Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Surgical management of sternal wound complications

Dennis P Orgill, MD, PhD
Section Editor
Charles E Butler, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Sternal dehiscence is an infrequent but serious complication that is often a precursor to mediastinitis. Median sternotomy, which provides excellent access to the heart and surrounding structures, is the most commonly used incision for open cardiac surgery. Transverse sternotomy in association with bilateral thoracotomy (ie, clamshell incision) is used less often but may be needed to manage large tumors, chest trauma or to perform bilateral lung transplantation. Median sternotomy complications occur in 0.5 to 5 percent of patients with 0.2 to 3 percent of patients developing mediastinitis [1]. For transverse sternotomy, the rate of wound complications appears to be similar [2,3]. The risk of sternal wound complications may be greater in adults undergoing open heart surgery due multiple medical comorbidities compared with other populations (eg, trauma, children).

The use of minimally invasive surgical methods (including robotic surgery), alternative surgical approaches and catheter-based techniques have reduced the incidence of sternal dehiscence and mediastinitis [4]. However, mortality remains high (up to 35 percent) [5-12].

The diagnosis, management, and measure to prevent sternal wound complications will be reviewed here. The diagnosis and medical management of mediastinitis is discussed elsewhere. (See "Postoperative mediastinitis after cardiac surgery".)


The etiology of sternal wound complications is multifactorial [11-16]. Any factor that contributes to poor wound or bone healing (eg, osteopenia, malnutrition), or increases the risk for surgical site infection (eg, diabetes, immunosuppression) may be clinically important, especially if two or more factors are present [17]. Although postoperative sternal wound infection is clearly associated with sternal dehiscence, whether the sternal wound infection has caused the sternal dehiscence or the sternal dehiscence has caused the sternal wound infection is usually not known. Thus, it is essential to follow measures that can help prevent surgical site infection [18]. (See 'Prevention' below.)

Sternal wound healing is impaired if the edges of the sternum are not aligned properly, the sternum is ischemic, or the bone is abnormal. Technical factors that contribute to poor sternal union include the creation of an asymmetric sternotomy incision that is difficult to realign, residual separation of the sternal edges after closure, and bone ischemia due to excessive use of electrocautery or possibly internal thoracic artery harvesting (especially if bilateral). Perioperative factors that increase the risk for sternal dehiscence include prolonged operative time, the need for chest compressions, postoperative bleeding, transfusion and reoperation [19]. (See 'Sternal closure' below.)  


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2016. | This topic last updated: Jun 30, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Olbrecht VA, Barreiro CJ, Bonde PN, et al. Clinical outcomes of noninfectious sternal dehiscence after median sternotomy. Ann Thorac Surg 2006; 82:902.
  2. Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision. J Thorac Cardiovasc Surg 1996; 112:137.
  3. Bertin KC, Rice RS, Doty DB, Jones KW. Repair of transverse sternal nonunions using metal plates and autogenous bone graft. Ann Thorac Surg 2002; 73:1661.
  4. McClure RS, Cohn LH, Wiegerinck E, et al. Early and late outcomes in minimally invasive mitral valve repair: an eleven-year experience in 707 patients. J Thorac Cardiovasc Surg 2009; 137:70.
  5. El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg 1996; 61:1030.
  6. Loop FD, Lytle BW, Cosgrove DM, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990; 49:179.
  7. Trouillet JL, Vuagnat A, Combes A, et al. Acute poststernotomy mediastinitis managed with debridement and closed-drainage aspiration: factors associated with death in the intensive care unit. J Thorac Cardiovasc Surg 2005; 129:518.
  8. Orgill, DP, Austen, WG, Butler, CE, et al. Guidelines for treatment of complex chest wounds with negative pressure wound therapy. Wounds 2004; .
  9. Mauermann WJ, Sampathkumar P, Thompson RL. Sternal wound infections. Best Pract Res Clin Anaesthesiol 2008; 22:423.
  10. Matros E, Aranki SF, Bayer LR, et al. Reduction in incidence of deep sternal wound infections: random or real? J Thorac Cardiovasc Surg 2010; 139:680.
  11. Wouters R, Wellens F, Vanermen H, et al. Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors. Tex Heart Inst J 1994; 21:183.
  12. Milano CA, Kesler K, Archibald N, et al. Mediastinitis after coronary artery bypass graft surgery. Risk factors and long-term survival. Circulation 1995; 92:2245.
  13. Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987; 44:173.
  14. Nagachinta T, Stephens M, Reitz B, Polk BF. Risk factors for surgical-wound infection following cardiac surgery. J Infect Dis 1987; 156:967.
  15. Gualis J, Flórez S, Tamayo E, et al. Risk factors for mediastinitis and endocarditis after cardiac surgery. Asian Cardiovasc Thorac Ann 2009; 17:612.
  16. Liu JY, Birkmeyer NJ, Sanders JH, et al. Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group. Circulation 2000; 102:2973.
  17. Okutan H, Tenekeci C, Kutsal A. The reinforced sternal closure system is reliable to use in elderly patients. J Card Surg 2005; 20:271.
  18. Ko W, Lazenby WD, Zelano JA, et al. Effects of shaving methods and intraoperative irrigation on suppurative mediastinitis after bypass operations. Ann Thorac Surg 1992; 53:301.
  19. Sjögren J, Malmsjö M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothorac Surg 2006; 30:898.
  20. Meszaros K, Fuehrer U, Grogg S, et al. Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation. Ann Thorac Surg 2016; 101:1418.
  21. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002; 21:831.
  22. Schimmer C, Sommer SP, Bensch M, et al. Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur J Cardiothorac Surg 2008; 34:132.
  23. Schimmer C, Reents W, Berneder S, et al. Prevention of sternal dehiscence and infection in high-risk patients: a prospective randomized multicenter trial. Ann Thorac Surg 2008; 86:1897.
  24. Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehiscence in obese patients: incidence and prevention. Ann Thorac Surg 2004; 78:912.
  25. Lilienfeld DE, Vlahov D, Tenney JH, McLaughlin JS. Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery. Am J Infect Control 1988; 16:3.
  26. Koshal A, Hendry P, Raman SV, Keon WJ. Should obese patients not undergo coronary artery surgery? Can J Surg 1985; 28:331.
  27. Copeland M, Senkowski C, Ulcickas M, et al. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994; 129:757.
  28. McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg 1999; 117:1144.
  29. Nishida H, Grooters RK, Soltanzadeh H, et al. Discriminate use of electrocautery on the median sternotomy incision. A 0.16% wound infection rate. J Thorac Cardiovasc Surg 1991; 101:488.
  30. Wilson SJ, Sexton DJ. Elevated preoperative fasting serum glucose levels increase the risk of postoperative mediastinitis in patients undergoing open heart surgery. Infect Control Hosp Epidemiol 2003; 24:776.
  31. Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997; 63:356.
  32. Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001; 22:607.
  33. Luciani N, Anselmi A, Gandolfo F, et al. Polydioxanone sternal sutures for prevention of sternal dehiscence. J Card Surg 2006; 21:580.
  34. Chughtai T, Chen LQ, Salasidis G, et al. Clips versus suture technique: is there a difference? Can J Cardiol 2000; 16:1403.
  35. Kiessling AH, Isgro F, Weisse U, et al. Advanced sternal closure to prevent dehiscence in obese patients. Ann Thorac Surg 2005; 80:1537.
  36. Ramzisham AR, Raflis AR, Khairulasri MG, et al. Figure-of-eight vs. interrupted sternal wire closure of median sternotomy. Asian Cardiovasc Thorac Ann 2009; 17:587.
  37. Iriz E, Erer D, Koksal P, et al. Corpus sterni reinforcement improves the stability of primary sternal closure in high-risk patients. Surg Today 2007; 37:197.
  38. Narang S, Banerjee A, Satsangi DK, Geelani MA. Sternal weave in high-risk patients to prevent noninfective sternal dehiscence. Asian Cardiovasc Thorac Ann 2009; 17:167.
  39. Bottio T, Rizzoli G, Vida V, et al. Double crisscross sternal wiring and chest wound infections: a prospective randomized study. J Thorac Cardiovasc Surg 2003; 126:1352.
  40. Sharma R, Puri D, Panigrahi BP, Virdi IS. A modified parasternal wire technique for prevention and treatment of sternal dehiscence. Ann Thorac Surg 2004; 77:210.
  41. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977; 73:267.
  42. Franco S, Herrera AM, Atehortúa M, et al. Use of steel bands in sternotomy closure: implications in high-risk cardiac surgical population. Interact Cardiovasc Thorac Surg 2009; 8:200.
  43. Soroff HS, Hartman AR, Pak E, et al. Improved sternal closure using steel bands: early experience with three-year follow-up. Ann Thorac Surg 1996; 61:1172.
  44. Riess FC, Awwad N, Hoffmann B, et al. A steel band in addition to 8 wire cerclages reduces the risk of sternal dehiscence after median sternotomy. Heart Surg Forum 2004; 7:387.
  45. Badellino M, Cavarocchi NC, Kolff J, et al. Sternotomy closure with Parham bands. J Card Surg 1988; 3:235.
  46. Raman J, Straus D, Song DH. Rigid plate fixation of the sternum. Ann Thorac Surg 2007; 84:1056.
  47. Fawzy H, Alhodaib N, Mazer CD, et al. Sternal plating for primary and secondary sternal closure; can it improve sternal stability? J Cardiothorac Surg 2009; 4:19.
  48. Song DH, Lohman RF, Renucci JD, et al. Primary sternal plating in high-risk patients prevents mediastinitis. Eur J Cardiothorac Surg 2004; 26:367.
  49. Snyder CW, Graham LA, Byers RE, Holman WL. Primary sternal plating to prevent sternal wound complications after cardiac surgery: early experience and patterns of failure. Interact Cardiovasc Thorac Surg 2009; 9:763.
  50. López Almodóvar LF, Bustos G, Lima P, et al. Transverse plate fixation of sternum: a new sternal-sparing technique. Ann Thorac Surg 2008; 86:1016.
  51. Gandy KL, Moulton MJ. Sternal plating to prevent malunion of transverse sternotomy in lung transplantation. Ann Thorac Surg 2008; 86:1384.
  52. Prziborowski J, Hartrumpf M, Stock UA, et al. Is bonewax safe and does it help? Ann Thorac Surg 2008; 85:1002.
  53. Jackson MR. Fibrin sealants in surgical practice: An overview. Am J Surg 2001; 182:1S.
  54. Seyfer AE, Shriver CD, Miller TR, Graeber GM. Sternal blood flow after median sternotomy and mobilization of the internal mammary arteries. Surgery 1988; 104:899.
  55. Grossi EA, Esposito R, Harris LJ, et al. Sternal wound infections and use of internal mammary artery grafts. J Thorac Cardiovasc Surg 1991; 102:342.
  56. De Paulis R, de Notaris S, Scaffa R, et al. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization. J Thorac Cardiovasc Surg 2005; 129:536.
  57. Kouchoukos NT, Wareing TH, Murphy SF, et al. Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg 1990; 49:210.
  58. Bical O, Braunberger E, Fischer M, et al. Bilateral skeletonized mammary artery grafting: experience with 560 consecutive patients. Eur J Cardiothorac Surg 1996; 10:971.
  59. Taggart DP, Altman DG, Gray AM, et al. Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART). Eur Heart J 2010; 31:2470.
  60. Agrifoglio M, Trezzi M, Barili F, et al. Double vs single internal thoracic artery harvesting in diabetic patients: role in perioperative infection rate. J Cardiothorac Surg 2008; 3:35.
  61. Walkes JC, Earle N, Reardon MJ, et al. Outcomes in single versus bilateral internal thoracic artery grafting in coronary artery bypass surgery. Curr Opin Cardiol 2002; 17:598.
  62. Zeitani J, Bertoldo F, Bassano C, et al. Superficial wound dehiscence after median sternotomy: surgical treatment versus secondary wound healing. Ann Thorac Surg 2004; 77:672.
  63. Bor DH, Rose RM, Modlin JF, et al. Mediastinitis after cardiovascular surgery. Rev Infect Dis 1983; 5:885.
  64. Chase CW, Franklin JD, Guest DP, Barker DE. Internal fixation of the sternum in median sternotomy dehiscence. Plast Reconstr Surg 1999; 103:1667.
  65. Gaynes R, Marosok R, Mowry-Hanley J, et al. Mediastinitis following coronary artery bypass surgery: a 3-year review. J Infect Dis 1991; 163:117.
  66. Jolles H, Henry DA, Roberson JP, et al. Mediastinitis following median sternotomy: CT findings. Radiology 1996; 201:463.
  67. Tom TS, Kruse MW, Reichman RT. Update: Methicillin-resistant Staphylococcus aureus screening and decolonization in cardiac surgery. Ann Thorac Surg 2009; 88:695.
  68. Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated sternal dehiscence. Eur J Cardiothorac Surg 2008; 34:139.
  69. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998; 65:1046.
  70. Zec N, Donovan JW, Aufiero TX, et al. Seizures in a patient treated with continuous povidone-iodine mediastinal irrigation. N Engl J Med 1992; 326:1784.
  71. Bovill E, Banwell PE, Teot L, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J 2008; 5:511.
  72. Song DH, Wu LC, Lohman RF, et al. Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure. Plast Reconstr Surg 2003; 111:92.
  73. Sjögren J, Gustafsson R, Nilsson J, et al. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005; 79:2049.
  74. Wackenfors A, Gustafsson R, Sjögren J, et al. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy. Ann Thorac Surg 2005; 79:1724.
  75. Gustafsson R, Sjögren J, Malmsjö M, et al. Vacuum-assisted closure of the sternotomy wound: respiratory mechanics and ventilation. Plast Reconstr Surg 2006; 117:1167.
  76. Conquest AM, Garofalo JH, Maziarz DM, et al. Hemodynamic effects of the vacuum-assisted closure device on open mediastinal wounds. J Surg Res 2003; 115:209.
  77. Abu-Omar Y, Naik MJ, Catarino PA, Ratnatunga C. Right ventricular rupture during use of high-pressure suction drainage in the management of poststernotomy mediastinitis. Ann Thorac Surg 2003; 76:974; author reply 974.
  78. Harlan JW. Treatment of open sternal wounds with the vacuum-assisted closure system: a safe, reliable method. Plast Reconstr Surg 2002; 109:710.
  79. Schimmer C, Sommer SP, Bensch M, et al. Management of poststernotomy mediastinitis: experience and results of different therapy modalities. Thorac Cardiovasc Surg 2008; 56:200.
  80. Hersh RE, Jack JM, Dahman MI, et al. The vacuum-assisted closure device as a bridge to sternal wound closure. Ann Plast Surg 2001; 46:250.
  81. Raja SG, Berg GA. Should vacuum-assisted closure therapy be routinely used for management of deep sternal wound infection after cardiac surgery? Interact Cardiovasc Thorac Surg 2007; 6:523.
  82. Gustafsson RI, Sjögren J, Ingemansson R. Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy. Ann Thorac Surg 2003; 76:2048.
  83. Petzina R, Hoffmann J, Navasardyan A, et al. Negative pressure wound therapy for post-sternotomy mediastinitis reduces mortality rate and sternal re-infection rate compared to conventional treatment. Eur J Cardiothorac Surg 2010; 38:110.
  84. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infections after cardiac surgery. Ann Thorac Surg 2002; 74:1596.
  85. Agarwal JP, Ogilvie M, Wu LC, et al. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. Plast Reconstr Surg 2005; 116:1035.
  86. Luckraz H, Murphy F, Bryant S, et al. Vacuum-assisted closure as a treatment modality for infections after cardiac surgery. J Thorac Cardiovasc Surg 2003; 125:301.
  87. Fuchs U, Zittermann A, Stuettgen B, et al. Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure compared to conventional therapy with open packing: a retrospective analysis. Ann Thorac Surg 2005; 79:526.
  88. Catarino PA, Chamberlain MH, Wright NC, et al. High-pressure suction drainage via a polyurethane foam in the management of poststernotomy mediastinitis. Ann Thorac Surg 2000; 70:1891.
  89. Salica A, Weltert L, Scaffa R, et al. Negative pressure wound treatment improves Acute Physiology and Chronic Health Evaluation II score in mediastinitis allowing a successful elective pectoralis muscle flap closure: six-year experience of a single protocol. J Thorac Cardiovasc Surg 2014; 148:2397.
  90. Bakri K, Mardini S, Evans KK, et al. Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps. Semin Plast Surg 2011; 25:43.
  91. Wettstein R, Weisser M, Schaefer DJ, Kalbermatten DF. Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:634.
  92. Eburdery H, Grolleau JL, Berthier C, et al. Management of Large Sternal Wound Infections With the Superior Epigastric Artery Perforator Flap. Ann Thorac Surg 2016; 101:375.
  93. Cabbabe EB, Cabbabe SW. Surgical management of the symptomatic unstable sternum with pectoralis major muscle flaps. Plast Reconstr Surg 2009; 123:1495.
  94. Krabatsch T, Schmitt DV, Mohr FW, Hetzer R. Thoracic transposition of the greater omentum as an adjunct in the treatment of mediastinitis--pros and cons within the context of a randomised study. Eur J Surg Suppl 1999; :45.
  95. López-Monjardin H, de-la-Peña-Salcedo A, Mendoza-Muñoz M, et al. Omentum flap versus pectoralis major flap in the treatment of mediastinitis. Plast Reconstr Surg 1998; 101:1481.
  96. Stamatis G, Freitag L, Wencker M, Greschuchna D. Omentopexy and muscle transposition: two alternative methods in the treatment of pleural empyema and mediastinitis. Thorac Cardiovasc Surg 1994; 42:225.
  97. Vyas RM, Prsic A, Orgill DP. Transdiaphragmatic omental harvest: a simple, efficient method for sternal wound coverage. Plast Reconstr Surg 2013; 131:544.
  98. Davison SP, Clemens MW, Armstrong D, et al. Sternotomy wounds: rectus flap versus modified pectoral reconstruction. Plast Reconstr Surg 2007; 120:929.
  99. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997; 225:766.
  100. Glower DD, Douglas JM Jr, Gaynor JW, et al. Candida mediastinitis after a cardiac operation. Ann Thorac Surg 1990; 49:157.
  101. Trick WE, Scheckler WE, Tokars JI, et al. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000; 119:108.
  102. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003; 125:1007.
  103. Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009; 87:663.
  104. Møller A, Villebro N. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2005; :CD002294.