Can rigid plate fixation be done after debridement for a patient with a sternal wound infection following cardiac surgery?

Rigid Fixation After Debridement for Sternal Wound Infection

Yes, rigid plate fixation can and should be performed after debridement for sternal wound infection, as this approach achieves superior sternal stability, healing, and infection resolution compared to wire cerclage alone. 1, 2

Evidence Supporting Rigid Fixation in Infected Settings

The most compelling recent evidence comes from a 2023 single-center study that directly addressed this question by examining 97 patients who underwent sternal rigid plate fixation (SRPF), including 68 patients with clinically infected or culture-positive wounds. Critically, there was no statistically significant difference in subsequent infection rates between patients plated in infected versus clean settings (16% vs 14%, respectively), and all but one patient achieved a healed and stable sternum regardless of initial infection status. 1

This finding is further supported by a 2006 series of 21 patients with established mediastinitis treated with titanium plate fixation after debridement, where 20 patients (95%) achieved complete wound healing without further operative intervention. 2

Technical Approach

The recommended technique involves:

• Aggressive surgical debridement of all infected and necrotic tissue, including bone, cartilage, and soft tissue 3, 2
• Application of rigid plate fixation using titanium plates secured with bi-cortical screws to achieve sternal stability 2, 4
• Consideration of muscle flap coverage in select cases, though not universally required with rigid fixation 2
• Continuous mediastinal irrigation over drainage tubes for 4-7 weeks 2

For enhanced stability in high-risk patients (morbidly obese, osteoporotic), a combined approach using rigid plate fixation with supplemental wire cerclage provides 360-degree stabilization. 5

Infection Prevention Bundle

Concurrent with rigid fixation, implement the comprehensive care bundle recommended by the Enhanced Recovery After Surgery (ERAS) guidelines:

• Topical intranasal mupirocin to eradicate staphylococcal colonization 3
• Weight-based cephalosporin (typically cefazolin) administered within 60 minutes before incision, with redosing for procedures exceeding 4 hours 3
• Limit prophylactic antibiotics to 48 hours maximum after surgery completion, as prolonged prophylaxis beyond this timeframe does not reduce infection rates and promotes resistance 6, 7
• Culture-directed antibiotic therapy for 4-7 weeks based on intraoperative cultures 2
• Daily incision washing with chlorhexidine after sterile dressing removal within 48 hours 3, 6

Outcomes Compared to Wire Cerclage

Rigid plate fixation demonstrates superior outcomes even in high-risk populations:

• Significantly lower deep wound infection rates (0.63% vs 3.45%) 4
• Lower 30-day mortality (1.57% vs 5.96%) 4
• Shorter hospital length of stay (8.2 vs 11.7 days) 4
• Superior sternal healing on CT imaging at 3 months 4
• Significantly lower pain scores and better upper-extremity function 3, 4
• Prevention of mediastinitis in high-risk patients (0% vs 14.8% with wire closure) 8

Critical Pitfalls to Avoid

• Do not delay rigid fixation due to presence of infection—the 2023 data shows no increased risk of subsequent infection when plating infected wounds after adequate debridement 1
• Avoid inadequate debridement—all infected tissue must be removed before plate application, as residual infection foci can lead to treatment failure 2
• Do not extend antibiotic prophylaxis beyond 48 hours without documented persistent infection, as this promotes resistance without benefit 6, 7
• Ensure adequate bone stock for bi-cortical screw purchase; in severely osteoporotic patients, consider supplemental wire cerclage for 360-degree stability 5

Special Considerations

The 2023 study noted that infection rates decreased significantly with increasing surgeon experience and frequency of plate fixation (p < 0.0001), suggesting a learning curve that should be acknowledged when implementing this technique. 1

For patients with severe osteoporosis, previous chest wall radiation, severe COPD, or steroid use, rigid fixation is particularly beneficial and should be strongly considered even in the primary setting to prevent subsequent complications. 3