Management of Protruding Sternal Wire from Remote Cardiac Surgery
The protruding sternal wire should be surgically removed, as retained foreign material near the skin surface poses significant infection risk, particularly in elderly patients with friable skin and compromised wound healing.
Primary Management Strategy
Surgical Wire Removal
Surgical excision of the protruding wire is the definitive treatment, as foreign material breaching or approaching the skin surface creates a direct pathway for bacterial colonization and infection 1.
The wire should be removed under sterile conditions with appropriate surgical technique, as elderly patients have friable skin that is more prone to tissue damage and pressure necrosis 1.
Rigid sternal fixation techniques have demonstrated superior outcomes compared to wire cerclage, with significantly better sternal healing, fewer complications, and improved quality-of-life scores in patients requiring sternal revision 1.
Infection Risk Assessment
Assess for any signs of local infection including erythema, warmth, fluctuance, wound dehiscence, tenderness, or purulent drainage, as these indicate established infection requiring more aggressive management 1.
Elderly patients are at particularly high risk for surgical site infections due to age-related immune changes, comorbidities, and skin fragility 1.
If signs of infection are present, obtain blood cultures before initiating antibiotics, as staphylococci (particularly S. aureus) are the predominant organisms in sternal wound infections 1, 2.
Perioperative Antibiotic Prophylaxis
Standard Prophylaxis Protocol
Administer weight-based cefazolin (typically 2g IV) within 60 minutes before surgical incision, with redosing if the procedure exceeds 4 hours 1, 3.
Continue prophylactic antibiotics for no more than 48 hours postoperatively, as prolonged prophylaxis does not reduce infection rates and promotes antibiotic resistance 1, 3.
Chlorhexidine-based skin preparation should be used rather than povidone-iodine, as it reduces surgical site infection rates (4.0% vs 6.5%) 4.
Special Considerations for Remote Surgery
No extended antibiotic prophylaxis is indicated solely because of the remote cardiac surgery, as there is insufficient evidence supporting secondary prophylaxis for unrelated procedures in patients with prior sternotomy 3.
The presence of old sternal wires does not require endocarditis prophylaxis, as these are not intracardiac devices and the patient does not have active valvular disease 3, 5.
Preoperative Evaluation
Imaging and Assessment
Obtain chest radiographs or CT imaging to assess the relationship of the wire to surrounding structures, particularly if the wire appears to be in close proximity to the sternum or mediastinum 1.
Evaluate for sternal instability or nonunion, as this may indicate the need for more extensive reconstruction with rigid plate fixation rather than simple wire removal 1.
Review prior operative notes if available to understand the original surgical anatomy and identify potential complications during wire removal 1.
Patient-Specific Risk Factors
Assess for high-risk features including diabetes mellitus, obesity (high BMI), chronic obstructive pulmonary disease, steroid use, or history of chest wall radiation, as these patients benefit most from rigid fixation if sternal reconstruction is needed 1.
Elderly patients require careful attention to positioning and padding during surgery to prevent peripheral nerve injuries and pressure necrosis over bony prominences 1.
Postoperative Management
Wound Care
Remove sterile dressings within 48 hours and implement daily incision washing with chlorhexidine, as this reduces surgical site infection rates 1.
Monitor closely for signs of infection, as elderly patients may have atypical presentations with less pronounced inflammatory responses 1.
Early mobilization should be encouraged to prevent venous stasis and thrombophlebitis, but with appropriate precautions for the elderly patient's functional limitations 1.
Surveillance for Complications
Watch for signs of mediastinitis or deep sternal wound infection, which would require urgent surgical debridement and prolonged antibiotic therapy (4-6 weeks minimum) 1.
If infection develops despite prophylaxis, staphylococcal coverage with vancomycin or daptomycin may be necessary, particularly in centers with high rates of methicillin-resistant S. aureus 1.
Critical Pitfalls to Avoid
Do not attempt conservative management or "watchful waiting" for a wire protruding near the skin surface, as progression to infection is highly likely and more difficult to treat once established 1.
Avoid using razors for hair removal if surgical site preparation is needed, as this increases infection rates (4.4% vs 2.5% with clippers) 4.
Do not extend antibiotic prophylaxis beyond 48 hours without documented infection, as this provides no additional benefit and promotes resistance 1, 3.
Ensure adequate anesthetic dosing adjustments for age, as elderly patients require lower doses of anesthetic agents and are at higher risk for prolonged hypotension if standard doses are used 1.