Application of transverse titanium plate refixation in deep sternal wound infection: a retrospective analysis.

Sir:

Deep sternal wound infection (DSWI) after cardiac operation remains a challenging problem for surgeons, and there is still a lack of consensus on its optimal surgical management. In recent years, the technique of sternum refixation by using titanium plate system in DSWI treatment has been reported in a few case reports,[1,2] and the results seemed to be quite encouraging. We present a retrospective case-controlled study to identify whether the titanium plate refixation would improve the outcome of patients with DSWI.

Between August 2006 and February 2012, 72 patients with DSWI were admitted into our department. We performed transverse titanium plate refixation of the sternum in combination with muscle flap reconstruction in 32 patients, and the other 40 patients received the conventional muscle flap reconstruction operations. Patients in both groups received the same pattern of antibiotic strategy and were comparable in sex distribution, recurrent DSWI cases, and DSWI risk factors (combined valve/CABG surgery, aortic surgery, left ventricular ejection fraction ≤ 30%, arterial hypertension, diabetes mellitus, current smoker, chronic obstructive pulmonary disease, renal insufficiency, and obesity). The only difference between the 2 groups was that patients in conventional treatment group were significantly younger than those in plate refixation group. All the patients were followed up for at least 18 months. Postoperative DSWI rate was significantly lower in plate refixation group (8.9% vs 40%, P < 0.05). Among patients who did not develop postoperative DSWI, the mean length of hospital stay was 12.4 ± 3.1 days in plate refixation group, significantly lower than 15.6 ± 3.1 days in conventional treatment group (P < 0.05). No significant difference was found between the 2 groups in mortality, major organ dysfunction, intensive care unit stay rate, or transfusion rate (Table 1).

Table 1.

Patient Characteristic and Clinical Outcomes

Sternal dehiscence had been demonstrated to have a direct relation with the development of sternal wound infection.[3] Good fixation and immobilization of the sternum could lead to an optimal bone healing, which might prevent sternal dehiscence after the operation, and would be able to decrease the recurrent rate of infection. For the technique of sternum restoration, rewiring the sternum often is futile because the bone is osteoporotic or has sustained fractures where the original wires have pulled through.[4] Titanium plate refixation had been demonstrated to be more secure than steel wires rewiring, especially at an early stage after the operation,[5] making it an optimal choice for patients with DSWI who had already failed a standard sternum closure. Solid fixation could restrict the motion between the 2 halves of the sternum and provided a stable plane between the anterior mediastinum and the superficial soft tissues, and this might lead to less output after the operation and earlier removal of the drainage tubes, thus to earlier discharge.

In conclusion, our study demonstrated that transverse titanium plate refixation of the sternum in combination with muscle flap reconstruction was able to reduce the incidence of postoperative DSWI and shorten the length of hospital stayin patients who did not develop postoperative DSWI.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.