Management of sterno-mediastinitis using titanium mesh following cardiac surgery.

Dear Editor,

We read with great interest the article entitled “Management of sterno-mediastinitis" by Ennker et al. in your journals last issue [1].

Sterno-mediastinitis is rare but unfortunately lifethreating complication following cardiac surgery worldwide. Various techniques have been used to decrease morbidity and mortality to date. Current treatment algoritm consist of early and agressive surgical debridement, antibiotics and vacuum assisted wound closure systems. Although this combined approach could provide encouraging results, additional reconstructive techniques must be used in patients with tissue loss or poor sternal bone quality. Reconstruction of the anterior chest wall with flap plasty has been used since early 80’s. Flap plasty techniques are generally an obligation rather than preference because of complex nature of procedure requiring advanced surgical skill and high complication rate. Nowadays, titanium mesh offer new and less invasive alternative in patiens who have anterior chest wall defect in consequence of surgical debridement of infected tissue.

In our clinic we prefer agressive antibiotherapy in accordance with culture antibiogram, early and radical surgical debridement, titanium mesh plasty, and vacuum assisted wound closure system in patients with wide chest wall defect including sternum.

Surgical technique. Following agressive debridement, and removal of all infected materials we evaluated lost tissue in anterior chest wall. Titanium mesh (Surgical Titanium Mesh™, DePuy AcroMed, Inc) was tailored in appropriate size and shape. Free margins of resected sternum were strengtened with no: 1 sternal wires. Titanium plate was mounted with an aid of bone screws to undamaged remnant sternum or costaes (Figure 1).

Peroperative view of titanium mesh plasty.

Bilateral pectoral muscles were dissected and used to cover titanium plate. Skin incision was trimmed and closed with 3/0 prolene suture by matrix technique. Additionaly, vacuum assisted incision management system (PrevenaTM KCI Medical Products Ltd Wimborne, Dorset United Kingdom) was used for one week. Patient was discharged in well condition. The anterior chest wall was found stabil at the postoperative 3rd month control examination by computerized tomography (Figures 2, 3).

Control computerized tomography shows successful stabilization of the sternum.

Maximum intensity projection view of reconstructed sternum.

Limiting sternal motion between broken bone segments is one the most important principles for bone healing. In general practice, reinforcement of sternum with the Robiscek technique is preferred approach but may fail to achieve bone fixation particularly in cases who have significant bone resection. In this cases sternal stabilization with titanium mesh appears to be new alternative promising encouracing results [2,3,4].

In conclusion, we want to emphasize that treatment of sternal dehiscence with titanium mesh may provide favorable outcomes. This technique should be kept in mind to repair sternum with poor bone quality and large defect.