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Significant Predictors of Complications Post Sternal Wound Reconstruction: A 21-Year Experience
Hamid R. Zahiri1, Alexandra Conde Green1, Kimberly Lumpkins, M.D.1, Shahrooz Kelishadi, M.D.1, Yue Zhu, MD1, Daniel Medina, M.D.1, Jeffrey A. Stromberg, M.D.2, Ronald P. Silverman, M.D.1, Sheri Slezak, MD3, Nelson H. Goldberg, MD3, Luther Holton, III, M.D.1, Devinder P. Singh, M.D.1.
1University of Maryland, Baltimore, MD, USA, 2Cleveland Clinic, Cleveland, OH, USA, 3University of Maryland, Ellicott City, MD, USA.

BACKGROUND:
Sternal wound reconstruction with tissue flaps is efficacious and well supported in the literature. We sought to identify patient comorbidities that predict complications post tissue flap sternal reconstruction.

METHODS:
A retrospective study of sternal reconstruction patients from December 1989 to December of 2010 was performed. Age, gender, diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), congestive heart failure (CHF), myocardial infarction (MI), renal insufficiency (RI), and chronic obstructive pulmonary disease (COPD) were analyzed as independent risk factors for post-operative complications.
Additionally, we divided patients based on the indication for their initial sternotomy in order to determine if their original surgery served as a risk factor for complications after sternal wound reconstruction. Five surgical indications were considered including coronary artery bypass grafting (CABG), aortic aneurysm repair or bypass, cardiac valve repair, heart transplantation, and thoracic oncologic surgery.
Finally, a subset analysis of 29 patients, with more complete medical records, was performed to determine if race, obesity (BMI ≥ 30), history of smoking, steroid use, immunosuppression, concurrent infections, and sepsis were also risk factors for morbidity and mortality as defined above.
Pearson chi-square, Fisher's exact test, logistic regression, two-sample t test, and median-unbiased estimation were used to analyze data. Significance was determined by p ≤ 0.05.

RESULTS:
Overall, 106 patients received 161 sternal tissue flap repairs. Nineteen patients (18%) required re-operation due to complications, including recurrent wound infection, tissue necrosis, wound dehiscence, mediastinitis, and hematoma formation. Nine additional patients (8%) developed minor complications.
Our analysis found DM, HTN, and CHF as significant predictors of complications post sternal reconstruction (p = 0.014, 0.012, and 0.006, respectively). The odds ratios were 2.6 for diabetics (95% CI 1.0-6.7), 4.3 for hypertensives (95% CI 1.5-11.9), and 5.0 for patients with CHF (95% CI 1.7-14.8). Age, gender, CAD, MI, RI, and COPD did not correlate with post-operative complications (all p values > 0.05).
Analysis of original sternotomy indications found that CABG, aortic bypass/aneurysm repair, cardiac valve repair, heart transplantation, and thoracic oncologic surgery did not correlate with post-operative complications (all p values > 0.05).
Our subgroup analysis of 29 patients, found obesity (BMI ≥ 30), race, history of smoking, steroid use, immunosuppression, concurrent infections, and sepsis did not correlate significantly with complications post tissue flap reconstruction of complex sternal wounds (all p values > 0.05).

CONCLUSIONS:
Our data suggest DM, HTN, and CHF may contribute to complications after tissue flap repair of sternal wounds, possibly through impaired perfusion and healing of repairs.


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