Research Article: Therapy options in deep sternal wound infection: Sternal plating versus muscle flap

Date Published: June 30, 2017

Publisher: Public Library of Science

Author(s): Martin Grapow, Martin Haug, Chistopher Tschung, Bernhard Winkler, Prerana Banerjee, Paul Philipp Heinisch, Jens Fassl, Oliver Reuthebuch, Friedrich Eckstein, Alberto G Passi.


Management of deep sternal wound infection (DSWI) in cardiac surgical patients still remains challenging. A variety of treatment strategies has been described. Aim of this cohort study was to analyse two different treatment strategies for DSWI: titanium sternal plating system (TSFS) and muscle flap coverage (MFC).

Between January 2007 and December 2011, from 3122 patients undergoing cardiac surgery 42 were identified with DSWI and treated with one of the above mentioned strategies. In-hospital data were collected, follow-up performed by telephone and assessment of Quality of Life (QoL) using the SF-12 Health Survey Questionnaire.

20 patients with deep sternal wound infection were stabilized with TSFS and 22 patients treated with MFC. Preoperative demographics and risk factors did not reveal any significant differences. Patients treated with TSFS had a significantly shorter operation time (p<0.05) and shorter hospitalization (p<0.05). A tendency towards lower mortality rate (p = n.s.) and less re-interventions were also noted (plating 0.6 vs. flap 1.17 per patient, n.s.). Quality of Life in the TSFS group for the physical-summary-score was significantly elevated compared to the MFC group (p<0.05). Relating to chest stability and cosmetic result the treatment with TSFS showed superior results, but the usage of MFC gave the patients more freedom in breathing and less chest pain. Our results demonstrate that the use of TSFS is a feasible and safe alternative in DSWI. However, MFC remains an absolutely essential option for complicated DSWI since the amount of perfused tissue can be the key for infection control.

Partial Text

Conventional medium sternotomy is the most common access to the heart and mediastinum for cardiac surgeons since Julian et al. re-introduced Milton’s operation for this access in 1957 [1]. Deep Sternal Wound Infection (DSWI) with sternal dehiscence after cardiac surgery is nowadays a rare but highly feared complication associated with considerable morbidity and mortality [2]. Longer duration of hospitalization, expansive antibiotic treatments, reinterventions and significantly increased costs to healthcare systems are relevant consequences [3–7]. Several authors have reported about 16 up to 30 additional hospital days compared to patients with uncomplicated postoperative courses [8–11]. Upton et al. showed an up to 2-fold increase of cost per patient [6], Lee et al. described an additional cost of $ 500’000 per incident of poststernotomy mediastinitis [5].

The application of a transverse titanium sternal plating system was first described by Cicilioni et al. in 2005 [24]. Since then evidence has accumulated that the approach of using titanium plate osteosynthesis in a preconditioned and preserved sternal surrounding offered by modern VAC therapy has the potential to become an alternative in the therapy of complex DSWI [12,16,26]. The goal of this study was to analyse the effect of different treatment options in DSWI, TSFS vs. MFC, on quality of life and outcome.




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