Management of the recurrent sternal wound infection: DISCUSSION (part 1)
Long term outcome studies have shown some concern, even with these workhorse flaps, particularly as regards donor site morbidity . Abdominal wall hernias and bulges, usually due to use of a rectus abdominis flap, occur in one-third of patients. Abdominal weakness is noted in another one-quarter, occurring even if only the pectoralis major muscle has been used. Its transfer can also be incriminated as causing shoulder weakness in an additional one-third . There has been little discussion of an acknowledged risk of recurrence of sternal infection. In our experience, recurrences typically present as the type III wounds of Pairolero and Arnold with chronic draining sinuses usually caused by residual osteomyelitis, costochondritis, or a retained foreign body.
Mediastinitis was not present in any of our cases. These could be presumed to be a sequela of inadequate original debridement. Although careful elevation and reinsetting of the original flap may be possible following wider debridement, one must always be prepared to select another alternative as we indeed have had to do (case reports).
Accrued donor site morbidity and anticipation of future flap requirements serve to validate our admonishment for minimizing the number of flaps transferred initially for any sternal wound. With this in mind, every surgeon should establish a hierarchy of preferences. Our suggested schema is biased toward maximal utilization of the pectoralis major and rectus abdominis muscles with which we are most familiar. Other rarely chosen alternatives include the latissimus dorsi or external oblique muscles, or omentum which requires a laparatomy. It’s your turn to find birth control mircette … to see how advantageous your shopping can be.
Tags: Median sternotomy, Muscle flaps, Sternal wound infection