Titanium plate fixation versus conventional approach in the treatment of deep sternal wound infection
Wang and Wang Journal of Cardiothoracic Surgery
Titanium plate fixation versus conventional approach in the treatment of deep sternal wound infection
Wei Wang 0
Shaohua Wang 0
0 Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta , Edmonton, AB , Canada
Background: Deep sternal wound infection (DSWI) is a serious complication post cardiac surgery and associated with increased mortality, morbidity and cost. Sternal titanium plate fixation could be an effective approach to treat DSWI. We sought to compare the effectiveness of titanium plate fixation with conventional approach in the treatment of DSWI. Methods: Retrospective data was analyzed from consecutive patients with DSWI post cardiac surgery who received either titanium plate fixation (sternal plate group) or conventional treatment with sternal debridement and rewiring (control group). Pre-operative risk factors and post-operative clinical outcome were compared between the 2 groups. Results: A total of 36 patients (mean age 65.0 ± 8.6, 63.9 % male) with DSWI were in the sternal plate group whereas 26 patients (mean age 64.0 ± 13.4, 65.4 % male) were in the control group. The mean follow-up period was 15.92 months. The major pre-operative comorbidities were comparable between the 2 groups. The rate of receiving multiple debridement procedures (≥3) was significantly lower in the sternal plate group (5.6 % vs. 26.9 %, P = 0.03). Patients in the sternal plate group had no treatment failure, whereas 42.3 % of patients in the control group had treatment failure requiring muscle flaps reconstruction by plastic surgery (0 % vs. 42.3 %, P < 0.001). There was a trend of lower in-hospital mortality (11.1 % vs. 19.2 %, P = 0.47) in the sternal plate group. Conclusion: Compared to conventional treatment, titanium plate fixation appears to have favorable clinical outcome.
Sternum; Wound infection
Median sternotomy remains the most commonly used
incision in patients undergoing cardiac surgery. Deep
sternal wound infection (DSWI) is a serious complication
post sternotomy. Although rates of DSWI are relatively
low (range 0.4 to 5.1 %) [
], it is associated with higher
mortality and morbidities, prolonged hospital stay, and
increased patient suffering and cost [
treatment of DSWI includes wound debridement, wound
vacuum therapy (VAC) and sternal rewiring . However,
dehisced and infected sternums are sometimes very fragile
that rewiring may not work, especially in patients with
multiple co-morbidities. Plastic surgery is often consulted
for chest wall reconstruction if rewiring fails to stabilize
the sternum [
Titanium sternal plate fixation is a relatively new
approach to treat DSWI. Early reports demonstrated
good clinical outcomes [
]. However, most of
previous studies were case series, and there was no
comparison between sternal plate fixation and conventional
treatment. In the current study, we sought to report our
experience of sternal plate fixation in patients with
DSWI post cardiac surgery, and to compare the clinical
outcome between these two approaches.
Retrospective data were analyzed from consecutive
patients with DSWI post cardiac surgery who received
titanium plate fixation (sternal plate group) from
November 2008 to July 2013 at Mazankowski Alberta
Heart Institute, University of Alberta. As comparison,
consecutive patients with DSWI who received
conventional treatment from January 2006 to October 2008
at the same heart institute before the titanium plate
was introduced were identified as the control group.
Pre-operative co-morbidities, post-operative mortality,
length of hospital stay (LOS), and recurrence rates of
infection were compared between the 2 groups. The
study was approved by the Health Research Ethics
Board, University of Alberta.
Preoperative blood cultures and wound swab were
conducted routinely for all the patients. Antibiotics were
given intravenously according to sensitivity results by
infectious disease team. In both groups, surgical wound
debridement followed by wound VAC therapy was
routinely used. During debridement, all previous sternal
wires were removed and wound edges including skin and
subcutaneous tissue were excised until the healthy tissue
was visible. A thin layer (1 mm) of bone was taken out
along both sternal edges with a sternal saw. Wound VAC
was set at negative pressure of 25–50 mmHg and changed
3 times a week. In the control group, sternal rewiring was
performed if applicable. Plastic surgery was consulted
when rewiring had failed. In the sternal plate group,
patients were deemed ready for sternal plate fixation when
good granulation was observed with no signs of local
infection. All sternal plate fixation procedures were
performed under general anesthesia. Bilateral composite
muscular-cutaneous flaps were developed to expose the
sternum and ribs to the midclavicular line. The Synthes
Titanium Sternal Fixation System was used. We first
reduced the sternum by using reduction forceps on both the
superior and inferior aspects of the sternum. Next, we
contoured the templates to the sternum and ribs, followed
by contouring the titanium plates to match the templates.
After anchoring the plates against the sternum and ribs
and confirming they had the correct shape, 8 to 10 screws
were screwed into the sternum and ribs. Three to four
transverse titanium plates were placed to achieve
complete sternal integrity. One “H” shape short plate was
often used at the top aspect of the sternum as very limited
muscular-cutaneous flaps could develop in this area
(Fig. 1). Bilateral small Hemovac drains were placed
between the sternal plates and the composite flaps. The
composite flaps were brought together with interrupted
No. 1 Vicryl (Ethicon Inc.) sutures. Skin was closed with
interrupted 3-0 prolene sutures. Patients in both groups
received intravenous antibiotics for a course of 6 weeks
after the last procedure.
Continuous data were reported as means ± standard
deviations (SD) and were compared by Student’s t-test.
Categorical data were reported as proportions and
compared using χ2 test. P value of <0.05 was adopted as
There were 36 patients (mean age 65.0 ± 8.6, 63.9 % male)
in the titanium plate fixation group and 26 patients (mean
age 64.0 ± 13.4, 65.4 % male) in the control group.
Demographic and pre-operative data were shown in Table 1.
The pre-operative comorbidities including hypertension,
hyperlipidemia, diabetes, body mass index, smoking,
chronic obstructive pulmonary disease (COPD), chronic
renal dysfunction and left ventricular ejection fraction
were all comparable between the 2 groups.
Post-operative clinical outcome was shown in Table 2.
Patients in the sternal plate group had a significantly lower
rate of having multiple (3 times or greater) debridement
procedures than patients in the control group (5.6 % vs.
26.9 %, P = 0.03). All patients in the sternal plate group
had stable sternum, whereas 42.3 % of patients in the
control group had treatment failure with unstable sternum
and required muscle flaps reconstruction by plastic
Abbreviations: HTN hypertension, DM diabetes mellitus, COPD chronic obstructive
pulmonary disease, BMI body mass index, LVEF left ventricular ejection fraction
Sternal plate group
(n = 36)
65.0 ± 8.6
(n = 26)
64.0 ± 13.4
surgery (0 % vs. 42.3 %, P < 0.001). Two patients in the
sternal plate group had failed rewiring previously.
Followup time was 6 to 47 months (mean 15.92 months) for all
patients. Although the mortality was much less in the
sternal plate group (11.1 %) than in the control group
(19.2 %), there was no statistical significant difference
between the 2 groups (P = 0.47). One patient in the sternal
plate group and one patient in the control group died
from sepsis and other deaths were not related to DSWI.
The hospital length of stay (LOS) was comparable
between the 2 groups (48.0 ± 46.0 vs. 57.4 ± 53.2 days,
respectively, P = 0.498). Five patients (13.9 %) in sternal
plate group and 5 patients (19.2 %) in the control group
had recurrent superficial sternal infection. Among those
patients, two (5.6 %) in the sternal plate group had plate
removal and one (3.8 %) in the control group had wires
removal due to chronic draining sinus.
Studies have shown that risk factors of DSWI post
cardiac surgery include prolonged intubation, bilateral
internal mammary arteries use, diabetes, post-op
bleeding, high body mass index (BMI) and combined surgery
]. Wound debridement, infection control and
achieving integrity of sternum by rewiring are the mainstays in
the management of DSWI. However, sternal rewiring
often fails to achieve sternum healing and stability due
to poor sternum quality and multiple fractures,
especially in patients who have advanced age, obesity,
diabetes and COPD. Failed rewiring can lead to partial
or complete sternum removal and consequent sternal
]. Although not reported very often, the rate of
primary rewiring failure can be as high as 45 % [
Our study showed similar results that even after multiple
debridement procedures, 42.3 % of patients in the
conventional treatment group had failure of rewiring
and required plastic surgery interventions. Titanium
sternal plate fixation is an effective and novel approach
to stabilize the sternum in patients with severe DSWI.
By pulling both the sternum and the ribs together, the
titanium plates have much stronger force to stabilize the
whole chest wall. It is important to note that rib-to-rib
plating does not provide consistent results. It is better to
salvage sternal fragments, if they are viable and use them
as anchoring points. In our study, none of the patients
who had received sternal plate fixation had sternum
instability. Indeed, 2 of the patients in the sternal plate
group were initially treated with rewiring but failed.
Sternal plates can also be used in patients who had
nonunion sternum post cardiac surgery without
sternal infection, especially when patients are in
Wound VAC system is an important supplementary
approach for DSWI management. The negative
pressure provided by wound VAC can reduce wound
edema and improve wound granulation and healing.
However, wound VAC alone did not decrease total
hospital stay [
], possibly because the sternum was
still unstable. Studies have shown that wound VAC
application followed by titanium sternal plating was a
good strategy to treat DSWI post cardiac surgery [
To date, the ideal duration of wound VAC therapy prior
to sternal plate application is not well defined. The
reported mean wound VAC therapy time varied from 2 to
5 weeks. Despite prolonged wound VAC time, the
recurrence rates of sternal infection were still high (9.8 to
18.2 %). Gaudreau et al suggested that the criteria for
switching wound VAC to sternal plate fixation
included: granulation tissue appeared in the wound;
repeated negative sternal wound cultures and low
Creactive protein levels . In our series, the decision
making to switch wound VAC to sternal plate fixation
was based on clinical assessment. Once the wound
looked healthy with good granulation and there were
no signs of systemic or local infection, sternal plate
fixation was carried out. Although the mean duration
of wound VAC before sternal plate fixation in our
study was relatively short (9.35 ± 9.99 days), there was
no recurrence of DSWI and the rate of recurrent
superficial sternal infection (13.9 %) was not higher
than others. Shortened wound VAC duration might
translate into shorter LOS and therefore reduces cost.
One concern of the titanium plate is recurrence of
infection after implanting large pieces of foreign body into
an already infected chest wall. In our series, 2 patients
(5.6 %) in the sternal plate group had plate removal due
to recurrence of superficial infection. However, at the
time of plate removal both patients had very stable and
fused sternum and no evidence of recurrence of deep
infection. Even though both patients required another
surgery to take out the plates, the quality of life was
much improved with lack of pain and breathing distress
due to moving sternum.
Our study has several limitations. Firstly, this is a
single center, retrospective cohort study. Although most
surgeons may agree that sternal plate fixation is an
effective approach for the treatment of DSWI post
cardiac surgery, a randomized control trial is warranted
to better compare this new approach with conventional
treatment. Secondly, our current study did not perform
cost efficient analysis. The titanium plate system is
expensive. However, it may have reduced the cost since
patients required less aggressive procedures.
In conclusion, titanium plate fixation appeared to be an
effective method in the treatment of DSWI post cardiac
surgery. Compared to conventional treatment, sternal
plate fixation is associated with less debridement
procedures and treatment failure.
The authors declare that they have no competing interests.
WW carried out the data collection and analysis, writing the manuscript. SW
designed the study and helped to draft the manuscript. Both authors read
and approved the final manuscript.
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