporarily or a couple of days later. Prolonged open dressing waiting for granulation is not necessary, as it is time consuming and has not demonstrated good results [9, 12, 22]. This approach has also led to psychologic and physical trauma [12].

The principles of reconstruction consist of using a well-vascularized coverage for optimal wound healing, ensuring anterior mediastinal protection, and maintaining chest wall stability [4, 10]. Muscle flaps, such as the pectoralis major and rectus abdominis, or omental flaps have been used. The use of the rectus abdominis muscle and the omentum requires additional abdominal incisions, which increase postoperative pain and may compromise respiratory functions. Moreover, this extra intervention may cause cross contamination, and the harvesting of the rectus abdominis muscle creates a risk of herniation or a diffuse bulging through the defect [3]. Laparotomy to harvest the omentum may cause fibrous adhesions and possibly small bowel obstructions [5]. The use of a pectoralis major muscle flap can avoid these complications. It is readily accessible and has viable tissue with an excellent blood supply from the thoracoacromial artery, segmental pedicles from the internal thoracic artery and some branches of the lateral thoracic and intercostals arteries. Because of its rich blood supply, various techniques for using pectoralis major muscle flaps have been developed [2, 4, 23].

We used the APMF technique. This maneuver provides an additional layer of tissue between the skin and sternum. Muscles provide material to close the defect and obliterate the potential dead space. There are theoretical and practical advantages in mobilizing the medial edge of the pectoralis major bilaterally and advancing it to the midline space with well-vascularized tissue. First, the technique is easy and not cumbersome. Second, distortion of the chest wall contour and symmetry following the use of APMF is minimal, whereas a pectoralis major turnover flap produces a concavity at the donor defect, and a relative prominence at the pedicle site. Third, to divide the sternocostal component of the insertion tendon from the humerus of the nondominant arm, the whole sternotomy wound, including the xiphoid process, can be covered without tension and without requiring additional flaps.

Nevertheless, pectoralis major muscle flaps have potential weaknesses for infants and children. First, musculoskeletal and functional disability may be caused. In adults, it is well established that the placement of one or both pectoralis major muscles produces minimal functional disability. Although we had a relatively short follow-up, we could not find any evidence of upper limb or upper trunk motor deficits, except for a minor protrusion of the lower sternum in one reoperated patient and mild aymmetric anterior chest wall deformity in 3 patients. Erez and associates [10] reported similar results. Second, breast hypoplasia, including sensory loss, may occur in late adolescence, especially in females, and should be followed up for longer.

We emphasize that during the follow-up period all of the 6 patients who had undergone palliative surgery underwent second or even third operations through the initial median sternotomy incision. Such reentry was not at all problematic in our patients.

In conclusion, early recognition, adequate debridement, adequate antibiotics, and viable tissue coverage are essential for the management of deep sternal infections. Chest wall reconstruction using APMFs offers a highly effective treatment. This technique is easy, promotes wound healing, facilitates additional operations, and produces minimal growth and developmental problems.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Gottlieb LJ, Beahm EK, Krizek TJ, et al. Approaches to sternal wound infections. In: Advances in cardiac surgery. St. Louis: Mosby Year Book, 1996:147–58
  2. Arnold P.G., Pairolero P.C. Use of pectoralis major muscle flaps to repair defects of anterior chest wall. Plast Reconstr Surg 1979;63:205-213.[Medline]
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  6. Milano C.A., Georgiade G., Muhlbaier L.H., Smith P.K., Wolfe W.G. Comparison of omental and pectoralis flaps for poststernotomy mediastinitis. Ann Thorac Surg 1999;67:377-381.[Abstract/Free Full Text]
  7. Majure J.A., Albin R.E., O'Donnell R.S., et al. Reconstruction of the infected median sternotomy wound. Ann Thorac Surg 1986;42:9-12.[Abstract]
  8. Culliford A.T., Cunningham J.N., Zeff R.H., et al. Sternal and costochondral infections following open-heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:714-726.[Abstract]
  9. Grossi E.A., Culliford A.T., Kreiger K.H., Kloth D., Baumann F.G., Spencer F.C. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-223.[Abstract]
  10. Erez E., Katz M., Sharoni E., et al. Pectoralis major muscle flap for deep sternal infection in neonates. Ann Thorac Surg 2000;69:572-577.[Abstract/Free Full Text]
  11. Baker C.L., Pensler J.M., Tobin G.R., Mavroudis C. Vascularized muscle flaps for life-threatening mediastinal wounds in children. Ann Thorac Surg 1994;57:797-802.[Abstract]
  12. Stiegel R.M., Beasley M.E., Sink J.D., et al. Management of postoperative mediastinitis in infants and children by muscle flap rotation. Ann Thorac Surg 1988;46:45-46.[Abstract]
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