Does the Type of Sternal Wound Reconstruction Affect Outcome in Patients with Deep Sternal Wound Infection after Cardiac Surgery?

Aim: To analyze the impact of various types of sternal wound reconstruction on the outcome and long-term survival of patients with deep sternal wound infection (DSWI) after cardiac surgery.

Methods and Patients: Retrospective analysis of 110 patients who underwent primary application of negative pressure wound therapy (NPWT) for DSWI treatment in our institution in the period between September 2004 to December 2016. Delayed sternal reconstructions for minor bone loss were performed either with wire re-cerclage (NPWT-C) or with titanium plates (NPWT-Plate) in 53 and 34 patients, respectively. Major residual sternal bone defects were covered only with pedicled muscle flap advancement (NPWT-Open) in 4 patients and auto/homograft bone graft mounted on titanium plates (NPWT-Plate+) has recently been used in 16 patients.

Results: Implementation of titanium sternal plating (NPWT-Plate) in management of minor residual sternal defects after DSWI treatment did not improve patients’ outcome in terms of treatment failure (2.9% vs. 3.8%, NS), achievement of chest stability (97.1% vs. 96.2%, NS), and 1-year mortality (8.8% vs. 5.7%, NS) in comparison with sternal re-cerclage (NPWT-C). Replenishment of major bone loss by auto/homograft bone graft (NPWT-Plate+) led to significantly decreased risk of treatment failure (12.5% vs. 50%, p<0.05) and 1-year mortality (18.8% vs. 50%, p<0.05) when compared with NPWT-Open group. Moreover, comparable achievement of sternal stability (93.8% vs. 97.1%, NS) and 1-year mortality (18.8% vs. 8.8%, NS) was found in NPWT-Plate+ group in which sternal plating was used for minor bone loss management (NPWT-Plate), however, accompanied by significant increases in the costs of sternal reconstruction (3.652±582 vs.2.527±606 EUR, p<0.01). Ten-year survival did not differ among those who achieved sternal stability after DSWI treatment (p= 0.73).

Conclusion: Recent armamentarium of reconstruction techniques enables us to achieve sternal stability after DSWI irrespectively of the range of chest bone loss. It also reduces the risk of DSWI treatment failure and promotes better long-term survival.