Deep Sternal Wound Infections (eBook)

Univ.-Prof. Dr. med. Dr. h.c. Raymund E. HorchUniversitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-NürnbergProf. Dr. med. Christian WillyAbteilung Unfallchirurgie und Orthopädie, Septische und Rekonstruktive ChirurgieWundzentrum (ICW e.V.), Bundeswehrkrankenhaus BerlinProf. Dr. med. Ingo KutschkaKlinik für Herz- und Thoraxchirurgie, Otto-von-Guericke-Universität Magdeburg

Preface 5
Table of content 6
Editors 8
Authors 9
1Definition, Classification, and Epidemiology of Sternal Osteomyelitis 11
Definition 12
Classification 12
Epidemiology and Economic Considerations 13
2Anatomy and Blood Supply of the Sternum 16
Bony Anatomy 17
Relationship to Muscles 17
Development 18
Arterial Supply 19
3Pathophysiology of Sternal Osteomyelitis 22
Role of Bacteria 23
Biofilm 23
Caveats and Treatment Implications 24
4Stabilization of Thoracic Wall and Ventilatory Function by Negative Pressure Wound Therapy 26
Background 27
Sternal Instability and Flail Chest 27
Implications of Deep Sternal Wound Infections 27
5Radiological Diagnostics of Postoperative Sternal Osteomyelitis 30
Background 31
Computed Tomography 31
Radionuclide Imaging 32
X-rays 33
Magnetic Resonance Imaging 34
6Microbiological Aspects and Epidemiological Data of Poststernotomy Deep Sternal Wound Infection 37
Introduction 38
Literature Search 38
Results 38
Frequency of DSWI 38
Spectrum of Pathogens 40
Conclusions for Clinical Practice 42
7Primary Wound Management of Poststernotomy Infection 45
Prevention 46
Diagnosis 46
Treatment 46
How We Do It 47
8Negative Pressure Wound Therapy in Poststernotomy Deep Sternal Wound Infection 49
Introduction 51
The Principle of NPWT 51
Functional Principle 51
Example of Application 51
Effects on Wound Healing 52
Handling and Duration of Application 54
Literature Overview 54
Literature Search and Selection Method 54
Results 55
Aspects of Evidence-Based Medicine 56
Science Behind NPWT in DSWI 60
NPWT-Induced Change in Perfusion 60
Effects of Different Suction Strengths on Wound Sealing 69
Decontamination, Bacterial Clearance, and Immunological Effects of NPWT 69
Molecular Mechanisms in Wound Healing with NPWT 71
Microdeformational Effects of NPWT 72
Effect on Topical Antibiotic Concentrations 74
Technical Aspects of NPWT in Treatment of DSWI 74
Selection of Foam Material 74
Selection of Suction Strength 74
Selection of Vacuum Source 75
Complications of NPWT in DSWI 75
Contraindications 76
Conclusions for Clinical Practice 76
9Bone Stabilization Methods After Sternal Osteotomy 82
Introduction 83
Standard Technique of Sternal Osteosynthesis 83
Different Sternal Closure Techniques 84
Sternal Osteosynthesis Under Special Conditions 84
Sternal Osteosynthesis in Neonates and Infants 86
10Principles of Plastic Surgery in Sternal Osteomyelitis 89
Introduction 90
Involvement of the Plastic Surgeon 90
Principles of Regional Flaps Versus Free Flaps 90
Managing the Microbiobial Burden of Sternal Wounds During Defect Coverage 92
Principles of Plastic Surgical Management 92
Preventive Plastic Surgery in High-Risk Patients (Flap Delay) 93
11Plastic Surgical Methods of Defect Coverage in Sternal Osteomyelitis with Pedicled Flaps 96
Introduction 97
Pectoralis Major Flap 98
Rectus Abdominis Flap 99
Latissimus Dorsi Flap 101
Greater Omentum Flap 103
Conclusion 104
12Indications for Free Flap Coverage and Interdisciplinary Combined Approaches with Vascular Surgery AV Loops 106
Introduction 107
Indications for Free Flap Reconstruction 107
Surgical Procedure of Free Flap Transplantation and Combined Approaches 108
Conclusion 112
13Anesthesiological Management 114
Introduction 115
Anesthesiological Management of DSWI 115
Basic Monitoring 116
Advanced Monitoring 116
Echocardiography 117
Anesthetic Considerations and Intraoperative Management 117
14Rehabilitation After Sternal Osteomyelitis 119
15Prevention of Poststernotomy Wound Infections by Closed Incision Negative Pressure Therapy 122
Introduction 123
Literature Review: The Randomized Trials 123
Clinical Experiences With ciNPT 129
How Does the Cost–Benefit Analysis Look? 131
Can Evidence-Based Recommendations Be Formulated for ciNPT Use? 131
Patient-Related Risk Factors in Sternotomy 131
Operation-Related Risk Factors 132
Conclusion 133
Servicepart 137
Index 138