Thoracic Surgery Unit, San Filippo Neri Hospital, Rome, Italy.
Eur J Cardiothorac Surg. 2013 Apr;43(4):715-21. doi: 10.1093/ejcts/ezs449. Epub 2012 Aug 5.
The goal of this study was to investigate alternative strategies to the sternal resection in the treatment of post-sternotomy osteomyelitis. We report our experience in the treatment of chronic infection of median sternotomy following open heart surgery without sternal resection.
A 4-year retrospective study was performed, consisting of 70 patients affected by post-sternotomy sternocutaneous fistulas due to chronic osteomyelitis: 45 patients underwent only medical treatment and 25 underwent steel wire removal and surgical debridement (conservative surgery). Of the 25, 7 patients underwent an additional vacuum assisted closure (VAC) therapy due to widespread infected subcutaneous tissue. The diagnosis of osteomyelitis was supported via 3D CT scan images.
Complete wound healing was achieved in 67 patients including a patient who achieved healing after being affected by a fistula for over 24 years before coming under our observation, another, affected by mycobacteria other than tuberculosis osteomyelitis, who needed antimicrobial treatment for a period of 30 months and 2 who were affected by Aspergillus infection and needed radical cartilage removal. Fistula relapses were observed in 6 patients of the total 70, possibly due to the too short-term antibiotic therapy used in the presence of coagulase-negative Staphylococcus (CoNS) with multiple resistances and in the presence of Corynebacterium species.
Post-sternotomy chronic osteomyelitis can be successfully treated mainly by systemic antimicrobial therapy alone, without mandatory surgical treatments, provided that accurate microbiological and radiological studies are performed. The presence of CoNS and Corynebacterium species seemed to be associated with a need for a prolonged combined antimicrobial therapy with a minimum of 6 months up to a maximum of 18 months. The CT scan and the 3D reconstruction of the sternum proved to be a good method to evaluate the status of the sternum and support the treatments. The VAC therapy was not useful in treating osteomyelitis, although, if used appropriately in the postoperative deep sternal wound infection with the sponge fitted between the sternal edges, it seems to be an effective method to eradicate the infection in the sternum and to prevent chronic osteomyelitis.
本研究旨在探讨胸骨切除以外的治疗方案在胸骨切开术后骨髓炎中的应用。我们报告了我们在不进行胸骨切除的情况下治疗心脏直视手术后正中胸骨切开术后慢性感染的经验。
进行了一项为期 4 年的回顾性研究，共纳入 70 例因慢性骨髓炎导致胸骨切开后胸骨皮瘘的患者：45 例仅接受药物治疗，25 例接受钢丝取出和外科清创（保守手术）。25 例中有 7 例因广泛感染的皮下组织而接受额外的真空辅助闭合（VAC）治疗。骨髓炎的诊断通过 3D CT 扫描图像得到支持。
67 例患者的伤口完全愈合，包括 1 例患者在我们观察前受瘘管影响超过 24 年才愈合，另 1 例患有非结核分枝杆菌骨髓炎，需要接受 30 个月的抗菌治疗，2 例患有曲霉菌感染，需要进行根治性软骨切除。70 例患者中有 6 例出现瘘管复发，可能是由于凝固酶阴性葡萄球菌（CoNS）存在多种耐药性和棒状杆菌属时使用的抗生素治疗时间过短。
通过系统的抗菌治疗，主要是单独使用，而不是强制性的手术治疗，可以成功治疗胸骨切开术后慢性骨髓炎，只要进行准确的微生物学和放射学研究。CoNS 和棒状杆菌属的存在似乎与需要联合抗菌治疗的时间延长相关，最短 6 个月，最长 18 个月。CT 扫描和胸骨 3D 重建被证明是一种很好的评估胸骨状况和支持治疗的方法。VAC 治疗对骨髓炎没有帮助，尽管如果在胸骨切开术后深部胸骨伤口感染时适当使用，将海绵置于胸骨边缘之间，似乎是一种有效根除感染和预防慢性骨髓炎的方法。
