ClinicalClinical PRACTICE PRACTICE DEVELOPMENT DEVELOPMENT Management of sternal dehiscence

Sternal wound complications may result from median sternotomy procedures following cardiothoracic surgery and can represent a significant management problem, for example, and dehiscence can increase hospital stay, morbidity and mortality. Morbidity from sternal wound dehiscence was close to 50% until recently, but with recent advances, including sternal fixation techniques and various reconstructive surgical options, this has improved. This article outlines the problems of wound dehiscence and delayed healing following median sternotomy and provides an overview of the pertinent management options.

Fouzia Choukairi, Joseph Ring, Joe Thekkudan, Stuart Enoch

However, postoperative wound as negative pressure wound therapy of the sternum is common (NPWT) has reduced the morbidity KEY WORDS and if severe, chronic or untreated, rate to approximately 10% (Miller and Sternal wound dehiscence can lead to sternal wound dehiscence. Nahai, 1989; Jones et al, 1997; Sjögren et Mediastinitis reconstruction The incidence of sternal wound al, 2006). Sternotomy infections following median sternotomy Sternal instability procedures is in the region of 0.5–8.4% Sternal wound infections and dehiscence also prolong recovery time ... postoperative wound as well as increasing hospital stay, re- operative rates, morbidity and mortality infection of the sternum (Losanoff et al, 2002b). ternal wound complications is common and if severe, may result from median chronic or untreated, can This article aims to highlight the Ssternotomy procedures following lead to sternal wound problems of sternal wound dehiscence cardiothoracic surgery. The median dehiscence. and delayed healing following median sternotomy is the incision of choice sternotomy, as well as providing an for most procedures that involve the overview of the management options. heart and great vessels, including trauma, (Grevious, 2009). This can be further bypass, valve replacement, heart failure complicated by development of Median sternotomy and transplant surgery. In addition, it osteomyelitis of the sternum which has a Median sternotomy was introduced allows access for many pulmonary reported incidence of 0.8–2.5%. in the 1950s (Julian et al, 1957) and procedures (Falor and Traylor, 1982). has revolutionised the world of When compared to approaching the Sternal wound dehiscence can cardiothoracic surgery. The midline chest cavity from the lateral side (lateral lead to mediastinitis, which is where incision is made through the bony thoracotomy), the median sternotomy the superficial wound infection travels sternum and provides excellent access provides excellent exposure and results deeper and affects the mediastinal to the thoracic organs as well as in less postoperative pain (Falor and structures. It has an incidence of 1–5% of permitting a range of procedures to be Traylor, 1982). median sternotomies (Grevious, 2009) performed on the thoracic structures and results in a chronic inflammatory (Grevious, 2009). state and infection, both on the surface (sternal wound) and the mediastinal Other incisions exist and newer Fouzia Choukairi is a Speciality Trainee in Plastic Surgery, structures. minimally invasive approaches are University Hospital of South Manchester; Joseph Ring is a being developed, however, the median Speciality Trainee in Orthopaedic Surgery, Royal Oldham Hospital; Joe Thekkudan is a Registrar in Cardiothoracic Morbidity from sternal wound sternotomy remains the incision of Surgery, New Cross Hospital, Wolverhampton; Stuart Enoch dehiscence and its associated choice for many procedures since is Programme Director — Education and Research at complications ran at nearly 50% until it provides the best access to the the Doctors’ Academy and Specialist Registrar in Plastic recently, but advances in management mediastinal structures as well as access Surgery, University Hospital of South Manchester options and medical devices such into both hemithoracies. It is considered

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to be less painful and provides a lower incidence of respiratory complications Table 1 when compared to other incisions Pairolero and Arnold Classification System of Mediastinitis (Pairolero and Arnold, 1984) (Farhat et al, 2004).

Complications Potential wound complications following Type 1 8 Occurs within a few days of initial surgery median sternotomy include superficial 8 There is serosanguinous discharge but no evidence of cellulitis, osteomyelitis or deep wound infections, desiccation or costochondritis of wound margins, wound breakdown, 8 There are no signs of wound breakdown or instability wound dehiscence, osteomyelitis, Type 2 8 Occurs in the first few weeks following surgery mediastinitis, and exposure of vital 8 Characterised by drainage, cellulitis and positive cultures structures and major vessels. 8 Usually classed as fulminant mediastinitis, often with bony involvement

Long-term problems include sternal Type 3 8 Chronic occurring months or years after surgery instability, paradoxical motion of the 8 Incorporate signs of chronic infection with sinuses, cellulitis and osteomyelitis chest wall and chronic pain. These 8 Medistinal involvement is uncommon with type III infections symptoms may have significant effects on the patient’s quality of life.

Pairolero and Arnold (1984) Table 2 classified sternal wound infections Risk factors for sternal wound complications into three types based on timing and presentation (Table 1). This system does not necessarily indicate the type of Patient risk factors Surgical factors treatment required, however type II and III will generally require specialist input 8 Increasing age 8 Poor technique and surgical reconstruction (Pairolero 8 Female sex 8 Extended operative time and Arnold, 1984). More recently, El 8Diabetes mellitus 8 Prolonged ventilation Oakley and Wright (1996) proposed 8Obesity 8 Insufficient sternal fixation another classification for mediastinitis 8Smoking 8 Excessive haemorrhage based on wound assessment during 8Malnutrition 8 Internal mammary artery harvest surgical debridement, which helps to 8Sepsis 8 Cardiopulmonary bypass determine a management approach. 8Renal failure 8 Hypoperfusion 8Immunosuppression 8 Use of bone wax Delayed healing 8Osteoporosis Following a median sternotomy, the 8Chronic obstructive pulmonary disease (COPD) integrity of the sternum and the surrounding structures are significantly compromised. There is little muscle essential to recognise the early signs with surrounding progressive cellulitis, or soft tissue overlying the sternum, and symptoms of sternal wound systemic infection or sepsis. However, and consequently the area does not dehiscence (Figure 1). Clinicians should if the infection is localised and minimal, have a generous blood supply. The be alert for signs of local wound it is reasonable to withhold close proximity of the bone to the changes such as erythema or increased until microbiological swab results skin also exacerbates the problem of exudate, pain, systemic signs such as (provisional or definitive) are available, recalcitrance and a superficial wound pyrexia, and respiratory symptoms or at least after obtaining tissue infection can soon enter the bone (e.g. pleural effusions). Clinicians should samples (either in ward or theatre) for leading to osteomyelitis. Furthermore, be extra-alert to the possibility of microbiological analysis. the area is subject to high stresses and complications in high-risk patients, such almost constant movement, both due to as increased risk of infection, delayed The key aim once infection is respiration and activities of the shoulder and wound dehiscence identified is to perform swift and girdle. Some recognised patient and (Losanoff et al, 2002a). thorough surgical debridement, following surgical factors in the aetiology of delayed which further management can be sternal wound healing are listed in Table 2. If infection is suspected, appropriate decided upon. The aim of surgical swabs, samples and cultures should debridement is to remove all non- Initial assessment for sternal be taken (Grevious, 2009). Empirical viable tissue back to tissue wound dehiscence broad-spectrum antibiotics may be and produce a clean wound that allows An accurate clinical evaluation is started if the infection is overwhelming definitive management to be performed

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or separation of the sternal half (when Current treatment options include: performing a median sternotomy, the 8 Promoting healing by secondary sternal bone is longitudinally [vertically] intention through the use of NPWT sawn in half and the ‘sternal half’ 8 Split-skin grafting if appropriate refers to these two halves of bone) 8 Sternal stabilisation procedures (Gualdi et al, 2005). Ultrasound may 8 Reconstructive procedures. be used to identify any collections of fluid. Computerised tomography (CT) The above management techniques scans are useful for detecting sternal have meant that the incidence of disruption, the location of fluid, and morbidity and subsequent mortality any underlying lung or mediastinal from sternal wounds has fallen to pathology. around 10% (Miller and Nahai, 1989; Jones et al, 1997; Sjögren et al, 2006). A If it is suspected that the infection suggested treatment algorithm for the has extended into the bones, this can management of sternal wounds is shown be established by a magnetic resonance in Figure 3. imaging (MRI) scan. However, the Figure 1. Chronic sternal wound. effectiveness of any MRI may be limited Negative pressure wound therapy (NPWT) by the presence of sternal metalwork The introduction of negative pressure (Gualdi et al, 2005). Intraoperatively, wound therapy (NPWT) in 1997 both superficial wound swabs and greatly improved the outcomes of deep tissue biopsy may be obtained sternal wound dehiscence (Song et al, for microbiological analysis (O’Brien 2003; Agarwal et al, 2005). This therapy Norris, 1995). involves the application of a negative pressure pump to the wound via a Management special occlusive (Sjögren et A number of factors need to be al, 2006). It can be applied to sternal considered when evaluating and wounds after initial debridement managing non-healing sternal wounds, (Sjögren et al, 2006) and can either be including: used to encourage secondary healing 8 Presence and depth of infection in selected patients (Song et al, 2003; 8 Any evidence of underlying Malmsjö et al, 2007), or as an interim osteomyelitis (Figure 2) measure between debridement and 8 Anatomy of any tissue defects attempts at definitive closure (Song et al, 8 Sternal stability 2003). Negative pressure wound therapy 8 General health of the patient and has been shown to: any associated comorbidities. 8 Reduce the number of dressing changes In the 1950s, dehisced and non- 8 Expedite time to definitive treatment healing sternal wounds were mostly 8 Lower costs Figure 2. Sternal osteomyelitis. left to heal by secondary intention, 8 Reduce the length of in-patient stay which included debridement, packing (Agarwal et al, 2005). immediately or at a later time and open drainage. However, with (Grevious, 2009). If there is evidence of these techniques alone, morbidity was Negative pressure wound therapy mediastinitis and extensive disruption of close to 50%. In 1963, the concept of has a number of local effects on wound the sternum, more radical surgery and catheter irrigation of sternal healing. It is known to decrease wound reconstruction should be considered. wounds was introduced, leading to area, stimulate blood flow, remove a reduction in morbidity from 50% excess fluid, and stimulate granulation Before surgery, baseline preoperative to approximately 20% (Shumacker and local inflammatory response investigations (for example, full blood and Mandelbaum, 1963). Although (Malmsjö et al, 2007). It also helps to count, electrolytes, inflammatory this reduction was considered to stabilise the sternum, thus decreasing markers such as C-reactive protein be a significant step forward, it was the ventilatory requirements of [CRP] and serum albumin levels) are associated with a major complication intensive care patients who are receiving needed to ensure the patient’s fitness — the erosion of major vessels by the respiratory support. for general anaesthesia. catheter, leading in some cases to fatal haemorrhage (Grevious, 2009). This Reconstruction with flaps Plain radiography of the sternum resulted in the drive for better and The concept of debridement and may also demonstrate mediastinal air alternative management options. reconstruction involves the use of flaps

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to reduce the dead space in the sternal Lee et al introduced the omental Defects of the upper third are most defect as well as to provide bulk (muscle flap in 1976 (Lee et al, 1976; Jurkiewicz easily and successfully covered using mass or omentum) to encourage healing and Arnold, 1977), and later more the pectoralis flap (Jones et al, 1997). (José, 1999). Previous irradiation of the complex myocutaneous flaps were Defects of the mid and lower third and chest wall or abdominal surgery may developed following the work of larger defects can be covered using preclude the use of certain types of Jurkiewicz (Jurkiewicz and Arnold, the rectus abdominis flap (Greig et flaps. Therefore, full assessment of the 1977). These include the pectoralis al, 2007). The two techniques can be patient is essential before embarking major, rectus abdominis and latissimus combined for larger defects, resulting in on a specific type of reconstruction dorsi flaps (Jurkiewicz et al, 1980; Tizian better outcome. (O’Brien Norris, 1995; Grevious, 2009). et al, 1985). A major study by Castelló et al Management of sternal wounds: An algorithm (1999) that examined sternal wounds demonstrated that pectoralis flaps were the most commonly used flap in sternal Sternal wound breakdown reconstruction, with the second choice being pectoralis combined with rectus abdominus flaps, and then the rectus Swab for cultures to identify if wound infected or associated osteomyelitis abdominus muscle alone. Latissmus dorsi or omental flaps were only used in a small number of cases. The study showed Positive Discuss with that there was an overall reduction in microbiology microbiologist and commence antibiotics mortality using these techniques (José et al, 1999).

Re-swab after Negative Pectoralis muscle flaps (Figure 4) 5–7 days microbiology Sternal wounds, particularly in the upper third, can be covered using the pectoralis muscle flap (Greig et al, Does the wound need surgical input? 2007). It is often the first choice due to its proximity to the defect requiring coverage. The muscle is harvested No Yes Pre-operative assessment through a midline incision. The flap is based either on the thoracoacromial pedicle or on the internal mammary Heal by secondary Patient fit for GA Patient not fit perforators (a flap involves taking a intention +/- VAC for GA therapy piece of tissue — usually fascia or muscle with or without the overlying skin — to cover a defect or wound. No Initial debridement +/- VAC In order for the ‘tissue’ to survive and healing to take place, the flap needs a blood supply. This comes from the Wound clean Wound not clean blood vessels supplying the original tissue, i.e. fascia or muscle, and the Does it need term ‘based’ is used to denote the further surgery or blood vessel that supplies the flap. reconstruction These ‘flaps’ can remain attached by their blood supply to their original location [pedicled flaps], or be divided Yes and re-attached by microsurgery to a new location [free flap]) (Tobin, 1989; Reconstruction with Further Leave to heal by Grevious, 2009). This flap can be used flaps +/- sternal fixation debridement/change secondary intention for ‘simpler’ wounds by dissecting only of VAC with regular dressing the medial portion of the muscle from changes +/- VAC the ribs and moving this medially over Continued infection/ the defect. One disadvantage of the non-healing wound pectoralis muscle flap is the resulting compromise in the functionality of the Figure 3. Flow chart summarising the management of sternal wounds. shoulder girdle.

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Figure 5a. A chronic non-healing dehisced sternal wound.

Figure 4. Pectoral muscle flap.

Rectus muscle flap (Figures 5a–5e) The rectus abdominus muscle forms part of the anterior abdominal wall. It provides abdominal flexion and offers support to the abdominal contents. The muscle originates from the pubic symphysis and crest and inserts into the costal cartilages. The rectus flap is based Figure 5b. The rectus abdominus muscle being Figure 5c. The rectus abdominus muscle divided on this muscle and it can be harvested identified intra-operatively. from its insertion and raised as a flap without the along with a skin paddle using a vertical overlying skin paddle. or transverse incision. Alternatively, the muscle can be used on its own and a split-skin graft placed over it. The rectus muscle flap is based on the superior and the inferior epigastric arteries (Coleman and Bostwick, 1989; Grevious, 2009), and the innervation is from the intercostal nerves. Figure 5d. The rectus abdominus muscle from the Figure 5e. A split skin graft applied over the If the internal mammary artery is abdomen is transposed onto the defect in the chest transposed rectus abdominus muscle to complete used for coronary bypass grafting, the to cover the sternal area. the procedure. contralateral rectus abdominus muscle should be used. There is, however, a the posterior cord of the brachial plexus. artery and the flap is based on the secondary blood supply from the eighth The flap can be developed to give a right omental artery. The versatility anterior intercostal perforator, but, in the pedicle of up to 10–15cm. However, the of the omentum enables coverage of authors’ experience, this is somewhat latissimus dorsi flap is not as commonly irregular defects and it has inherent unreliable. If there are concerns over used as the pectoralis or the rectus resistance to infection. However, since the blood supply or if both internal muscle flaps since pectoralis and rectus this flap is harvested via a laparotomy mammary arteries have been harvested, abdominus muscles are in closer vicinity (abdominal surgery), it has its own another flap option or a free flap to the sternum, and dissection and set of complications such as needs to be considered (Coleman and movement of these muscles leads to less to abdominal viscera, wound healing Bostwick, 1989; Grevious, 2009). functional deficit as compared to the problems, incisional hernias and spread latissimus dorsi muscle. of infection from the chest wall to Latissimus dorsi muscle flap the abdomen. The latissimus dorsi is a large muscle The omental flap (Figure 6) in the back that normally helps with The greater omentum is a connective To circumvent this, laparoscopic activities that involve the shoulder tissue structure found in the abdomen harvest techniques are being developed, girdle such as climbing and swimming. that has a role in combating infection although these are not widely used. This muscle flap is based on the and adhesions within the abdomen. In addition, as there is no option for thoracodorsal artery and is supplied by The omental flap is vascularised via a cutaneous island as part of the flap the thoracodorsal nerve that arises from omental branches of the gastroepipoloc (i.e. no skin covering), skin grafting over

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Key points

8 Sternal wound infection and dehiscence are important consequences of median sternotomy in cardiothoracic surgical procedures.

8 Sternal wound infections and dehiscence prolong recovery time, and increase hospital stay, re-operation rate, morbidity and mortality.

8 One should be alert to early Figure 6. Omental flap. warning signs such as local the top is required to complete the wound erythema, increased procedure. Previous intra-abdominal The constant motion exudate, pain, pyrexia and surgery or pathology may limit the and stress placed on the respiratory symptoms. usability of this flap (Jurkiewicz and sternum makes it a difficult Arnold, 1977; Grevious, 2009). area for bony healing. This 8 NPWT is a useful adjunct in the management of non- can lead to respiratory Bony union healing sternal wounds and To achieve complete healing of a insufficiency, chronic pain has reduced overall morbidity. complicated sternal wound, adequate and instability if sound bony fixation of the sternum must be achieved union is not achieved. 8 Most superficial dehiscences to ensure the optimum environment heal with good wound for healing and to prevent long-term care and regular dressings complications. The constant motion and can be tensioned more accurately than supplemented with NPWT, stress placed on the sternum makes it traditional sternal wires and they are less but major or complicated a difficult area for bony healing. This can prone to breakage and cutting into bone. sternal wound dehiscence lead to respiratory insufficiency, chronic They are also less expensive than sternal requires multidisciplinary input pain and instability if sound bony union is plates (Eich and Heinz, 2000). and reconstructive surgery. not achieved. The aim of sternal fixation is to achieve close opposition of the Literature suggests that rigid fixation sternal edges with minimal movement to of the sternum using plating techniques is allow the best environment for primary superior to traditional wiring techniques wires parasternally and weaving them bone healing to occur (Voss et al, 2008; (Voss et al, 2008). Plates, consisting of between the ribs, and reinforcing this Grevious, 2009). rigid titanium with locking screws, can further with ‘figure-of-eight’ wires passed be applied transversely or longitudinally across the sternal halves (Robicsek et The traditional approach to achieving (Cicilioni et al, 2005; Voss et al, 2008). al, 1977). Modification and variation of fixation of the sternum is sternal wiring. They allow primary closure or flap the Robicsek wiring technique as well as However, since wires can break, cut out, reconstruction to be performed on a other novel techniques for closure have loosen or cause skin problems, more stable base with reduced wound tension been subsequently described (Losanoff recently, sternal fixation using rigid plates (Cicilioni et al, 2005). et al, 2001a). and screws has been introduced. With this technique, a lower rate of sternal When sternal non-union occurs When there is extensive wound infections and a lower incidence alone or as part of a dehiscence, osteomyelitis of the sternum, fixation of non-union has been demonstrated removal of any existing fixation devices may not be possible, or, in cases where (Cicilioni et al, 2005; Voss et al, 2008). followed by debridement of devitalised metal work has become infected, and scar tissue and re-fixation is the resection of a portion of the sternum Another alternative is the use of Dall- treatment of choice. This can involve may be required. If the manubrium can Miles cables (Stryker) that are thicker re-wiring or plate fixation. One be preserved and stabilised, patients than traditional sternal wires and are established method is the Robicsek often have no major functional deficit tensioned using special equipment. They wiring technique that involves passing (Douville et al, 2004; Grevious, 2009).

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Conclusion and management. Ann Thorac Surg 61(3): Losanoff JE, Richman BW, Jones JW Sternal wound complications exist on a 1030–6 (2002b) Disruption and infection of spectrum of severity but, fortunately, a median sternotomy: a comprehensive Falor WH,Traylor R (1982) Extended review. Eur J Cardiothorac Surg 21(5): large proportion heal with appropriate indications for the median sternotomy 831–9 conservative management. Most incision. Am Surg 48(11) 582–3 superficial dehiscence heals with regular McDonald WS, Brame M, Sharp C, dressings and good wound care, but Farhat F, Metton O, Jegaden O (2004) Eggerstedt J (1989) Risk factors for median Benefits and complications of total sternotomy dehiscence in cardiac surgery. major or complicated sternal wound sternotomy and ministernotomy in cardiac South Med J 82(11): 1361–4 dehiscence requires multidisciplinary surgery. Surg Technol Int 13: 199–205 input and surgery. 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