Risk factors for predicting surgical salvage of sternal wound-healing complications

A retrospective study was performed to determine whether clinical factors c an predict which complicated poststernotomy wounds can be managed successfu lly by debridement and reclosure, and which wounds require a muscle flap fo r healing. Between January 1990 and December 1996, 3,435 median sternotomie s were performed at Indiana University Medical Center and affiliated hospit als. A total of 91 patients (2.6%) were reoperated for sternal wound-healin g complications. Seventy-six patients (83.5%) underwent debridement and rew iring, and 15 patients (16.5%) underwent primary flap coverage. Of the 76 p atients who underwent initial rewiring, 45 (59%) healed and 31 (41%) requir ed additional operative procedures, Of the 31 rewiring failures, 26 patient s (84%) were healed with muscle flaps and 4 patients (13%) were managed wit h a second successful rewiring. The following clinical factors were correla ted with operative procedure and outcome: history of smoking, chronic obstr uctive pulmonary disease, steroid use, previous sternotomy, age, diabetes, harvest of the left or right internal mammary artery (IMA), emergency opera tion, operation time, pump time, cross-clamp time, ischemic time, coronary artery bypass grafting alone versus combined with a valve replacement, posi tive wound cultures, positive blood cultures, elevated white blood cell cou nt, and fever. When comparing patients with successful rewiring with those who had a failed rewiring, positive wound and blood cultures were significa nt risk factors (p < 0.05) on univariate analysis. Presence of a positive w ound culture was significant on multivariate analysis. When comparing risk factors in patients who were rewired successfully versus all patients who h ad muscle flap coverage, the presence of a positive blood culture was signi ficant on both univariate and multivariate analyses. We conclude patients m ost likely to fail rewiring and to require muscle flap closure are those wi th infected wounds, positive blood cultures, and possibly left IMA bypasses .