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Ann Thorac Surg 2004;77:672-675
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Superficial wound dehiscence after median sternotomy: surgical treatment versus secondary wound healing

^a Division of Cardiac Surgery, Tor Vergata University, Rome, Italy

Accepted for publication August 6, 2003.

^* Address reprint requests to Dr Zeitani, Division of Cardiac Surgery, Tor Vergata University, European Hospital, Via Portuense 700, 00149 Rome, Italy.
e-mail: zeitani{at}hotmail.com

	Abstract

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BACKGROUND: Superficial wound dehiscence after midline sternotomy is considered a minor complication in cardiac surgery, although it is quite frequent and requires prolonged medical treatment. It can be managed conventionally by topical treatment, with delayed secondary healing, or by surgical treatment and primary skin closure. We report the outcome of 96 patients who underwent conventional treatment, compared with a second group of 42 patients who underwent surgical treatment and direct closure.

METHODS: From October 1999 to December 2002, 2400 consecutive patients underwent median sternotomy: 207 patients had sternal wound complications: 3 patients (0.125%) had mediastinitis, 66 patients (2.75%) had aseptic deep sternal wound dehiscence, and 138 patients (5.75%) had superficial wound dehiscence. The latter are the object of the present study; patients entered a protocol of skin wound care on an outpatient basis. The first 96 consecutive patients (group 1) required medications three times a week until complete healing. The last 42 patients (group 2) were treated by extensive surgical debridement of skin and subcutaneous tissue, direct closure of the superficial layers, and suture removal after 15 days.

RESULTS: The two groups were comparable as to age, sex, and preoperative risk factors. The incidence of contaminated wounds was similar in the two groups (32 of 96 in group 1 and 11 of 42 in group 2; p = NS). The length of treatment was 29.7 days (range 2 to 144 days) for group 1 and 12.2 days (range 2 to 37 days) for group 2 (p < 0.0001). The mean number of medical treatments was 9.4 per patient in group 1 and 3.7 per patient in group 2 (p < 0.0001).

CONCLUSIONS: Surgical debridement and primary closure of superficial surgical wound dehiscence after median sternotomy is a safe and valid treatment. Wound infection is not a contraindication to surgical treatment. Primary closure may contribute to reduce the risk for later infection. It also definitely contributes to decreasing healing time and strongly lessens patients' discomfort, diminishing hospital costs and hospital staff workload.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Median sternotomy is used to approach thoracic organs in most cardiac surgery procedures. Superficial wound dehiscence (SWD) after midline sternotomy is considered a minor complication in cardiac surgery, although it is quite frequent [1], and requires prolonged medical treatment. Moreover, nonhealed, aseptic wounds might experience superimposed infection. This is especially common in patients with diabetes mellitus or other unfavorable conditions, such as malnutrition, obesity, or reduced immune response. These concomitant factors increase patient's risk for possible extension to mediastinal sepsis (and involvement of mediastinal organs and prosthetic material).

Superficial wound dehiscence can be managed by topical treatment, with delayed secondary healing, using irrigation of disinfectant agents and gauze packing. Alternatively, surgical treatment consists of extensive debridement and primary skin closure.

Prolonged treatment, patients' discomfort, and medical staff involvement required for secondary wound healing encouraged us to try surgical treatment and primary closure. We report the outcome of 96 patients who underwent conventional treatment compared with a second group of 42 patients who underwent surgical debridement and direct closure.

	Material and methods

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From October 1999 to December 2002, 2400 consecutive patients underwent median sternotomy for open heart surgery at our institution. Surgery was performed after skin disinfection with povidone iodine and intravenous antibiotic prophylaxis with 2 g of ceftizoxime. The sternum was reapproximated using stainless steel wires. The fascia and the subcutaneous layers were routinely closed with two continues absorbable #0 polyglycolic acid (Dexon) suture lines and the skin with an intradermic absorbable #4-0 polyglycolic acid (Dexon) suture line. 207 patients had sternal wound complications: 3 patients (0.125%) had mediastinitis, 66 patients (2.75%) had aseptic deep sternal wound dehiscence with mobile sternal edges, and 138 patients (5.75%) had SWD. Therefeore, the latter was defined as dehiscence involving the skin, subcutaneous and fascia layers with stable sternum edges, farther divided into aseptic (negative cultures) and septic (positive cultures). Among the 138 patients with SWD, 112 patients (81.2%) had previous isolated coronary artery bypass grafting, 12 patients (8.7%) had valve replacement, and 14 patients (10.1%) had a combined operation. After exclusion of sternal bone and mediastinal organ involvement, the patients entered a protocol of skin wound care on an ambulatory basis.

The first consecutive 96 patients (group 1) were treated by local debridement of fibrin deposition and medication with solution of chloramine (Dakin) steeped gauzes. Medications were then repeated in the outpatient clinic three times a week, until complete healing. The last 42 patients (group 2) were treated by extensive surgical debridement of skin and subcutaneous tissue and direct closure of the superficial layers. Depending on severity of wound dehiscence they were treated in the outpatient clinic, using local anesthesia, or temporarily readmitted to the surgical ward, operated on under general anesthesia, and discharged home after 24 hours. In these patients surgical debridement included necrotic and devascularised tissue. In some patients, when wound dehiscence was particularly large and tension on suture lines was expected, the subcutaneous layer was widely mobilized. However, it was not necessary to mobilize the pectoralis major muscles in any patient. Use of the electrocauthery was avoided to prevent tissue damage. The subcutaneous and skin layers were first reapproximated by large #2 silk interrupted sutures, placed at a 2-cm distance from each other, and made tight. Approximation of the skin edges was then improved by placement of several loose #2-0 silk interrupted sutures. No absorbable suture lines for the subcutaneous layer were used. Culture samples were taken before the treatment. A single intravenous injection of 2-g ceftizoxime was given before the procedure to patients with aseptic wounds; an antibiogram-guided antibiotic therapy was given to patients with positive cultures.

The two groups were compared with regard to known preoperative risk factors for surgical wound dehiscence and infection by means of ² table or two-tail t test for unpaired data, for dichotomic or continues variables, respectively. The number of required medications and length of treatment were compared with two-tail t test for unpaired data. A p value less than 0.05 was considered statistically significant.

	Results

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The two groups were comparable as to age, sex, and preoperative risk factors, such as diabetes and chronic obstructive pulmonary disease (Table 1). The incidence of contaminated wounds, defined as wounds with positive cultures, was similar in the two groups (32 of 96 in group 1 and 11 of 42 in group 2; p = NS). The type of bacteria isolated from contaminated wounds are reported in Table 2.

The length of treatment was 29.7 days (range 2 to 144 days) for group 1 and 12.2 days (range 2 to 37 days), including the day of surgical direct closure and sutures removal, for group 2 (p < 0.0001). The mean number of medical treatments was 9.4 per patient in group 1 and 3.7 per patient in group 2 (p < 0.0001).

	Comment

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Median sternotomy was first advocated by Julian and associates in 1957 [2], and is currently used in most cardiac surgical procedures. While mediastinitis is rare [3, 4], superficial wound dehiscence occurs more frequently [5]. In our department, approximately 6% of all patients undergoing cardiac surgery procedures experience superficial wound dehiscence, with or without bacterial contamination. Jonkers and coworkers [1] reported a 7.7% occurrence rate. The relatively high rate of this complication can be attributed to several risk factors: diabetes mellitus, obesity, chronic obstructive pulmonary disease, low cardiac output, advanced age, and chronic renal failure are all known to increase the risk of incision dehiscence [6, 7]. Surgical techniques might also favor this complication; for example, harvesting of the internal mammary arteries [8–11] has been revealed to reduce blood supply [12] to the sternum and Seyfer and colleagues [13] were able to demonstrate a 90% decrease of blood supply to the hemisternum where the internal mammary artery was mobilized. Also, instability of sternum after closure may increase tension on the suture lines, as reported by Shafir and coworkers [14], who identified paramedian sternotomy as the main risk factor causing wound complications. Different surgical techniques have been proposed in order to reduce superficial wound dehiscence, especially in obese patients [15–19].

Recently, a vacuum-assisted closure (VAC) system has been introduced in cardiac surgery as a method to treat wound dehiscence. Tang and associates [20] reported the use of VAC (KCI, Oxfordshire, UK) for deep and superficial wound dehiscence. They reported a mean duration of treatment of 27 days (range 8 to 66 days), changing wound dressing every 48 hours. Although all patients experienced complete healing, this procedure appears costly and time consuming. In fact, considering the healing time and the number of medications per patient, it seems comparable with the topical treatment and secondary wound healing approach.

The following factors encouraged us to try primary SWD closure regardless of the presence of positive cultures: less patient discomfort and less medical staff involvement due to the shorter length of treatment.

Our data indicate that superficial wound dehiscence, with or without superimposed infection, was treated effectively both by a conservative approach and a more aggressive surgical strategy. However there was a striking difference in the length of treatment, such as the number of required medications, between the two methods, with the surgical method clearly proving most effective.

It has to be pointed out that we did not use a separate suture line to close the subcutaneous layer. Patients with wound dehiscence returned to our unit after a mean period of 29.3 days (range 4 to 115 days) after operation. At that time, due to inflammatory process, the subcutaneous tissue would lose its elasticity and the suture line under tension will cut through. Therefore we included both the subcutaneous and skin layers in the interrupted unabsorbable suture line. Most patients in group 2, regardless of culture results, underwent surgical revision of the wound dehiscence within 2 to 3 days from presentation at the outpatient clinic.

Faster healing means reduced hospital cost and reduced need of nurses and physicians for a prolonged ambulatory care, because most patients requiring repeated medications would return to the hospital for treatment. In all patients in group 1 repeated medications were performed on an outpatient basis, with a mean of 29.7 visits (range 2 to 144 visits) per patient, lasting for a mean of 4 weeks (range 1 to 48 weeks). Direct closure would have greatly reduced discomfort and loss of time in most of these patients; moreover, ambulatory care often requires involvement of other members of the patient's family.

Faster healing might also prevent migration of a superimposed infection to the mediastinum, which has been described as a life-threatening complication in conservative treatment of superficial wound dehiscence [21], especially in patients with concomitant risk factors, such as diabetes mellitus, poor nutritional status, or advanced age.

The presence of a superficial superimposed infection does not seem to contraindicate direct closure in our experience, as suggested by the prompt healing observed in most patients with positive cultures. Nevertheless, failure of primary closure was observed in 2 of 11 patients (18%) with positive cultures, which required topical treatment and subsequently underwent an uneventful secondary healing. Both patients had positive cultures for Staphylococcus aureus; 1 patient required revision of the lower two-thirds of the sternal wound and presented only minor bacterial contamination (10,000 colonies); the other patient required revision of the lower third of the wound and bacterial contamination was high (> 10⁵ colonies). The other 7 patients who presented positive cultures for Staphylococcus aureus experienced complete healing. The extension of wound dehiscence and the amount of bacterial colonies was high in most patients: 3 patients required revision of the all length of the sternal wound and presented extensive to confluent bacteria colonies (1 patient had < 10⁵ colonies, and the other 2 patients had > 10⁵ colonies); and 4 patients required revision of one-third to two-thirds of the wound, and also presented extensive to confluent bacterial contamination.

In conclusion, aggressive surgical debridement and direct primary closure of superficial wound dehiscence after median sternotomy seems to be a safe and effective treatment. A positive culture of open wounds does not seem to contraindicate primary closure and may reduce the risk of spreading infection. When compared with secondary healing, the healing time, patients' discomfort, hospital costs, and hospital staff involvement are significantly reduced.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Jonkers D., Elenbaas T., Terporten P., Nieman F., Stobberingh E. Prevalence of 90-days postoperative wound infections after cardiac surgery. Eur J Cardiothorac Surg 2003;23:97-102.[Abstract/Free Full Text]
2. Julian O.C., Lopez-Belio M., Dye W.S., Javid H., Grove W.J. The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evolution of its use in heart surgery. Surgery 1957;42:753-761.[Medline]
3. Culliford A.T., Cunningham J.N., Jr, Zeff R.H., Isom O.W., Teiko P., Spencer F.C. Sternal and costochondral infections following open-heart surgery: review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:714-726.[Abstract]
4. El Oakley R.M., Wright J.E. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61:1030-1036.[Abstract/Free Full Text]
5. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
6. Wilson A.P.R., Livesey S.A., Treasure T., Gruneberg R.N., Sturridge M.F. Factors predisposing to wound infection in cardiac surgery: a prospective study of 517 patients. Eur J Cadiothorac Surg 1987;1:158-164.[Abstract]
7. Ottino G., De Paulis R., Pansini S., et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173-179.[Abstract]
8. Uva M.S., Braunberger E., Fisher M., et al. Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients?. Ann Thorac Surg 1998;65:2051-2055.
9. Calafiore A.M., Contini M., Vitolla G., et al. Bilateral internal thoracic artery grafting: long-term clinical and angiographic results of in situ versus Y grafts. J Thorac Cardiovasc Surg 2000;120:990-998.[Abstract/Free Full Text]
10. Lytle B.W. Skeletonized internal thoracic artery grafts and wound complications. J Thorac Cardiovasc Surg 2001;121:625-627.[Free Full Text]
11. Matsa M., Paz Y., Gurevitch J., et al. Bilateral skeletonized internal thoracic artery grafts in patient with diabetes mellitus. J Thorac Cadiovasc Surg 2001;121:668-674.[Abstract/Free Full Text]
12. Arnold M. The surgical anatomy of sternal blood supply. J Thorac Cardiovasc (Ann Thorac Surg) 1972;64:596-610.
13. Seyfer A.E., Shriver C.D., Miller G.M., Graeber G.M. Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries. Surgery 1988;104:899-904.[Medline]
14. Shafir R., Weiss J., Herman O., Cohen N., Stern D., Igra Y. Faulty sternotomy and complications after median sternotomy. J Thorac Cardiovasc Surg 1988;96:310-313.[Abstract]
15. Robicsek F., Daugherty H.K., Cook J.W. The prevention and treatment of sternum separation following open heart surgery. J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]
16. Pezzella A.T., Fall S.M., Pauling F.W. Management of high-risk sternotomy wounds with retention sutures. Tex Heart Inst J 1987;14:293-296.
17. Nishida H., Grooters P.K., Merkley D.F., Thieman K.C., Soltanzadeh H. Post-operative mediastinitis: a comparison of two electrocautery techniques on presternal soft tissues. J Thorac Cardiovasc Surg 1990;99:969-976.[Abstract]
18. Lamm P., Gödje O.L., Lange T., Reichart B. Reduction of wound healing problems after median sternotomy by use of retention sutures. Ann Thorac Surg 1998;66:2125-2126.[Abstract/Free Full Text]
19. Totaro P., Lorusso R., Zogno M. Reinforced sternal closure for prevention of sternal dehiscence in high risk patients. J Cardiovasc Surg 2001;42:601-603.[Medline]
20. Tang A.T.M., Ohri S.K., Haw M.P. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg 2000;17:482-484.[Abstract/Free Full Text]
21. Molina J.E. Primary closure for infected dehiscence of the sternum. Ann Thorac Surg 1993;55:459-463.[Abstract]

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