Patient's condition based algorhythm in the management of sternal dehiscence leads to an excellent outcome

Objectives: Sternal dehiscence (SD) is a rare but serious complication after median sternotomy. SD may be caused by deep sternal wound infection possibly extending to mediastinitis with sepsis or may be related purely to sternal osteosynthesis' mechanical breakdown. The management of affected patients is still challenging. We retrospectively analyzed our patient's condition based algorhythm (PCBA) based on the concept of delineating infected from non infected cases.

Methods: From 01/2009 until 09/2011 3988 patients underwent cardiac surgery via median sternotomy in our institution. SD was diagnosed in 47 patients (1.2%). These patients were managed according to a clinical algorhythm.

Group 1 (n=12, 62.8±7.8 years, BMI 30.7±5) was characterized by a CRP <100mg/l and normal WBC, no fever, absence of psychotic syndrome and a firm bone quality. The sternum was immediately refixated using titanium plate osteosynthesis and/or Nitinol clips and/or sternal wires.

In group 2 (n=35, 68.9±10.8 years, BMI 27.5±4.3) patients with at least one of the following symptoms: fever, elevated CRP, elevated WBC, presence of psychotic syndrome or extenuated bone quality underwent a staged approach. Initially sternal wires were removed and a vacuum assisted closure device was inserted. Secondary after clinical stabilization and improvement of symptoms sternal osteosynthesis was performed as in group 1.

Results: In group 1 neither death nor multi organ failure (MOF) occurred. Mean postoperative ventilation time was 3.8±7.1 hours. None of these patients required long term ventilation.

In group 2 sternal refixation was performed 10.3±5.3 days after initiating of vacuum therapy. Three patients died from sepsis induced MOF (8.6%). MOF was successfully treated in 6 patients. Mean postoperative ventilation time was 217.8±625.6 hours. Seven patients required long term ventilation ranging from 152 to 3216 hours.

All survivors were discharged with a stable sternum and a closed sternal wound. In our experience sternal dehiscence including deep sternal wound infection and primary osteosynthesis break down led to a mortality of 6.4%.

Conclusions: Managing patients with sternal dehiscence by delineating between sternal instability and deep sternal wound infection and appling a cause adapted concept provides excellent results.

Furthermore using a staged approach in patients with deep sternal wound infection results in an outstanding clinical and functional outcome.