Thoracic Wall Reconstruction Following Sternal Osteomyelitis: An Algorithm To Simplify The Choice For An Ideal Recipient Vessel
Volker J. Schmidt, MD, Florian Falkner, MD, Christoph Hirche, MD, Dominic Henn, MD, Amir K. Bigdeli, MD, Emre Gazyakan, MD, Ulrich Kneser, MD.
BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
Purpose Thoracic wall reconstruction after sternal osteomyelitis is challenging as it is associated with severe comorbidities and a history of bacterial infection. The required debridement of infected or nonvital bone typically impairs the respiratory capacity. Pedicled regional flaps such as the latissimus dorsi (LD) flap or the vertical rectus abdominis (VRAM) flap further aggravate this problem and exhibit a reduced tip perfusion at the sternal defect. Thus, free flaps from distant donor sites have become a serious alternative. However, cardiac surgery and sternal osteomyelitis usually affect the local internal mammary recipient vessels.
Methods Outcome after free flap coverage of sternal wounds following osteomyelitis was investigated with regard to different vascular recipient configurations. The multimodal usage of the cephalic vein as a turn down graft was the central object of the study. The cephalic vein was used as a reliable venous outflow extension or for creating an arteriovenous (AV) loop either to the right internal mammary artery (RIMA) or to the subclavian artery (SA). The AV Loop setting enabled a customizable flap connection with a safe distance to the former area of infection.
Results Since 2013 35 patients with sternal defect wounds (mean size 25x10cm) and microbiologically confirmed osteomyelitis were treated via free flap coverage (flap: Tensor Fascia Lata [TFL], n=30; VRAM, n=2, Anterior Lateral Thigh [ALT], n=1; Vastus lateralis [VL], n=1). In 30 flaps the cephalic vein was used as a recipient turn down graft: I. AV Loop to SA (n=11), II. AV Loop to RIMA (n=5), III. Venous outflow extension (n=14). In 4 cases an AV Loop between the subclavian artery and vein was created using a saphena vein graft. In only one patient vessels were connected directly to RIMA and its concomitant vein. Despite a high degree of comorbidities (coronary heart disease 100%, heart failure 53%, diabetes 55%, COPD 28%) total flap loss was absent. One partial necrosis occurred in the distal part of a TFL flap which was treated by an intercostal perforator propeller flap. In one patient secondary wound healing was present which was addressed by split skin grafting. In 8 patients revision surgery was required due to a minor degree of hematoma, whereas the threshold for revision surgery was set low due to the proximity to the mediastinum. One patient died within the first postoperative week because of pulmonary sepsis.
Conclusion The use of free flaps from distant donor sites is a safe tool for the coverage thoracic wall defects following sternal osteomyelitis. The procedure further spars respiratory function compared to regional pedicled flaps. Utilisation of the cephalic vein as a turn down graft enhance free flap safety at this challenging defect location. After cardiac surgery with involvement of both mammary arteries the cephalic vein can serve as an AV Loop to the SA. In sternal wounds following valve surgery the cephalic vein graft can serve as a reliable venous outflow extension or as an AV Loop to the RIMA.
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