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Predictors of Recurrent Deep Infection following Sternal Wound Reconstruction with Pectoralis Major Flaps: A 30-Year Single-Surgeon Experience
Michael B. Amrami
*, Jeffrey A. Ascherman
Department of Surgery, Division of Plastic Surgery, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY
Background: Recurrent deep infection after flap closure for sternal wounds is a devastating complication requiring reoperation and prolonged care. Independent predictors of recurrence have not been defined in a large consecutive cohort. We evaluated a 30-year single-surgeon experience to identify independent predictors and outcomes of recurrent deep infection following flap-based sternal wound reconstruction.
Methods: A retrospective review of 584 sternal wound reconstruction patients (1995-2024) was performed. Group 1 (recurrent deep infection requiring operative re-exploration) was compared with Group 2 (no recurrent infection). Multivariable logistic regression was restricted to clinically plausible wound-presentation and operative variables with univariate association.
Results: Recurrent deep infection occurred in 21 patients (3.6%). Demographics, comorbidities, and index procedures were comparable between groups (all p>0.05). The median interval from index cardiac surgery to reconstruction was significantly longer in Group 1 (64 days [IQR 36-137] vs. 31 days [IQR 16-57], p<0.001). Culture-positive wound infection was more common in Group 1 (85.7% vs. 55.2%, p=0.006), as was limited debridement (42.9% vs. 13.5%, p=0.001); observed absolute recurrence rates were 10.6% (9/85) after limited debridement versus 2.4% (12/499) after full debridement. On multivariable analysis, independent predictors were culture-positive infection (OR 4.20, 95% CI 1.18-14.91, p=0.027), limited debridement (OR 3.75, 95% CI 1.39-10.17, p=0.009), and longer interval from index surgery (OR 1.57 per log-unit, p=0.022).
Conclusion: In this 30-year single-surgeon series, recurrent deep infection occurred in 3.6% of patients. Recurrence was independently associated with culture-positive wound infection, limited debridement, and longer interval from index cardiac surgery. These findings support heightened caution when considering limited debridement for delayed, culture-positive wounds, while underscoring that recurrence may occur despite full debridement in complex presentations.
Table 1. Multivariable Logistic Regression: Independent Predictors of Recurrent Deep Infection Requiring Reoperation (n=21 events)
| Variable | Odds ratio | 95% Confidence Interval | p-value |
| Culture-Positive Wound Infection | 4.20 | 1.18 - 14.91 | 0.027* |
| Limited Debridement at Initial Reconstruction | 3.75 | 1.39 - 10.17 | 0.009* |
| Interval from Index Cardiac Surgery to Reconstruction (per log-unit increase) | 1.57 | 1.07 - 2.31 | 0.022* |
| Wound Drainage as Indication | 0.27 | 0.10 - 0.74 | 0.011* |
| Sternal Instability or Click as Indication | 0.30 | 0.04 - 2.32 | 0.246 |
Model restricted to clinically plausible wound-presentation and operative variables with univariate association; size constrained by limited event count (EPV ≈4.2). * p<0.05.
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