Using Titanium Plate with Muscle Flap in Difficult Sternal Wound Reconstruction

併用胸骨骨板固定及肌肉皮瓣在困難胸骨傷口的重建

何彥儀(Yen-Yi Ho) ； 陳理維(Lee-Wei Chen) ； 陳錦時(Jin-Shyr Chen) ； 楊國強(Kao-Chang Yang) ； 徐圭璋(Kuei-Chang Hsu) ； 劉文忠(Wen-Chung Liu) ； 林政達(Cheng-Ta Lin)

《臺灣整形外科醫學會雜誌》 23卷2期 (2014/06) Pp. 126-139

摘要

背景：在胸骨正中切開術後發生的深部胸骨傷口感染，是一種可能致死的疾病，過去報告的發生率僅0.2-8%，而死亡率則高達47%。深部胸骨傷口感染由於傷口癒合的問題，以及難以治癒或復發性的胸骨骨髓炎，其治療對外科醫師來說是極具挑戰性的。目的及目標：在此篇論文中，我們呈現對於胸骨重建的治療經驗，以及評估併用胸骨骨板固定和肌肉皮瓣重建在困難胸骨傷口的治療結果。材料及方法：自西元1997年4月至2013年4月間，共有12位在胸骨正中切開術後發生困難胸骨傷口及胸骨不穩固的病患，接受了鈦合金重建骨板固定胸骨，同時利用肌肉皮瓣覆蓋胸骨傷口。我們以回顧性研究的方式分析這些病患的資料，包括合併症、臨床病程發展、重建的方式、結果、以及併發症等。結果：在12位胸骨正中切開術後發生深部胸骨傷口感染的病患中，所有的病患都有胸骨裂開及胸骨不穩固的情形。其中有6位病患在接受了加強性的Robicsek胸骨兩側編織鋼線固定術後，仍無法恢復其胸骨的穩固性。而所有接受鈦合金重建骨板和胸大肌皮瓣重建後仍存活的病患（有2位多重併發症的病患分別在術後3日及31日死亡）都能達到穩固的胸骨固定，並且在術後平均追蹤16個月（範圍：2至56個月）的期間均未發現胸骨骨髓炎的復發。在10位存活病患的平均術後加護病房留置時間為8.7天（範圍：2至32天）。有5位病患在重建術後第1天即可脫離呼吸器，而其他4位病患則在術後1週內脫離呼吸器。只有1位在重建術前發生肺炎的病患術後無法脫離呼吸器。重建後的併發症包括：1位病患發生氣胸，1位病患發生皮下積液，以及4位病患在術後表面傷口裂開；術後併發症均可以簡單的方式治療。結論：併用胸骨骨板固定和胸大肌皮瓣重建對於困難胸骨傷口的病患，是一種有效的治療策略，能夠重建胸骨的穩固性以及促進胸骨傷口感染的控制。

並列摘要

Background: Deep sternal wound infection (DSWI) following median sternotomy is a rare but potentially fatal disease, with reported incidence of 0.2-8%, and mortality rate up to 47%. The management of DSWI poses a challenge to the treating surgeons due to problematic wound healing accompanied by intractable or recurrent sternal osteomyelitis. Aim and Objectives: The purpose of this study was to examine our outcomes of sternal reconstruction with titanium reconstruction plates and muscle flaps. Materials and Methods: From April 1997 to April 2013, 12 patients with difficult sternal wounds and sternal instability after median sternotomy were reconstructed with titanium plates and muscle flaps. In a retrospective review, the comorbidities, clinical course of disease, method, outcome and complications of reconstruction were analyzed. Results: Among the 12 patients with post-sternotomy DSWI, all exhibited sternal dehiscence and instability. Six of the patients had failed attempts to restore sternal stability, despite rewiring with the reinforced Robicsek parasternal weaving technique. Following sternal fixation with titanium reconstruction plates and muscle flaps coverage, sternal stability was achieved in 10 surviving patients (2 multi-morbid patients expired at 3 days and 31 days after reconstruction). There was no recurrence of sternal osteomyelitis in the mean follow-up period of 16 months (range, 2-56 months). The mean postoperative ICU stay in 10 surviving patients was 8.7 days (range, 2-32days). Five patients were able to wean off the ventilator on postoperative day 1, and 4 patients were able to wean off the ventilator within one week. Only 1 patient with pre-existing pneumonia failed to wean off the ventilator after reconstruction. Postoperative complications, including pneumothorax in 1 patient, seroma in 1 patient, and superficial wound dehiscence in 4 patients, were manageable with simple modalities. Conclusion: Sternal plating with muscle flap reconstruction is an effective treatment strategy for difficult sternal wounds to restore sternal stability and facilitate the control of sternal wound infection.

並列關鍵字

deep sternal wound infection ； sternal reconstruction ； titanium reconstruction plate ； pectoralis muscle flap