Complex Redo-Reconstruction of Recurrent Sterile Sternal Non-Union

We present 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 from 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

1. 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
2. Fabre D et al. European Journal of Cardio-Thoracic Surgery 00 (2012) 1–6. doi:10.1093/ejcts/ezs211

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