Search

The presumption that computed tomography is the "gold standard" imaging method for diagnosing poststernotomy sternal wound infection was never validated. This study was designed to evaluate the accuracy and role of computed tomography in diagnosing the extent of infectious complications following sternotomy. A high postoperative infection recurrence rate in our earliest cases (30 percent, 1984 to 1988) motivated us to assess whether this modality enables the surgeon to choose the optimal surgical approach, which will make it possible to reduce morbidity and mortality rates. Two-hundred three patients with poststernotomy sternal wound infections were operated upon between 1984 and 1993. All pertinent clinical and radiological data of these patients were collected retrospectively and reinterpreted by an unbiased radiologist; the radiological data were correlated both to the intraoperative clinical findings and to histological interpretation of the surgical specimens. The study group available for statistical analysis included 160 patients. Predictive statistical analysis confirmed that computed tomography is a highly reliable imaging method for identifying the different pathologies as soft tissue, sternum mediastinal infections, in sternal wound infection with overall sensitivity of 93.5 percent and specificity of 81.7 percent. New radiographic findings were identified for the distinction of costochondral infection. This complication was, and still is, a major deceptive clinical problem in these patients and the major contributor to recurrences. We propose a sternal wound infection classification system that outlines the recommended approach for each clinical-radiological condition. Since computerized tomography was found to be a highly accurate modality, we strongly believe that the surgeon should take its pathological-radiographic findings into serious consideration, even if there are no "clear-cut" clinical signs for an existing or recurring infection.

The objective of the study was to evaluate the lung function of patients with median sternotomy wound complication during the early postmedian sternotomy period and to compare the long-term pulmonary effects of reconstruction using pectoralis major and rectus abdominis muscle flaps. The percentage of predicted, standardized forced vital capacity (FVC); the standardized forced expiratory volume in 1 second (FEV1), and FEV1/FVC ratios of 45 patients with a median sternotomy wound complication were evaluated before and at a mean time of 10.6 months after wound reconstruction. Both mean FVC and FEV1 increased after wound revision compared with the prereconstruction results (8.4% and 9.2% increase, respectively). Patients with painful chest wall movement had the worst (60%) mean FVC and FEV1 before reconstruction when compared with a nonpainful complication. Reconstruction with a muscle flap was followed by an increase of 8.6% and 7.3% in FEV1 and FVC, respectively, from prereconstruction results. However, long-term results indicate that these patients have a mild, restrictive impairment of their lung function tests (LFTs), with about 80% of the predicted FVC and FEV1. Among the muscle flaps, the best improvement and best long-term LFT results were after sternectomy and reconstruction with a pectoralis major muscle flap as compared with a rectus abdominis muscle flap. Sternectomy and reconstruction with a muscle flap is a well-tolerated procedure associated with improvement of lung function compared with prereconstruction values. A pectoralis major muscle flap should be the first choice for muscle flap reconstruction while a rectus abdominis muscle flap should be reserved only for patients with good LFTs before reconstruction.

During 1984-1992 162 patients with post-sternotomy sternal wound infections were treated. Between 0.4-5% of these undergoing sternotomy suffer from this complication which carries a mortality of about 50% when treated by conventional, nonsurgical methods. 80% of our patients had undergone aortocoronary bypass surgery and 11% valve replacement. Major risk factors identified for postoperative infection were prolonged mechanical ventilation, prolonged extracorporeal bypass, smoking, diabetes, obesity and chronic lung disease. Of 152 patients who underwent surgery, 35 had recurrent infections, especially during the first years of the study. 10 were managed by conservative methods. Reconstruction of the chest wall was performed in 125, using pectoralis major flaps (74 cases), rectus abdominis muscle flaps (53), myocutaneous flaps (5) and omental flap (1). Our series demonstrates the importance of a comprehensive, multi-disciplinary approach in evaluating and stabilizing these often critically ill patients. Computed tomography together with sinography have proven to be of major importance in diagnosing the location and extent of sternal wound infections. Strict adherence to antibiotic protocols, radical debridement of infected bone and soft tissues and subsequent reconstruction with muscle flaps has enabled us to reduce recurrent infection and improve morbidity and mortality rates.