Asian Journal of Surgery (2014) 37, 24e29

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ORIGINAL ARTICLE

Treatment of sternal wound infections after

open-heart surgery
Yue-Dong Shi, Fa-Zhi Qi*, Yong Zhang

Department of Plastic and Reconstructive Surgery, Zhongshan Hospital, Fudan University, Shanghai,
China

Received 29 September 2012; received in revised form 23 May 2013; accepted 9 July 2013
Available online 22 August 2013

KEYWORDS Summary Objective: The aim of this study was to investigate the proper treatment of in-
infection; fected median sternotomy wounds.
muscle flap; Methods: A retrospective study was conducted to investigate the proper treatment of infected
sternotomy median sternotomy wounds on patients with sternal wound infections from January 2007 to
July 2009. The characteristics of the sternal infections and the treatment outcomes were ana-
lysed.
Results: Ninety-seven patients with sternal wound infections were treated. A total of 32 pa-
tients acquired the infection within one month after open-heart surgery, 10 patients got the
infection one to two months after the surgery, and 1 patient died two days after debridement.
There were 54 patients who acquired the infection beyond two months post-surgery, while 1
patient died on the day before the operation. One patient received four cycles of wound
debridement, 18 patients received two cycles and 78 patients only received one cycle. A total
of 14 patients received a vacuum-assisted closure treatment. There were 73 patients who had
surgery for repair of muscle flaps, 1 patient for breast tissue flap, 63 patients for pectoralis
major muscle flap, and 9 patients with rectus abdominis muscle flap. There were 12 patients
who received a transverse plate fixation of the sternum with titanium plating.
Conclusion: A positive prognosis can be obtained by the algorithm treatment based on the
onset and depth of the sternal infection.
Copyright ª 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights
reserved.

Conflicts of interest: The authors declare that they have no financial or non-financial conflicts of interest related to the subject matter
or materials discussed in this article.
* Corresponding author. Department of Plastic and Reconstructive Surgery, Zhongshan Hospital, Fudan University, Number 180, Fenglin
Road, Xuhui District, Shanghai 200032, China.
E-mail address: [email protected] (F.-Z. Qi).

1015-9584/$36 Copyright ª 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.asjsur.2013.07.006
Treatment of sternal wound infections 25

1. Introduction accepted suffered serious infection or had recurrence after

debridement. This study was conducted in accordance with
Open-heart surgery is usually performed through median the Declaration of Helsinki and with approval from the
sternotomy, as first described by Milton in 1897.1 A rare but Ethics Committee of the Central Department of Cardiac
serious complication associated with this approach is the Study of ZhongShan Hospital, Shanghai. Written informed
development of a deep sternal wound infection (DSWI), consents were obtained from all the participants.
which has a 0.4e5.1% incidence of occurrence after cardiac
surgery.2 The development of a sternal wound infection 2.2. Treatment
often has a late onset and is usually detected only after
discharge. DSWI can cause a high morbidity rate of up to
Preoperative preparation included a basic evaluation of the
50%,3 with a prolonged hospital stay and an increased cost
patient, chest enhanced computed tomography (CT), bac-
of care. In acute stages, sternal collapse and deep media-
terial cultures, antibiotics use, anticoagulant therapy,
stinitis can often result in a functional disorder of the
nutritional status assessment, and control of comorbidities
organ, which, if not treated adequately, may lead to the
such as diabetes mellitus and chronic obstructive pulmo-
patient’s death.4e9 Chronic infections are usually associ-
nary disease. All the patients were treated with various
ated with chronic draining sinus tracts, osteomyelitis, and
surgical procedures according to the onset of infection. In
costochondritis,8,9 which can affect the patient’s quality of
diabetic patients, preoperative glycemic index should be
life. Early detection and aggressive treatment with
controlled at 8.0 mmol/L. The low protein blood syndrome
debridement, drainage, and immediate wound closure
should also be corrected prior to the operation.
using various muscle flaps are necessary to prevent the
development of sternal wound infection. Sternal stability is
also an important factor in surgery; this stability can be 2.3. Type I wounds
maintained by transverse fixation of the sternum using ti-
tanium plates, if necessary.8,10 The current study reports on Type I wounds occur in the first postoperative month. Sur-
97 patients who received sternal wound reconstruction out gical debridement includes open wounds, lavage using
of 6398 patients who underwent cardiac surgery from antibiotic saline, removal of old sternal wires, and excision
January 2007 to July 2009. of all wound edges including skin, subcutaneous tissue, and
necrotic tissue in the mediastinum. To achieve complete
2. Materials and methods wound closure in the pericardium and under the sternum,
drains are placed after rewiring the sternal wire and per-
forming subcutaneous drainage. In cases of serious infec-
2.1. Patients tion, steel wires are removed and then the sternum is fixed
using a titanium plate to strengthen sternal stability.
This study included a total of 97 patients who suffered
sternal wound infections in our institution from January
2007 to July 2009. The patients consisted of 53 (54%) males 2.4. Type II wounds
and 44 (46%) females, with an average age of 57 years
(22e76 years). Cardiac surgical procedures included 44 Type II wounds occur between 1 month and 2 months post-
cases of coronary artery bypass graft (CABG), 32 cases of operation. These wounds manifest with purulent drainage
valve surgery, and 21 cases of other procedures. Over 40% and loose wire. Vacuum-assisted closure (VAC) is performed
of the patients were accompanied by different degrees of for wound preparation, or wound dressing is used until 8
diabetes, hypertension and heart failure, and 90% were weeks post-operation to provide the fibrous tissue with
found to have positive bacterial culture. sufficient antitension support. Afterward, wire removal and
Table 1 summarizes the patient data of surgical revision. wound debridement are performed, and the wound is
A total of 33 patients underwent wound debridement within closed using a muscle flap.
1 month after cardiac surgery, 10 patients received it
within 1e2 months after surgery, and 54 patients received
it after 2 months. The reason most of the patients we 2.5. Type III wounds
treated were infected after 2 months was because patients
found to have wound infection within the first post- Type III wounds occur more than 2 months post-operation
operative month had already been debrided at the and usually manifest with chronic draining sinus tracts,
Department of Cardiac Surgery. Most of the patients we localized cellulitis, osteomyelitis, costochondritis, or a
retained foreign body. At this point, radical sternal
debridement is performed to remove wires and bone wax,
Table 1 Timing of presentation of patients. and an extensive resection of the necrotic sternum and
cartilages is conducted. The wound can immediately be
Timing (mo) Patients (n) % repaired with the use of muscle flaps. Usually, patients with
<1 33 34 mediastinitis do not receive radical debridement, so a VAC
(1 died prior to debridement) followed by muscle flap reconstruction for secondary
1e2 10 10.3 wound closure is used. In cases of serious sternal instability
>2 54 55.7 due to increased sternal necrosis elimination, a titanium
plate is implanted to reconstruct the chest wall (Fig. 1).
26 Y.-D. Shi et al.

3. Results

Of the 97 patients who received wound surgery treatment,

95 were healed completely by the time of discharge. The
remaining two patients dieddthe first (with whole sternum
necrosis and heart exposure) of a serious infection 1 day
prior to debridement (Fig. 2) and the second of a serious
infection 2 days after debridement. Both patients had an
onset of DSWI within 1 month after cardiac surgery. All the
patients who suffered from underlying diseases were sub-
ject to the effective control of specialists in surgery. The
average hospital stay and duration of antibiotics use
(intravenous injection) are detailed in Table 2. None of the
patients were cured without surgery. Follow-ups were
conducted for all participants for more than 3 months after
wound healing.
The frequency of debridement for the whole treatment
Figure 2 Patient with whole sternum necrosis and heart
varied among the patients. Bacterial culture preoperation
exposure prior to debridement.
showed that Staphylococcus aureus (37%), Pseudomonas
aeruginosa (31%), and Acinetobacter baumannii (21%) were
the most common bacterial colonies. We used sensitive implantation can be introduced in surgery, whereas tissue
antibiotics in this perioperative period, such as the third- repair may be used based on the dimension, location, and
generation cephalosporins joint ornidazole through intra- depth of the remaining wound. The VAC technique was
venous injection. The duration of antibiotic use was 1 performed in 14 patients: three were prepared for prede-
week. For patients who underwent titanium plate fixation, bridement and 11 were to receive tissue flap reconstruction
we added oral medication for about 2e4 weeks after the after debridement. Table 3 lists the flaps used to recon-
injection treatment. struct the DSWIs, which included three mammary tissue
Our statistics showed that of the 97 patients who flaps, 63 pectoralis major muscle flaps, and the rectus
received surgical wound treatment, 76 (78.35%) were cured abdominis muscle flaps. Fig. 3 shows that two patients
after the initial wound debridement, 18 were debrided received skin grafts, 19 patients received local tissue flaps
twice (18.56%), one received four cycles of debridement after debridement, and 32 patients received titanium plate
(1.03%), and two died. Three patients with minor post- implantation.
operative bleeding were sent to the operating room for Fig. 3A illustrates the case of Patient 1, a 66-year-old
hematoma evacuation. male patient who manifested a chest wound infection 5
In the clinical treatment of the 97 cases of sternal wound months after CABG. Physical examinations after hospitali-
infections, elimination of pustular drainage and removal of zation showed a 15 cm tear at the middle of the sternum
necrotic tissue were initiated as soon as possible according reaching up to the poststernum with outmoded granulated
to the level of infection and sternal stability. The VAC tissues accompanied by some abscesses. A sternal fracture
technique and chest reconstruction such as titanium plate was also shown at 2e2.5 cm. After 1 week of routine wound

Figure 1 Flow chart of the treatment. VAC Z vacuum-assisted closure.

Treatment of sternal wound infections 27

is pathogen-causing microorganisms13 such as coagulase-

Table 2 Course of the treatment.a
negative staphylococci (most common) and S. aureus.
Type Hospital stay Antibiotic (i.v.) These factors must be considered by a cardiac surgeon to
Average (d) avoid the development of infection.
Sternal wound infection should be treated aggressively
Type I 12.3 7
at the time of diagnosis. All the patients in this study were
Type II 21.7 7
evaluated on risk factors and provided with medical in-
Type III 18.2 7
terventions to improve anemia and control blood glucose,
i.v. Z intravenous. as well as to adjust coagulant dose, preoperative prepara-
a
Oral medication for 2e4 weeks for titanium plate implant tion of wound, bacterial cultures, and the use of culture-
patients after intravenous injection. specific antibiotics.14 Enhanced CT examination must be
performed prior to surgery to evaluate the level and extent
of infections as well as the stability of the sternum.
culture and wound dressing change, the sternal wound Pairolero and Arnold4 described a useful classification
infection healed, and the titanium plate and titanium nail system for infected median sternotomy wounds based on
were implanted together with bilateral pectoralis major the onset and characteristics of the wound. Based on our
myocutaneous flaps to reconstruct the chest wall. The experience, we divided the wounds into three categories
debridement process included extensive resection of the according to sternal stability. For guidance in clinical
necrotic sternum, removal of wires and bone wax, and treatment strategy, the three subgroups with Type III
wound lavage with the use of hydrogen peroxide, benzal- wounds were classified according to the depth of the wound
konium bromide, and saline (Fig. 3B and D). VAC must be at the onset of infection.
performed after the operation. No recurrence was detec- Type I wounds occur in the first month after cardiac
ted after 6 months of follow-up. operation with a serum drainage coming from the sternal
Fig. 4A and B show the case of Patient 2, a 63-year old wound, with no osteomyelitis, costochondritis, or serious
male patient who manifested a sternal infection 1 month infection of the subcutaneous tissue. Therapeutic strategy
after pericardial stripping operation. He achieved complete focuses on the immediate repair of the sternum after
wound elimination and received titanium plate and tita- excision of the unhealthy tissue from the wound edges,
nium nail implantation with chest wall reconstruction using mediastinum, and pericardium. Drains should be placed in
a rectus abdominis myocutaneous flap. He displayed good the pericardium, under the sternum, or in the subcutaneous
recovery after the surgery. tissues prior to sternal refixation, with the use of antibiotics
if necessary. An open wound always involves mechanical
ventilation, which may mean increased morbidity.
4. Discussion Type II wounds occur 1e2 months post-operation due to
sternal instability, as manifested by purulent drainage,
Median sternotomy is one of the most commonly used in- exposure of wire, sternal osteomyelitis, mediastinitis, and
cisions in open-heart surgery.11 DSWI is a rare complication, very rare costochondritis. The medical status of the patient
and its improper treatment may result in serious compli- is often stable, so a two-stage debridement with VAC9,15 or
cations that can even lead to death. The reported inci- wet compress for 2 months is more suitable for treatment.
dence of morbidity for sternal wound infection ranges from Type III wounds occur more than 2 months after surgery
7% to 80%. Prevention and early recognition of sternal in- and usually manifest with chronic draining sinus tracts,
fections are important factors for optimal treatment and osteomyelitis, costochondritis, and very rare mediastinitis.
management. Sternal refixation is unnecessary if debridement of fibrous
Ridderstolpe2 concluded that the risk factors associated tissue can achieve sufficient antitension support.
with sternal infections include age, gender, obesity, dia- Based on the depth of infection, wounds can be divided
betes mellitus, chronic obstructive pulmonary disease, into three subgroups: subcutaneous tissue involving the
peripheral vascular disease,12 bilateral use of internal sternum, subcutaneous tissue involving the costal cartilage,
mammary arteries, prolonged use of ventilator support, and mediastinitis. Skin and subcutaneous tissue infections
and reoperation for bleeding. Another important risk factor can be treated by direct wound closure with debridement
or skin graft. Chronic osteomyelitis and costochondritis
should be treated by radical debridement to remove su-
Table 3 Methods for wound reconstruction. tures, wires, and bone wax, and by extensive resection of
the necrotic sternum and cartilages.
Methods Patients (n)
The success of the operation depends on how thoroughly
Muscle flap 63 (pectoralis major muscle flaps) the debridement has been performed. Dead space that
reconstruction 9 (rectus abdominis muscle flaps) remains after extensive debridement should be obliterated
Mammary tissue flaps 3 using a muscle or a myocutaneous flap. Debridement to
Skin grafting 2 treat mediastinitis may injure the vital organs. Therefore,
Local tissue flap 19 this type of infection should be kept open and treated with
VAC 3 (prior to debridement) VAC, followed by secondary tissue flap reconstruction.
11 (after debridement) The most common flaps used to reconstruct deep sternal
wounds include pectoralis major muscle, rectus abdominis
VAC Z vacuum-assisted closure.
muscle, and latissimus dorsi muscle flaps. Muscle flap is
28 Y.-D. Shi et al.

Figure 3 (A) Man (66 years old) presented with chest wound infection 5 months after CABG. Debridement was performed prior to
admission to remove a part of the wire. (B) Debridement included extensive resection of the necrotic sternum, removal of wires
and bone wax, and lavage with hydrogen peroxide, benzalkonium bromide, and saline. (C) Immediate reconstruction with a
bilateral pectoralis major myocutaneous flap after debridement; titanium plate and titanium nail were implanted during the
operation. (D) Two weeks post-operation.

more suitable for treating deep infections or large defects grafts and obturate dead sternal space, but the risk of
of soft tissues with fine blood supply and anti-infection opening the abdominal cavity makes the omentum flap a
property. To assist in flap selection, Nahai et al5 proposed a reserved choice.16
flap classification based on the types of bypass grafts, such The timing of the reconstruction using muscle flaps is
as vein graft, unilateral graft, or bilateral internal mam- still controversial. Most scholars recommend radical
mary artery graft. Greig et al6 proposed an anatomical debridement followed by one-step flap reconstruction to
classification to aid in flap selection using the location of obturate dead spaces and reduce bleeding and mortality.
infection: the upper half of the sternum, the lower half of However, a previous study9 shows that immediate recon-
the sternum, and the whole sternum. They recommended struction using muscle flaps may diffuse the infection or
pectoralis major muscle flap for defects in the upper half of lead to reinfection, especially in a complex wound. For
the sternum, and the combined pectoralis major and rectus DSWI patients who cannot be treated with initial radical
abdominis bipedicled muscle flaps for defects in the lower debridement, open and dressing are more important. Sec-
half and the whole sternum. The omentum can also protect ondary tissue flap reconstruction should be conducted after

Figure 4 Man (65 years old) with sternum infection 1 month after the pericardial stripping operation. Three-dimensional CT
imaging: (A) preoperation and (B) 2 weeks post-operation.
Treatment of sternal wound infections 29

good wound preparation. In our group, 76 patients (78.35%) 3. Sarr MG, Gott VL, Townsend TR. Mediastinal infection after
were cured after initial wound debridement, whereas cardiac surgery. Ann Thorac Surg. 1984;38:415e423.
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debridements. Based on our experience, when the medi- sternotomy wounds. Ann Thorac Surg. 1986;42:1e2.
5. Nahai F, Rand RP, Hester TR, Bostwick 3rd J, Jurkiewicz MJ.
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Primary treatment of the infected sternotomy wound with
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