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Sternal plate fixation for sternal wound reconstruction: initial experience (retrospective study).

Fawzy H, Osei-Tutu K, Errett L, Latter D, Bonneau D, Musgrave M, Mahoney J - J Cardiothorac Surg (2011)

Bottom Line: Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge.Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability.Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Terrence Donnelly Heart Center, Keenan Research Center in the Li Ka Shing Knowledge Institute of St, Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. hosamfawzy@hotmail.com

ABSTRACT

Background: Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4-5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.

Methods: A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean±SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).

Results: There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.

Conclusion: Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

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Pre and Post-operative chest CT scan following sternal plates' fixation. It demonstrates resolving of mediastinitis and sternal union.
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Figure 3: Pre and Post-operative chest CT scan following sternal plates' fixation. It demonstrates resolving of mediastinitis and sternal union.

Mentions: Our first few patients were kept sedated and ventilated for 48 hours before extubation was attempted to minimize excessive movements that might affect the wound. Later, we have modified our post-operative care protocol, so all patients were extubated immediately after surgery unless haemodynamically unstable. Seventy five percent of the patients were extubated immediately after surgery, 10% extubated in the first 24 hours and 15% were late (> 24 hours). Those of late extubation compromised a group of six patients with severe COPD that were on the ventilator for a long time and who ultimately required tracheostomy. Median post-op ICU stay was one day (range 1-29 days). Total median hospital stay was 18 days, with a range from 3-88 days after sternal plating. The wide variability was mostly due to prolonged stay of few patients due to other medical problems not related to the sternum. There was one death unrelated to the sternal closure that had infective endocarditits of his prosthetic valve and died of refractory septic shock. Post-operative hospital course is shown in Table 5. The median follow-up time at one year revealed thoracic stability in all patients (figure 3). No patient showed clinically significant restrictive pulmonary compromise, although formal postoperative pulmonary function measurements were not obtained. Postoperative chest pain disappeared in the majority of the patients. Chronic postoperative pain was reported in two patients, the first one was well managed with oral nonsteroidal medications. The second patient required plate removal to relieve his pain.


Sternal plate fixation for sternal wound reconstruction: initial experience (retrospective study).

Fawzy H, Osei-Tutu K, Errett L, Latter D, Bonneau D, Musgrave M, Mahoney J - J Cardiothorac Surg (2011)

Pre and Post-operative chest CT scan following sternal plates' fixation. It demonstrates resolving of mediastinitis and sternal union.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3108287&req=5

Figure 3: Pre and Post-operative chest CT scan following sternal plates' fixation. It demonstrates resolving of mediastinitis and sternal union.
Mentions: Our first few patients were kept sedated and ventilated for 48 hours before extubation was attempted to minimize excessive movements that might affect the wound. Later, we have modified our post-operative care protocol, so all patients were extubated immediately after surgery unless haemodynamically unstable. Seventy five percent of the patients were extubated immediately after surgery, 10% extubated in the first 24 hours and 15% were late (> 24 hours). Those of late extubation compromised a group of six patients with severe COPD that were on the ventilator for a long time and who ultimately required tracheostomy. Median post-op ICU stay was one day (range 1-29 days). Total median hospital stay was 18 days, with a range from 3-88 days after sternal plating. The wide variability was mostly due to prolonged stay of few patients due to other medical problems not related to the sternum. There was one death unrelated to the sternal closure that had infective endocarditits of his prosthetic valve and died of refractory septic shock. Post-operative hospital course is shown in Table 5. The median follow-up time at one year revealed thoracic stability in all patients (figure 3). No patient showed clinically significant restrictive pulmonary compromise, although formal postoperative pulmonary function measurements were not obtained. Postoperative chest pain disappeared in the majority of the patients. Chronic postoperative pain was reported in two patients, the first one was well managed with oral nonsteroidal medications. The second patient required plate removal to relieve his pain.

Bottom Line: Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge.Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability.Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Terrence Donnelly Heart Center, Keenan Research Center in the Li Ka Shing Knowledge Institute of St, Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. hosamfawzy@hotmail.com

ABSTRACT

Background: Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4-5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.

Methods: A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean±SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).

Results: There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.

Conclusion: Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

Show MeSH
Related in: MedlinePlus