Ann Thorac Surg 2005;79:359-360
© 2005 The Society of Thoracic Surgeons
How to do it
Achilles Tendon for Sternal Synthesis in the Treatment of Mediastinitis
Marisa De Feo, MDa,*,
Antonio Carozza, MD, PhDa,
Alessandro Della Corte, MD,
Cesare Quarto, MDa,
Michele Torella, MDa,
Luca Salvatore De Santo, MDa,
Gianantonio Nappi, MDa,
Maurizio Cotrufo, MDa
a Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, V. Monaldi Hospital, Naples, Italy
Accepted for publication October 16, 2003.
* Address reprint requests to Dr De Feo, Via Due Principati 1 Trav. 37, 83100 Avellino, Italy
marisa.defeo{at}tin.it
 |
Abstract
|
|---|
Surgical approaches to postoperative mediastinitis that imply wire removal achieve earlier infection recovery but leave the patient with sternal instability. In 10 patients after wound surgical debridement, my colleagues and I achieved sternal synthesis by using Achilles tendons retrieved from multiorgan donors and stored in glutaraldehyde. Three tendons were used in each patient; they were passed through the bone at the manubrium and parasternally at the midsternum and the lower sternum. Thirty-day computed tomographic scan results, infection recovery, and quality of life were satisfactory.
|
Introduction
|
|---|
Early surgical wound debridement for postoperative mediastinitis with wire removal and closed irrigation achieves good rates of infection recovery, but the resulting diastasis of the unwired sternum may cause marked discomfort and complications such as ventilatory dysfunction, chest pain, and delayed superficial wound healing [1]. To address sternal diastasis after surgical wound debridement, my colleagues and I used Achilles tendons retrieved from multiorgan donors to reconstruct the sternum.
|
Technique
|
|---|
Both the calcaneal tendons were aseptically harvested from multiorgan donors. With the donor in a procumbent position, a longitudinal incision from the poples to the calcaneum was performed to expose the tendon, which was excised at the level of its origin from both the gastrocnemius and soleus muscles and then from its site of insertion on the calcaneum and was eventually detached from its bed. On a back table, it was prepared (Fig 1) by removing residual muscular or aponeurotic fringes and was longitudinally incised so that it reached approximately twice the original length (Fig 2). Subsequently it was stored in 0.2% glutaraldehyde solution for 15 days, and then specimens were sent for cultures to confirm asepsis.
View larger version (65K):
[in this window]
[in a new window]
|
Fig 1. Right (bottom) and left (top) Achilles tendons soon after their sterile explantation from a multiorgan donor.
|
|
In 10 informed, consenting patients (6 men and 4 women; mean age, 62.1 ± 12.2 years) who were referred for postoperative mediastinitis and who all presented with sternal gross instability and wound drainage, we performed accurate debridement of the infected tissues along with removal of all foreign bodies (including wires) from the sternum and the presternal tissues. An irrigation and aspiration system was then implanted and was maintained for at least 7 days. Sternal synthesis was obtained with 3 tendons: 1 each was passed through the manubrium (by boring each half), through the intercostal spaces at the midsternum, and at the lower sternum (Fig 3). The 2 hemisterna were reapproximated, and the tendons were tied up with at least 3 knots each; the superficial tissues were reconstructed with monolayer nylon sutures knotted over narrow rubber tubes or Teflon (DuPont, Wilmington, DE) strips on the skin. Details on our postoperative management with closed-chest irrigation have been described previously [2].
Clinical recovery—with defervescence, white blood cell count normalization, wound healing, and satisfactory sternal stabilization—was obtained in all patients within an average postoperative period of 8 days. Thirty-day chest computed tomographic scans (Fig 4) documented an absence of sternal diastasis in all cases. As for wound complications, the follow-up period (range, 3 to 21 months; mean, 11.4 ± 4.5 months) was uneventful in all patients. When interviewed about the postoperative subjective physical status, no patient complained of any kind of discomfort or any limitation to daily activity that could be ascribed to sternal wound conditions.
View larger version (99K):
[in this window]
[in a new window]
|
Fig 4. Thirty-day chest computed tomographic scan of a patient in whom sternal synthesis was obtained with Achilles tendons, showing the absence of diastasis of the hemisterna.
|
|
|
Comment
|
|---|
Septic mediastinitis is a rare but threatening complication of cardiac surgery. It causes a considerable hospital cost increase and has a mortality rate of 14% to 47% [3]. No general consensus has been reached on the best method of treatment, but the need for an operative approach is uncontroversial, and increasing importance has been attributed to early diagnosis and aggressive operative reexploration [2].
We believe that the wires, insofar as they represent a foreign body, can sustain the inflammatory response, making tissues more prone to infection; therefore, they should be avoided in reconstruction after debridement. We decided to use homologous tissue according to the concept behind the already-validated use of homografts in cardiac or vascular surgery as an approach to prosthetic infections [4]. The homologous Achilles tendon was chosen because it combines resistance and length better than other tendons in the human body, because of its situation (it is easily explanted), and because tendons are expected to have a low antigenic activity [5], which is further decreased by pretreatment with glutaraldehyde. The use of allograft Achilles tendons in orthopedic surgery has already been successfully applied [6]. Multiple thin filaments can be obtained from a single tendon, whose elasticity prevents sawing the sternal edges or causing fractures, even when bone structure is deteriorated by infection.
In our 10 patients, the procedure of sternal closure was proven simple and well tolerated, and 30-day computed tomographic scans evidenced sternal knitting in all cases. No infective complication or technique-related inconvenience was observed in the follow-up. Obviously the efficacy of this technique needs to be validated in larger series, and comparative studies versus rewiring should be undertaken.
|
Acknowledgments
|
|---|
Supported by the PhD Program in Medical-Surgical Physiopathology of the Cardio-Respiratory Apparatus and Associated Biotechnologies (MDF and MT).
|
References
|
|---|
- Prevosti LG, Subramainian VA, Rothaus KO, Dineen P. A comparison of open and closed methods in the initial treatment of sternal wound infections. J Cardiovasc Surg. 1989;30:757–763[Medline]
- De Feo M, Gregorio R, Della Corte A, et al. Deep sternal wound infection: the role of early debridement surgery. Eur J Cardiothorac Surg. 2001;19:811–816[Abstract/Free Full Text]
- El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61:1030–1036[Abstract/Free Full Text]
- Vogt PR, Turina MI. Management of infected aortic grafts: development of less invasive surgery using cryopreserved homografts. Ann Thorac Surg. 1999;67:1986–1989[Abstract/Free Full Text]
- Pinkowski JL, Reiman PR, Chen SL. Human lymphocyte reaction to freeze-dried allograft and xenograft ligamentous tissue. Am J Sports Med. 1989;17:595–600[Abstract/Free Full Text]
- Sanchez-Sotelo J, Morrey BF. Surgical techniques for reconstruction of chronic insufficiency of the triceps. Rotation flap using anconeus and tendo achillis allograft. J Bone Joint Surg Br. 2002;84:1116–1120
Top
Abstract
Introduction
