Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A
Division of Plastic Surgery, Inselspital University Hospital, Berne, Switzerland.
J Thorac Cardiovasc Surg. 2002 Jun;123(6):1185-90. doi: 10.1067/mtc.2002.121304.
Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach.
Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies).
Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups.
We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.
正中开胸术后胸骨骨髓炎与相当高的发病率和死亡率相关。已证明使用肌肉和大网膜瓣是对抗这些严重感染的有效辅助手段。在本研究中，我们介绍了一种更激进方法的经验。
胸骨切除术包括切除整个胸骨，包括肋软骨弓和胸锁关节，然后用肌皮瓣修复缺损，胸壁不进行任何再稳定处理。13例患者接受了腹直肌垂直肌皮瓣，14例患者接受了带蒂背阔肌肌皮瓣，12例患者接受了游离背阔肌肌皮瓣（在6078例接受胸骨切开术的患者中，66例因胸骨骨髓炎需要手术翻修的患者中的39例共使用了40个皮瓣）。
2例患者在术后30天内死亡（早期死亡率为5.1%）；然而，他们并非死于胸骨感染，所有病例的胸骨感染均治愈且无复发。17例患者（44%）因局部并发症需要进行二次手术，多数为小手术。尽管存在一些反常的胸部运动，但在长期随访（0.4至8.5年，中位时间2.3年）中患者满意度一致较高。三组的短期和长期并发症发生率相似。
我们得出结论认为，即使在最严重的病例中，根治性胸骨切除术和立即进行肌皮瓣修复也能对胸骨感染提供确切控制，从而降低感染相关死亡率。权衡之处是局部并发症发生率较高；然而，这些并发症并未导致任何相关的发病情况。
