Management of Patients (ASA III, IV) with Sternum Osteomyelitis

The authors reported on their treatment of a selective group of patients with sternum osteomyelitis. The patients had had multiple previous operations ( El Oakley III to V) and their overall morbidity led to a classification of ASA III or IV. All patients needed a free flap for chest wall reconstruction.

Between March 2003 and October 2004, the authors treated 7 patients, 4 women and 3 men, with an average age of 64 (34–76) years. All patients received a free tensor fasciae latae (TFL) flap. No flap was lost. Twice the anastomoses had to be revised with a subsequent uneventful courses. The operating time was 5.98 (4.7-7.3) hr on average. The procedure was always performed with two teams, and no repositioning was necessary. The postoperative ventilation time was 180.5 (9–338) hr on average. The mean hospital stay was 51 (13-135) days. Three patients died within 6 months postoperatively due to multiple organ failure.

The free TFL flap is the authors' flap of choice in these seriously ill patients with sternum osteomyelitis. It is reliable, easy to harvest, and without a noticeable donor site morbidity. The semi-rigid layer of the fascia lata is an important component of the flap that provides additional structural support at the site of chest-wall reconstruction. In the last four reported cases, the descending branch of the lateral circumflex femoral artery was included in the flap and a combined TFL/ALT free flap was raised. This modification augmented the blood flow to the former distal part of the TFL and helped in the overall survival of the flap.

The authors also anastomose the flap to an arteriovenous loop that runs from the thoracoacromial artery to the cephalic vein. With this technical maneuver, the receipient vessels are readily available at the time of anastomosis, and positioning of the flap is much easier. This proposed strategy lowers the costs of treatment in this selective group of patients. Despite this management, three patients were lost. But a persistent, fungating defect that is painful, infected, and bleeding is hardly an alternative for a patient's remaining life span.