The midline sternotomy made its entrance into the clinical world, but not without complications. Sternal infection was on the rise. Sternal dehiscence was treated with open drainage and debridement with packing. Results included complications like graft exposure, desiccation of wound margins, osteomyelitis, and death. In 1963, Shucker and Mandelbaum introduced closed management with catheter-antibiotic irrigation. Survival rates increased, but they were still pretty slim. With the mortality risks, there was great desire to discover better wound care.
Changes in Management
First of all, sternal instability was causing mediastinal infections of the wounds. The surgeon must take the time to use the meticulous technique when doing a sternotomy. Proper placement reduces the risks of mediastinitis.
The principles of wide debridement and muscle and mucocutaneous flap translation entered the stage and helped manage infected sternal wounds. In 1976 Lee, et al. introduced the concept of flaps to reduce dead space in the anterior mediastinum. A few years later in 1980 Jurkiewicz continued to improve the management of sternal dehiscence and wound infection by the concept of muscle and mucocutaneous flaps.
The use of vascularized regional tissue meant:
- Greater blood flow
- Obliteration of dead space
- Quicker healing time
- Less infection
Other flaps have been introduced to help repair chest walls. Finally, the mortality rate dropped to 10%. Things weren't yet perfected, however, and soft tissue flaps don't repair the bony sternum (resulting in pain, paradoxical motion and impaired pulmonary function testing). Vacuum-assisted closure devices provide a solution to bridge the gap between debridement and reconstruction.
Today many surgical strategies are in use, including flaps. Reconstruction is continually being refined to avoid the issue of bony sternal repair. A newer device is the sternal clamp to reduce sternal instability.
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