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Interact CardioVasc Thorac Surg 2005;4:49-51. doi:10.1510/icvts.2004.096065 © 2005 European Association of Cardio-Thoracic Surgery
Single stage sternal reconstruction using titanium mesh for dehiscence following open-heart surgeryDepartment of Cardiac Surgery, Jubilee Building, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK *Corresponding author. Tel.: +44-113-392-5786; fax: +44-113-392-5408. E-mail address: Unnikrishnan.Nair{at}leedsth.nhs.uk (U.R. Nair). Received 13 August 2004; received in revised form 11 October 2004; accepted 26 October 2004
Wound complications are a well-recognised entity following median sternotomy. Soft tissue reconstruction in the form of muscle flaps generally provides adequate wound stability; nevertheless, skeletal reconstruction of the anterior chest wall is sometimes necessary. We describe a novel technique applied in three patients for reconstructing fragments of the sternum using a titanium mesh that provides a scaffold for the bony union.
Key Words: Sternum; Infection; Wound dehiscence; Complications of surgery
Sternal instability or infection following median sternotomy are rare but important complications of median sternotomy. They are associated with prolonged hospitalization, increased hospital costs and high morbidity and even mortality [1]. Risk factors have been categorized in three groups [2]. Preoperative factors include diabetes mellitus, chronic obstructive airway disease, obesity and smoking. The most important perioperative risk factor remains prolonged bypass time with concerns raised about arterial revacsularisation using unilateral or bilateral internal mammary grafts especially in diabetic patients [3,4]. Main postoperative risk factors include the need for transfusions, reexploration and prolonged ventilatory support. Sternal dehiscence in the presence or not of infection may present a challenge for every cardiac surgeon. Muscle transposition has been reported by many investigators as the treatment of choice for patients in whom sufficient bony fragments are not available for closure with wires [5–7] or even rigid plates [8,9]. Good results have been shown with both rectus abdominis free flaps as well as myocutaneous latissimus dorsi flaps [2]. Bilateral pectoralis major flap repair has also been reported as a safe technique when complete sternal resection is necessitated without the need for extensive reconstructive surgery [10]. Soft tissue reconstruction in the form of muscle flaps generally provides adequate wound stability; nevertheless, skeletal reconstruction of the anterior chest wall might be more appropriate.
Between October 2000 and May 2002 three patients with sternal dehiscence following coronary artery surgery developed sternal wound dehiscence. All patients were male (age: 53, 54 and 68 years old) and shared the same risk factors for developing sternal complications including obesity (body mass indices: 30.35, 34 and 35), smoking and airway diseases. Pedicled left internal thoracic artery was only unitized in two patients; saphenous vein grafts were used solely in the third case. Two patients presented with deep sternal wound infection in the early postoperative period and the third patient was a late non-infected presentation. Conventional methods using initial debridement and wire removal were unsuccessful. Standard anesthesia techniques and monitoring lines were used in all patients. Appropriate prophylactic antibiotics were given intravenously at induction. Sternotomy wounds were excised in toto. Any previous stainless steel wires and suture material were removed. Infected and necrotic tissue was debrided along with all sternal or rib edges and sent for microbiology culture. This was followed by bilateral medial to lateral mobilization of the pectoralis major and overlying soft tissue layers. Along the inferior wound border the rectus sheath was elevated in the same plane. The distance required to achieve midline approximation guided the extent of mobilization. Internal fixation of the sternum was performed with an individually measured segment of titanium mesh (Surgical Titanium MeshTM, DePuy AcroMed, Inc.) for each patient. This was anchored to the surrounding bony edges with stainless steel wires (Fig. 1). At this point bone marrow from adjacent sharply debrided bony edges was curetted and applied as a paste to the anterior surface of the mesh.
The reconstructed sternum was covered with the advancement flaps sutured in the midline with absorbable sutures. Two suction drains were inserted between the mesh and the advancement flap. Subcutaneous layers and skin are sutured in routine fashion. Antibiotic coverage based on sensitivities was continued appropriately. All three patients achieved excellent sternal stability with full bony union on clinical and radiographic examination (Fig. 2). Clinical observations included minimal pain and good stability on palpation. Removal of metalwork was necessary in one case for chronic infection presenting as a discharging sinus 2 years following implantation. Removal was not difficult. The anchoring steel wires were cut and removed. The edge of the mesh was grasped in sternal wire needle holder and the mesh was peeled off the underlying bone without any difficulty. The underlying bone was stable and appeared strong. The other two patients remain clinically well at 28 and 47 months post-implantation, respectively.
Titanium mesh has been used extensively in orthopedic and maxillofacial surgery with excellent long-term results [11,12]. The mesh provides a scaffold for bony union due to its ideal physical and biomechanical properties. Very low susceptibility to infection has been shown [12]. By maintaining bony stability of the anterior chest wall, functional thoracic movement is preserved and any paradoxical respiration avoided. Physical and psychological support must be part of the post-operative management. Sternal reconstruction is a standard practice following sternectomy for malignant processes [13]. Polypropylene mesh along with various types of internal fixation such as stainless steel or titanium plates have been widely used [14]. The sternum and adjoining ribs are effective sites of haempoiesis in adulthood. The proliferation of marrow stromal cells within the vicinity of the wound in combination with the mesh acting as a scaffold leads to the ‘regeneration’ of the sternum [15]. It is our belief that the development of absorbable mesh material with similar physical characteristics will facilitate possible redo cardiac surgical procedures. Our technique of sternal reconstruction using an appropriate titanium wire mesh is simple and safe. It can be used even in the presence of chronic infection and avoids extensive plastic reconstructive surgery. We must add that there was no pre-operative selection of our three cases. In all patients the decision was taken on the operating table as soon as it was realized that insufficient bony fragments ruled out conventional reconstruction. This was not a clinical trial or randomized study. Hence ethics committee approval was not taken. We have not had any further case since May 2002. It is not possible to randomize such a rare event. We do not intend to do a prospective study given such low occurrence of this problem in our experience. No conflict of interest exists.
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Abstract
1. Introduction
