Kaláb M, Karkoška J, Kamínek M, Šantavý P
Rozhl Chir. 2016 Fall;95(11):399-406.
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.
In the period of 20112015 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.
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 (136). 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.
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.
心脏手术中，深部胸骨伤口感染引起的早期并发症是一个严重问题，死亡率高达40%。胸骨骨组织和相邻肋骨的大量缺失导致胸壁严重不稳定，采用经典的AO接骨术难以解决，进而导致呼吸功能不全，难以脱离人工肺通气，还会出现软组织愈合的额外缺陷。基于骨科在骨缺损修复方面的经验，我们采用同种异体骨移植方法重建胸壁。
2011年至2015年期间，我们对13例患者进行了同种异体骨移植。其中10例使用胸骨同种异体移植，1例使用颅骨同种异体移植，2例使用粉碎的松质骨。在初次心脏手术后，所有13例患者均因深部胸骨感染及胸骨和相邻肋骨的骨髓炎出现了胸骨切开术后胸壁巨大缺损。所有患者均采用伤口负压引流治疗。为稳定胸部和移植骨，使用了横向钛板，并用双皮质螺钉固定。骨同种异体移植由官方组织中心制备。应用粉碎的同种异体松质骨加强移植骨与残余骨骼边缘的接触线。12例患者通过游离胸大肌皮瓣直接缝合关闭软组织。1例患者进行了胸大肌皮瓣的V-Y移位。
8例患者重建胸壁愈合，无进一步并发症。4例患者在住院期间仍需对伤口下极的软组织和皮肤进行再次缝合。然而，所有12例患者均实现了出色的胸壁稳定性，呼吸功能不全得到改善，伤口美观效果良好。2例患者需要取出钢板。1例患者出现严重的伴随并发症，伤口未愈合，重建后半年内死亡。该系列所有患者的中位随访期为21个月（13至6个月）。5例合作患者在随访期间多次进行胸壁闪烁扫描，显示移植骨尤其是粉碎的松质骨愈合活性高。
我们目前的结果表明，同种异体骨移植是治疗胸骨裂开严重组织缺损的一种有前景且易于应用的方法，具有良好的功能和美观效果。关键词：胸骨切开术；深部胸骨伤口感染；胸骨切开术后巨大缺损；同种异体骨移植
