Surgical options to treat massive sternal defect after failed Robicsek procedure

Full median sternotomy is still the most commonly used surgical approach for exposing the heart in cardiac surgery. However, early sternotomy wound complications represent a major cause of morbidity in heart surgery with an incidence from 0.5% to 10% in most surgical studies. Different classifications of sternal wound complications were reported. Mainly we consider three principal categories: mechanical uninfected sternal instability/dehiscence; sternal instability/dehiscence with superficial wound sternal infection (SWSI); and deep sternal wound infection (DSWI or mediastinitis) with sternal instability/dehiscence (1,5). In particular mediastinitis with sternal dehiscence is a life-threatening condition with reported mortality between 14% to 47%. The loss of sternal bone and adjacent ribs due to osteomyelitis and previous surgical debridement causes large defects of the anterior chest wall that increase the risk of heart and lung damage and in particular impairs respiratory function due to pain and paradox movement of the thorax, often necessitating prolonged mechanical ventilation and increasing the postoperative mortality. Sometimes DSWI and massive sternal loss is the result of previous attempts to fix mechanical sternal dehiscence with or without SWSI in patients with multiple risk factor for sternal instability and infection. In cardiac surgery the most common technique to repair a sternal instability/dehiscence is the Robicsek technique. Generally this is a very effective procedure, but in case of its failure the subsequent repair of the anterior chest wall could become very complex due to massive bone loss. We report our experience with two different surgical approaches to treat a massive sternal loss after a failed Robicsek repair.