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. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: J Card Surg. 2022 Aug 18;37(11):3703–3704. doi: 10.1111/jocs.16845

Commentary: Small Patients with Big Wounds

Andrew M Young 1, Anthony V Norman 1, Irving L Kron 1
PMCID: PMC9578670  NIHMSID: NIHMS1828786  PMID: 35979689

Abstract

Some would argue that kids aren’t just little adults, but what about their sternums? We are reviewing a manuscript by Horriat, McCandless, and colleagues in the Journal of Cardiac Surgery1 describing their experience with managing sternal wound infections (SWI) after congenital heart surgery. They report encouraging results in 14 patients who required plastic surgery consultation to manage their sternal wounds. The nature of congenital cardiac abnormalities and the necessary steps to repair them leads to physiologic derangements predisposing patients to SWI. Rates of SWI vary and have been reported at 1.53% in this population. There is little guidance on how the management of the congenital cardiac surgery patient should differ from the adult patient.2

Commentary:

In this month’s Journal, Horriat, McCandless, and co-authors present their outcomes in the management of SWI in congenital cardiac surgery patients. 14 patients were evaluated and treated by their team. The authors clearly describe their approach to the management of these wounds as well as the demographics of their patients. They appear to have favorable outcomes within the limitations of this limited case series. In addition to several immediate SWIs, the authors successfully managed several late SWIs, one at 133 days and another at 574 days. We are interested in whether the authors modify their management in the case of these delayed/chronic wounds.

We (Figure 1) commend the authors for their excellent outcomes. SWI is a challenging problem, and the authors highlight some factors they consider when approaching closure. Their step-wise approach to the management of these wounds is clear and logical. We are interested in how the authors decide which pedicled flap to use. The delicate nature of the pectoralis major muscle is described in the manuscript, although it is still the primary tissue used for closure. Is it a case of the best of several poor options? The authors indicate they routinely use incisional wound VAC therapy, which has strong support in literature for adult sternal wounds and has been shown to be feasible in the pediatric population.3,4 The authors describe a case in which a patient with sternal instability required the wires to be left in place. This challenging situation required interval wound VAC prior to reconstruction and despite best efforts developed osteomyelitis, requiring prolonged IV antibiotics. 1

Figure:

Figure:

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Andrew M. Young, MD (left), Anthony Norman, MD (center) and Irving L. Kron, MD (right)

There may be benefits in continuous glucose monitoring and in sending mediastinal wound cultures at the time of closure, but there is a lack of consensus on how to manage SWI once they develop.2 This manuscript and the cases described within illustrate the importance of a multidisciplinary approach to these complicated wounds. From critical care, to reconstruction, to wound care, to antibiotics, a team approach is needed. We appreciate the authors’ description of their processes and methods and wish them continued success.

Funding Statement:

This work was supported by a research grant from NHLBI/NIH (T32HL007849). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Footnotes

Conflict of Interest: none

Disclosures: The authors have nothing to disclose

IRB approval and informed consent: N/A

Data Availability Statement:

This invited commentary does not include any original data.

References:

  • 1.Horriat Narges L. MD, McCandless *Martin G. BS, Humphries Laura S. MD, Ghanamah Mohammed MD, Kogon Brian E. MD, and Hoppe Ian C.. Management of Pediatric Sternal Wounds following Congenital Heart Surgery: The Role of the Plastic Surgeon in Debridement and Closure. Journal of Cardiac Surgery. [DOI] [PubMed] [Google Scholar]
  • 2.Woodward CS, Son M, Calhoon J, Michalek J, Husain SA. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice. Ann Thorac Surg. 2011;91(3):799–804. [DOI] [PubMed] [Google Scholar]
  • 3.Song DH, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M. Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure. Plast Reconstr Surg. 2003;111(1):92–97. [DOI] [PubMed] [Google Scholar]
  • 4.Costello JP, Amling JK, Emerson DA, et al. Negative pressure wound therapy for sternal wound infections following congenital heart surgery. J Wound Care. 2014;23(1):31–36. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

This invited commentary does not include any original data.

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