An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience
Ryan P Cauley1, Sivana Barron1, Brianna Slatnick1
1Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Insights
Deep sternal wound dehiscence after sternotomy is challenging but manageable. An aggressive algorithm using debridement, flap closure, and rigid sternal fixation (RSF) shows good outcomes, with RSF not increasing reoperation risk in low-risk patients.
Area of Science:
- Cardiothoracic Surgery
- Surgical Site Infections
- Wound Healing
Background:
- Deep sternal wound complications following sternotomy present significant management challenges.
- Current treatments include debridement, flap reconstruction, and rigid sternal fixation (RSF).
Purpose of the Study:
- To evaluate the long-term outcomes of a standardized surgical treatment algorithm for deep sternal wound dehiscence.
- To assess the role and impact of rigid sternal fixation (RSF) in managing sternal dehiscence.
Main Methods:
- Retrospective review of 134 cardiac patients undergoing operative debridement for deep sternal dehiscence (October 2007 - March 2019).
- Data collected included demographics, perioperative factors, and patient outcomes.
- Univariate and subgroup analyses were performed to identify factors influencing outcomes.
Main Results:
- 112 patients (83.5%) underwent flap closure, and 56 (50%) received rigid sternal fixation (RSF).
- 30-day mortality was 3.9%. Median length of stay after debridement was 8 days.
- Fewer complications requiring reoperation, additional flaps, or plate removal were observed in patients needing only a single debridement.
Conclusions:
- An aggressive treatment algorithm involving debridement, flap closure, and consideration of RSF can lead to favorable long-term outcomes for sternal dehiscence.
- Rigid sternal fixation (RSF) did not appear to increase reoperation rates in low-risk patients.
- Earlier surgical intervention before systemic symptoms may improve patient outcomes.
Background:
Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.
Methods:
A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.
Results:
One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5-15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).
Conclusion:
Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.
