Complex Redo-Reconstruction of Recurrent Sterile Sternal Non-Union
We present here a case of complex redo-reconstruction
surgery for recurrent sternal non-union. Our 63yo female patient initially
underwent coronary artery bypass grafting with four grafts in 2018 with
utilization of both internal mammary arteries. Unfortunately, she developed
sternal dehiscence six months afterwards and required sternal reconstruction
which failed to heal. She represented with persistent pain and uncomfortable
sternal clicking.
The old sternotomy scar was opened and the sternum was exposed. The top of the
repair was unstable with multiple loose plates and screws. The underlying upper
third of the sternum was largely absent. All previous plates of the SternaLock
system were removed and the sequestrum was excised
Simultaneously a second surgical team performed an upper midline laparotomy-
the colon and omentum were adherent to an old laparotomy surgical scar. These
adhesions were carefully divided. The omentum was then divided form the
transverse colon along the avascular plane. The right gastroepiploic arcade was
divided from the gastric wall close to the confluence with the left arcade. All
gastric tributaries were sequentially divided preserving the primary arcade.
The edges of the sternal defect were wedged out with the use of saw – these
along with the ziphoid process, were used as bone grafts within the upper
sternal defect. A window was created in the anterior portion of the diaphragm.
The omentum was passed through this window and split longitudinally. The
smaller portion was placed directly over the sternal defect and secured with
interrupted Vicryl sutures. Four Stratos bars were measured and fit to the
mobilized ribs in order to bridge the sternum without compromising the sternum
itself.
All bars were secured over the small portion of the omentum. The larger portion
was then positioned over the exposed area of the chest wall and again secured
with interrupted Vicryl sutures. The window in the diaphragm was also partially
closed without compressing the pedicle.
A vacuum drain was positioned across the omental flap. Bilateral pectoral major
muscle flaps were mobilized. The muscle flaps were connected in the midline
with a running stitch.Sternotomy wound closure was done in layers.
Haemostasis was checked in the abdomen and the laparotomy wound was closed in
layers with loop PDS to fascia and subcutaneous and subcuticular stitches. The
patient was successfully extubated in theatre and transferred to ITU.
Reference
Transomental Titanium Plates for Sternal Osteomyelitis in
Cardiac Surgery. F Sansone et al. J Card Surg 2011;26:600‐603 https://doi.org/10.1111/j.1540-8191.2011.01336
Fabre D et al. European Journal of Cardio-Thoracic Surgery 00 (2012) 1–6.
doi:10.1093/ejcts/ezs211
