Transplantation of allogeneic bone graft in the therapy of massive post-sternotomy defects – 6 years of experience with the method
Authors:
M. Kaláb 1; J. Karkoška 2; M. Kamínek 3; P. Šantavý 1
Authors‘ workplace:
Kardiochirurgická klinika Lékařské fakulty Univerzity Palackého a FN Olomouc, přednosta: prof. MUDr. V. Lonský, Ph. D.
1; Národní centrum tkání a buněk, Brno, primář: MUDr. D. Hrůzová
2; Klinika nukleární medicíny Lékařské fakulty Univerzity Palackého a FN Olomouc, přednosta: doc. MUDr. P. Koranda, Ph. D.
3
Published in:
Rozhl. Chir., 2016, roč. 95, č. 11, s. 398-406.
Category:
Original articles
Overview
Introduction:
Early complications due to deep sternal wound infection pose a serious problem in cardiac surgery, with an up to 40% risk of mortality. Massive loss of sternum bone tissue and adjacent ribs results in major chest wall instability difficult to resolve using classical AO osteosynthesis procedures, causing respiratory insufficiency making the disconnection from artificial pulmonary ventilation difficult, and additional defects of soft tissue healing. Based on orthopaedic experience with bone defect replacement, we used the allogeneic bone graft method to reconstruct the chest wall.
Methods:
In the period of 2011−2015 we performed the transplantation of an allogeneic bone graft in 13 patients. In 10 cases, an allograft of the sternum was used, in one case an allograft of the calva bone and in two cases the crushed spongy bone was used. After primary cardiac surgery, a massive post-sternotomy defect of the chest wall developed in all the 13 patients due to deep sternal infection and osteomyelitis of the sternum and adjacent ribs. Vacuum wound drainage was applied in the treatment of all the patients. To stabilize the chest and the graft, transverse titanium plates were used, fixed using bicortical screws. The bone allograft was prepared by the official Tissue Centre. Crushed allogeneic spongy bone was applied to reinforce the line of contact of the graft and the edges of the residual skeleton. In 12 cases, the soft tissue was closed by direct suture of mobilized pectoral flaps. In one case, V-Y transposition of the pectoral flap was performed.
Results:
In 8 cases, healing of the reconstructed chest wall occurred without further complications. In 4 cases, additional re-suture of soft tissues and skin in the lower pole of the wound was needed while the patients were still in the hospital. However, excellent chest wall stability along with adjustment of respiratory insufficiency and a very good cosmetic effect in the wound were achieved in all the 12 cases. In two cases, explantation of the plates was required. In one case, severe concomitant complications and no healing of the wound resulted in death within half a year after the reconstruction. The median follow-up period of all patients in the series was 21 months (1−36). In 5 cooperating patients, scintigraphy of the chest wall was performed repeatedly during the follow-up period showing a high healing activity of the graft and particularly of the crushed spongy bone.
Conclusion:
Our existing results show that allogeneic bone graft transplantation is a promising and easily applied method in the management of serious tissue loss in sternal dehiscence with favourable functional and cosmetic effects.
Key words:
sternotomy − deep sternal wound infection − massive post-sternotomy defect − allogeneic bone graft
Sources
1. Julian OC, Lopez-Belio M, Dye WS, et al. The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evaluation of its use in heart surgery. Surgery 1957;42:753.
2. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21:831−9.
3. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996;61:1030−6.
4. Gaudreau G, Costache V, Houde C, et al. Recurrent sternal infection following treatment with negative pressure wound therapy and titanium transverse plate fixation, Eur J Cardiothorac Surg 2010;37 888−92.
5. Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence, Eur J Cardiothorac 2008;34:139−45.
6. Tarzia V, Carrozzini M, Bortolussi G, et al. Impact of vacuum-assisted closure therapy on outcomes of sternal wound dehiscence. Interact Cardiovasc Thorac Surg 2014;19:70−5. doi: 10.1093/icvts/ivu101.
7. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309−32.
8. Simek M, Hajek R, Fluger I, et al. Superiority of topical negative pressure over closed irrigation therapy of deep sternal wound infection in cardiac surgery. J Cardiovasc Surg (Torino). 2012;53:113−2.
9. Sbírka zákonů České republiky. Act No. 296/2008 Zákon o lidských tkáních a buňkách. Praha 2008.
10. European Association of Tissue Banks. General Standards for Tissue Banking, ÖBIG-Transplant, Vienna 1995.
11. Copeland M, Senkowski C, Ulcickas M, et al. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994;129:757−9.
12. Loop FD, Lytle BW, Cosgrove DM, et al. Maxwell Chamberlain memorial paper: sternal wound complications after isolated coronary artery bypass grafting: early and late mortality,morbidity and cost of care. Ann Surg 1990;49:179−87.
13. Song DH, Wu LC, Lohman RF, et al. Vacuum assisted closure for the treatment of sternal wounds: the bridge between debridement and definitive closure. Plast Reconstr Surg 2003;111:92−7.
14. Robicsek F, Fokin A, Cook J, et al. Sternal instability after midline sternotomy. Thorac Cardiovasc Surg 2000;48: 1–8. doi:10.1055/s-2000-9945.
15. Wettstein R, Erni D, Berdat P, et al. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis. J Thorac Cardiovasc Surg 2002;123:1185−90.
16. Shibata T, Hattori K, Hirai H, et al. Rectus abdominis myocutaneous flap after unsuccessful delayed sternal closure. Ann Thorac Surg 2003;76:956−8.
17. Lee Jr AB, Schimert G, Shaktin S, et al. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery. Surgery 1976;80:433−6.
18. Nahabedian MY, Riley LH, Greene PS, et al. Sternal stabilization using allograft fibula following cardiac transplantation. Plastic Reconstr Surg 2001;108:1284−8.
19. Chai Y, Zhang G, Shen G. Autogenous rib grafts for reconstruction of sternal defects after partial resection: a new surgical technique. Plast Reconstr Surg 2008;121:353−5.
20. De Feo M, Carozza A, Della Corte A, et al. Achilles tendon for sternal synthesis in the treatment of mediastinitis. Ann Thorac Surg 2005;79:359−60.
21. Demondion P, Mercier O, Kolb F, et al. Sternal replacement with a custom-made titanium plate after resection of a solitary breast cancer metastasis.Interact Cardiovasc Thorac Surg. 2014;18:145–7. doi: 10.1093/icvts/ivt456.
22. Rocco G. Overview on current and future materials for chest wall reconstruction. Thorac Surg Clin 2010;20:559−62.
23. Marulli G, Hamad AM, Cogliati E, et al. Allograft sternochondral replacement after resection of large sternal chondrosarcoma. J Thorac Cardiovasc Surg 2010;139:e69−70.
24. Stella F, Dell’Amore A, Dolci G, et al. Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma. Ann Thorac Surg 2012;93:e 71−2.
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Surgery Orthopaedics Trauma surgeryArticle was published in
Perspectives in Surgery
2016 Issue 11
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