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Ann Thorac Surg 2004;78:1659-1664
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Sternal Preservation: A Better Way to Treat Most Sternal Wound Complications After Cardiac Surgery

E. Charles Douville, MDa,*, James W. Asaph, MDb, Ronald J. Dworkin, MDc, John R. Handy, Jr, MDa, Clifford S. Canepa, MDd, Gary L. Grunkemeier, PhDe, YingXing Wu, MDe

a Division of Cardiothoracic Surgery, The Oregon Clinic PC, Portland, Oregon, USA
b Earle A. Chiles Research Institute, Portland, Oregon, USA
c Infectious Disease Department, Providence Portland Medical Center, Portland, Oregon, USA
d Surgery Department (Plastic), Providence Portland Medical Center, Portland, Oregon, USA
e Medical Data Research Center, Providence Health System, Portland, Oregon, USA

Accepted for publication April 27, 2004.

* Address reprint requests to Dr Douville, The Oregon Clinic PC, 507 NE 47th Ave, Portland, OR, USA 97213
ecdouville{at}orclinic.com


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Conclusion
 References
 
BACKGROUND: Postcardiotomy sternal wound complications remain challenging. The prevailing approach for deep sternal wound infection of débridement and flap coverage without osseous closure makes subsequent reoperation difficult.

METHODS: An analysis of all patients undergoing cardiac surgery at a single institution between 1986 and 2001 was conducted. Prospective data collection and chart review were used to compare different treatment strategies for sternal complications.

RESULTS: Of 5337 patients, 122 had sternal wound complications (2.2%) comprising 15 (0.3%) uninfected dehiscences (El Oakley class 1), 45 (0.8%) superficial infections (El Oakley class 2A), and 62 (1.1%) deep sternal wound infections (El Oakley class 2B). Thirty-two patients with deep sternal infection were treated by débridement, rewiring, and delayed primary closure. There were initial treatment failures in 6 patients (18.8%) and ultimate failures in 2 patients (6.3%), both of whom died. One of these patients had previously received external beam radiation after a radical mastectomy for breast cancer. Median length of stay was 32 days and median time to wound healing was 85 days. Twenty-five patients were managed by muscle flap coverage without sternal reclosure. There were 6 initial treatment failures (24%) but no ultimate failures or deaths (p = NS). Median length of stay was 31 days and median infection time was 161 days.

CONCLUSIONS: In patients with postcardiotomy deep sternal wound infection without previous chest radiation, débridement, rewiring, and delayed skin closure is effective. It offers a shorter healing time and probably makes late cardiac reoperation safer. We propose an algorithm for the management of poststernotomy complications.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Conclusion
 References
 
Sternal wound complications, including dehiscence and infection, occur in 1% to 3% of patients undergoing cardiac surgery [1–4]. They remain a significant source of mortality, and treatment entails extended hospitalization(s), long-term antibiotics, multiple operative procedures, and high cost. Before 1980 débridement and sternal rewiring was the preferred approach but was associated with high mortality and failure rates [5, 6]. Treatment strategy changed with the introduction of muscle flap coverage without sternal closure [7], and this became the approach of choice for deep sternal wound infections (DSWI). However, the absence of sternal integrity makes subsequent reoperation difficult, particularly for coronary artery bypass grafting (CABG). Our surgical approach varied according to surgeon preference, thus enabling us to evaluate treatment of DSWI with and without sternal preservation.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Conclusion
 References
 
Prospectively compiled data maintained in a computerized registry (Patient Analysis and Tracking System, Axis Software, Portland, OR) of all cardiac surgical procedures performed by a single surgery group operating in one tertiary care medical center from January 1986 through December 2001 were analyzed. Hospital and outpatient records of patients with sternal wound complications were reviewed. Sternal wound infections were characterized by the Centers for Disease Control and Prevention (CDC) definitions: superficial, deep, or organ/space surgical site infections [8] and codified according to classification of El Oakley and colleagues [9]. Patients were grouped, according to intention to treat at the time of the definitive diagnosis of a deep sternal wound complication, into sternal preservation (sternal reclosure) and open sternum with flap (débridement and mediastinal drainage without attempting to rewire the sternum and either immediate or staged muscle flap coverage).

All patients received standardized preoperative intravenous antibiotics (first generation cephalosporin or, in allergic patients, vancomycin) within 1 hour of operation and for the next 24 hours. Infectious disease specialists were consulted in every case of DSWI. Patients were cared for on the cardiothoracic surgery service until healed. All open wounds underwent wet to dry saline dressings until the skin was closed.

Data collected included patient demographics, preoperative risk factors, intraoperative details, all postoperative complications and mortality, treatment schemes for wound complications, and final outcomes. Death at any time during hospitalization was counted as hospital mortality. Microbiology data were available for each patient.

Sternal complications were categorized as follows:

  1. uninfected dehiscence (El Oakley class 1),
  2. superficial wound infections without sternal instability (El Oakley class 2A), or
  3. DSWI with or without dehiscence (El Oakley class 2B).
Follow-up data included date of last follow-up, current wound status, and cause of death, if any. Infection time was defined as the duration of time between diagnosis of the infection and documentation of a completely healed wound in the outpatient clinic.

Statistical calculations were performed with SPSS 9.0 (SPSS, Inc., Chicago, IL) and PATS (Axis Software, Portland, OR), and p values of less than 0.05 were defined as significant. Postoperative length of stay and infection time were compared by the Mann-Whitney U test.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Conclusion
 References
 
Over 15 years, 5337 patients underwent 5459 cardiac procedures; 9.8% of those underwent valve replacement or repair. There were 287 hospital deaths (5.3%), and 5050 patients were discharged alive without sternal complications. Sternal complications developed in 122 patients (2.2%) comprising 15 (0.2%) uninfected dehiscences (El Oakley class 1), 45 (0.8%) superficial wound infections (El Oakley class 2A), and 62 (1.1%) DSWI (El Oakley class 2B).

Risk factors for sternal complications (Table 1) are similar to those reported by others [3, 4]. Preoperative characteristics predictive of sternal complication risk include current smoking, chronic obstructive pulmonary disease (COPD), diabetes, corticosteroid use, and history of thoracic malignancy. Significant operative risk factors include preoperative or postoperative intraaortic balloon pump (IABP) use, and internal thoracic artery use. The sole postoperative risk factor was the presence of pulmonary complications.


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  		Table 1. Sternal Wound Complications: Patient Risk Factors

 
Uninfected Dehiscence (El Oakley Class 1)
Twenty-seven (0.2%) patients presented with an apparent uninfected dehiscence. Each was reexplored and cultured. Twelve subsequently proved to be infected and were treated accordingly. Patients with uninfected dehiscence tended to be current smokers (87% vs 58%, p = 0.060) and had COPD (33% vs 13%, p = 0.070).

Of 15 uninfected dehiscences, 5 had positive cultures that were deemed skin contaminants and were not treated. One was treated by drainage without sternal rewiring, primary muscle flap closure, and required no further surgery. All others were treated by sternal débridement, mediastinal drainage, sternal rewiring, and primary subcutaneous tissue/skin closure. One patient dehisced three times. A broken sternal wire ultimately lacerated his aorta, which led to his death; no organism was ever grown in culture.

Superficial Sternal Wound Infection (El Oakley Class 2A)
Fifty-two patients were initially diagnosed with superficial wound infections. Seven (13.4%) subsequently proved to be DSWI. Of the remainder, in 37 patients the wound was opened, skin and subcutaneous tissue were débrided, and antibiotics were administered. Eight patients were treated with antibiotics alone. Six patients required subsequent surgery that consisted of the removal of protruding sternal wires in 5 and multiple superficial débridements in 1. The mean interval between their cardiac operation and presentation with infection was 13 days, with an average infection time of 98 days.

Deep Sternal Infection (El Oakley Class 2B)
There were 62 (1.1%) DSWIs, including 28 (0.5%) infected dehiscences and 34 (0.6%) pure deep infections (Table 2). Management for these more serious infections evolved over the study period. All patients with major sternal complications were treated in a multidisciplinary approach that included cardiothoracic surgeons, plastic surgeons, and infectious disease specialists. All received 4 to 6 weeks of intravenous antibiotic therapy based on bacteriology results. Before 1992 the preferred surgical treatment was sternal preservation. Continuous mediastinal irrigation and omental flaps were not used. Muscle flaps and other reconstructive procedures were used when it was apparent sternal preservation had failed. After 1992 open sternum with flap was favored.


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  		Table 2. Comparison of "Sternal Preservation" to "Open Sternum" in Deep Sternal Wound Infections

 
The spectrum of organisms encountered was similar to other reports. Staphylococcus aureus and coagulase-negative staphylococcus predominated (Fig 1). There was no significant difference in outcome based on organism, though multiresistant organisms such as methicillin-resistant S. aureus and Pseudomonas aeruginosa were infrequent.



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  		Fig 1. Organisms associated with sternal wound infections (El Oakley class 2B). (CNS = coagulase-negative Staphylococcus aureus; E coli = Escherichia coli; Eb = Enterobacter; MRSA = methicillin-resistant Staphylococcus aureus; Staph aureus = methicillin-sensitive Staphylococcus aureus.)

 
Of 62 patients with DSWIs, 32 (51.6%) underwent an initial definitive treatment by sternal preservation, and 25 (40.3%) were treated by open sternum with flap. Five other patients with DSWI were not included in the analysis because they were not surgical candidates.

Sternal preservation failed in 6 patients (18.8%) (Table 2). Four failures were initially misdiagnosed as uninfected dehiscences in 3 patients (9.4%) and as superficial infection in 1 (3.1%). Three initial treatment failures were converted to open sternum procedures: staged muscle flaps in 2 and a planned muscle flap closure in 1; however, that patient died of uncontrolled sepsis before definitive reconstruction. The remaining 3 patients with initial failure had additional sternal preservation operations. An average of 2.0 operations were required to definitively treat these infections. The median length of stay was 32 days, with a median infection time of 85 days.

The open sternum with flap had 6 (24.0%) initial failures, but no ultimate failures or mortality. The median hospital stay was 31 days with a median infection time of 161 days.

The hospital length of stay for the two treatments of DSWI was the same. However, the group with open sternum and muscle flap underwent more operations (3.1 vs 2.0, p = 0.004). They also had a longer median infection time (161 vs 85 days, p = 0.04). Overall, the mortality directly attributable to major sternal wound complications in our series was 3 patients (3.9%), although 5 (6.5%) additional patients died of causes not directly related to their sternal wound complications (Table 2).


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Conclusion
 References
 
Our management of DSWI historically included sternal preservation (débridement, drainage, and sternal wire reclosure, leaving the skin and subcutaneous tissue to heal by secondary intention) and open sternum with flap (débridement, drainage without sternal reclosure, followed by immediate or staged muscle flaps). We demonstrated similar lengths of stay for these strategies, but the open sternum with flap procedure required more operations and the mean infection time was significantly longer. Two patients (3.5%) with DSWI died; both were in the sternal preservation group (Table 2). One had a history of breast cancer treated with radical mastectomy and high-dose radiation therapy.

Efforts to improve the historically high mortality associated with DSWI [6, 7] led to the use of catheter irrigation of the mediastinum [10, 11]. The introduction of muscle flap coverage of the mediastinum without sternal rewiring [7] improved mortality and led to the rapid adoption of this technique. Because of our positive experience with sternal preservation as a treatment of DSWI, we did not use catheter irrigation and were slow to adopt the open sternum and muscle flap approach until the past 10 years.

A major disadvantage with the open sternum with flap approach is the loss of sternal integrity. Reoperation is difficult, particularly for CABG patients. Although better lipid management [12], multiple arterial grafts [13], and the introduction of drug-eluting stents [14] may reduce the need for reoperative cardiac surgery, it will never disappear completely. Any thoracic surgeon who has faced reoperative CABG surgery in a patient who has previously had muscle flap coverage without sternal closure can attest to the difficulty this situation poses. In all cases, preservation of the sternum is a service to the patient, particularly if reoperation in the future is a possibility.

Our review identifies current smoking, treatment for COPD, steroid therapy, obesity, diabetes, and a history of chest malignancy as placing patients at a higher risk for postoperative sternal wound infection. Intraoperatively, only IABP use and bilateral internal mammary grafting were significant. These data are strikingly similar to those reported by Borger and colleagues [15], except that they found that male sex was a highly significant risk factor for DSWI.

The Parisian Mediastinitis study group found, as did we, significantly higher infection rates with bilateral internal mammary grafting and obesity [16]. Another recent review emphasized appropriate timing of antimicrobial prophylaxis, control of preoperative blood glucose levels, and the avoidance of staple use in patients with normal body mass index [17]. We did not adopt routine perioperative intravenous insulin management for diabetics until the report of its importance in 1998 [18], similar to most programs. We have had no experience with the vacuum-assisted closure systems for DSWI recently reported [19].

One risk factor appears to present a particularly difficult problem. Two patients with deep wound infectious complications had undergone a radical mastectomy followed by irradiation for carcinoma of the breast. Management proved challenging in these two patients. One died of complications of the dehiscence after the second attempt to rewire the sternum, the other ultimately required seven operations, including an omental and a free gracilis magnus myocutaneous flap to close the defect. Therefore, we recommend immediate, nonradiated muscle flap coverage at the time of the initial cardiac operation for these patients [20].

Not closing the sternum makes it very difficult, if not impossible, to perform a reoperation because of the absence of a plane between the heart and sternum. With sternal reclosure, reoperation is easier. We demonstrated that for most patients with DSWI, reclosing the sternum and allowing the skin and subcutaneous tissue to heal by secondary intention is effective and will allow a safer cardiac reoperation, when necessary. Bray and colleagues reported this approach in 1996; they had success in 12 of 17 patients with simple débridement and rewiring [21]. The mortality rates we report here compare favorably with other recent reports that range between 14% and 47% [8, 13, 21].

In patients where sternal preservation is not successful, conversion to open sternum with muscle flap closure remains an option. It is evident from our data that one must have a flexible armamentarium for dealing with DSWI, as no single approach is appropriate in every clinical scenario (eg, with an entirely necrotic sternum, preservation is not possible).

One potential limitation of this study is that the two treatments were largely consecutive, not concurrent. Although a retrospective analysis, it is likely that the parity of results is not because of general improvements over time, but rather the merits of the sternal preservation method that was most prevalent in the earlier years of the series. Based on our experience, we have generated treatment algorithms for the management of DSWI (Fig 2) and sternal dehiscence (Fig 3).



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  		Fig 2. Algorithm for the management of deep sternal wound infections (El Oakley class 2B). (CT = computed tomography; IV = intravenous.)

 


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  		Fig. 3. Algorithm for the management of clinically uninfected dehiscence (El Oakley class 1). (IV = intravenous.)

 

   Conclusion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Conclusion
References
 
Patients with superficial sternal wound infections need close follow-up. Most will heal with simple drainage and antibiotics; however, approximately 10% to 15% will ultimately prove to be deep infections that require more complex care.

Patients suffering major sternal complications should be treated in a multidisciplinary fashion with the involvement of both surgeons and infectious disease specialists. Most can be treated by open débridement, drainage, and sternal reclosure. If, upon exploration the patient has an apparent uninfected dehiscence, sternal rewiring with primary skin and subcutaneous tissue closure is appropriate. Patients with infection can be treated either by drainage, rewiring the sternum, and staged muscle flap closure, or by allowing the skin and subcutaneous tissue to heal by secondary intention. Our data demonstrate that preservation of the sternum will succeed in most; they will have shorter time to healing and a lower risk of future cardiac reoperation. Open sternum with muscle flap coverage should be reserved for precardiotomy wound compromise (radiation or steroids), obvious severe sternal necrosis precluding rewiring, or for those who fail initial sternal preservation attempts.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Conclusion
 References
 

  1. Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity and cost of care. Ann Thorac Surg. 1990;49:179–187[Abstract]
  2. Ehrenkranz NJ, Pfaff SJ. Mediastinitis complicating cardiac operations: evidence of postoperative causation. Rev Infect Dis. 1991;13:803–814[Medline]
  3. Borger MA, Rao V, Weisel RD, et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 1998;65:1050–1056[Abstract/Free Full Text]
  4. Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery—microbiology and pathogenesis. Eur J Cardiothorac Surg. 2002;21:825–830[Abstract/Free Full Text]
  5. Grossi EA, Culliford AT, Krieger KH, et al. 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]
  6. Serry C, Bleck PC, Javid H, et al. Sternal wound complications: management and results. J Thorac Cardiovasc Surg. 1980;80:861–867[Abstract]
  7. Jurkiewicz MF, Bostwick J, Hester TR, Bishop JB, Craver J. Infected median sternotomy wound: successful treatment by muscle flaps. Ann Surg. 1980;191:738–744[Medline]
  8. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13:606–608[Medline]
  9. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61:1030–1036[Abstract/Free Full Text]
  10. Scully HE, Leclerc Y, Martin RD, et al. Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of deep sternal infections. J Thorac Cardiovasc Surg. 1985;90:523–531[Abstract]
  11. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg. 1998;65:1046–1049[Abstract/Free Full Text]
  12. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease. Pathogenesis, predisposition and prevention. Circulation. 1998;97:916–931[Abstract/Free Full Text]
  13. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg. 1999;117:855–887[Abstract/Free Full Text]
  14. Morice M-C, Serruys PW, Sousa JE, et al. A randomized comparison of a sirolimus-eluting stent for coronary revascularization. New Engl J Med. 2002;346:1773–1780[Abstract/Free Full Text]
  15. Borger MA, Rao V, Weisel RD, et al. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 1998;65:1050–1056[Abstract/Free Full Text]
  16. The Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg. 1996;111:1200–1207[Abstract/Free Full Text]
  17. Trick WE, Scheckler WE, Tokars JI, et al. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2000;119:108–114[Abstract/Free Full Text]
  18. Furnary AP, Zerr KF, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep chest wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352–360[Abstract/Free Full Text]
  19. Fleck TJ, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep Sternal wound infections after cardiac surgery. Ann Thor Surg. 2002;74:1596–1600[Abstract/Free Full Text]
  20. Arnold PG, Lovich SF, Pairolero TC. Muscle flaps in irradiated wounds: an account of 100 consecutive cases. Plast Reconstruct Surg. 1994;93:324–327[Medline]
  21. Bray PW, Mahoney JL, Anastakins D, Yao JKY. Sternotomy infections: sternal salvage and the importance of sternal stability. Can J Surg. 1996;39:297–301[Medline]



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