c  2012 Wiley Periodicals, Inc. 557 SURGICAL TECHNIQUE A Massive Post-Sternotomy Sternal Defect Treated by Allograft Sternal Transplantation Andrea Dell’Amore, M.D., Giampiero Dolci, M.D., Nicola Cassanelli, M.D., Alessandro Bini, M.D., and Franco Stella, M.D. Thoracic Surgery Operative Unit, S.Orsola Malpighi University Hospital, Bologna, Italy ABSTRACT We report a case of a patient with complete sternal destruction after cardiac surgery, who underwent total sternal replacement with sternal allograft, titanium bars, and screws. doi: 10.1111/j.1540- 8191.2012.01518.x (J Card Surg 2012;27:557-559) In the case of complicated sternal dehiscence or massive sternal deficit, the treatment can be a chal- lenging situation. 1–3 We report a case of a patient with complete sternal destruction after cardiac surgery, who underwent total sternal replacement with sternal allo- graft, titanium bars, and screws. SURGICAL TECHNIQUE The patient and institutional ethical committee per- mission were obtained to report this case. A 68-year-old male with diabetes, chronic obstructive pulmonary disease, hypertension, mild chronic renal failure, and obesity underwent coronary artery by-pass grafting with mammary arteries 18 months ago. The postoperative period was complicated by deep sternal wound infection due to Staphylococcus aureus. The first treatment was the surgical revision and debrid- ment of the surgical site. Daily mediastinal irrigation with diluted 1% povidone iodine was performed un- til cultures were negative; the patient then underwent sternal closure with the Robicsek procedure. 4 After two months, the patient had complete sternal dehis- cence due to multiple fractures of the sternal body. The cultures were negative and the patient underwent removal of the metal wires and attempted sternal fixa- tion using ethibond sutures. After a couple of weeks he had a further sternal dehiscence. A third surgical revi- sion was performed, but, because of the complete frac- tures of the sternal bone, sternal fixation was not pos- Conflict of interest: All authors declare that they have no conflict of interest nor have they received any kind of financial support. Address for correspondence: Andrea Dell’Amore, M.D., Thoracic Surgery Unit, S.Orsola Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy. Fax: +390516364199; e-mail: dellamore76@libero.it sible, and the defect was covered by a pectoralis major muscle flap. The patient was then referred to us be- cause of chronic pain exacerbated by cough and respi- ratory movements with breathing difficulties. Physical examination showed a paradoxical movement of the chest wall during respiration. The preoperative com- puted tomography (CT-scan) showed an almost com- plete absence of the sternum (Figs. 1A, B). A cardiac cath showed that the grafts were patent. The respi- ratory function test showed a moderate COPD with a FEV1 of 65% (1.72L). To reconstruct the sternum we decided to use a sternal allograft (SA). The SA was harvested from a multi-tissue donor following Italian legislation for tis- sue donation. The graft underwent washing immersion in sterile saline solution with antibiotics for 72 hours. After packaging, the allograft was irradiated and then stored at –80 ◦ C. The day before surgery the graft un- derwent defrosting at 4–6 ◦ C for 12 hours, then under sterile conditions it was immersed in a 0.9% NaCl so- lution with antibiotics and stored to 4–6 ◦ C until its use. The patient was placed in supine position and the skin incision followed the previous scar (Fig. 2A). The pec- toralis muscle flap had failed and the muscles were retracted but still usable. The dissection of the pec- toralis muscles was extensively performed as far as the midaxillary line. The small residual fragments of the sternum were removed. The chest wall was dissected to clean the anterior cortical surface of the ribs. The SA was tailored, removing all the rib stumps, and was positioned to fill the chest wall defect (Fig. 2B). The new-sternum was fixed to the ribs using titanium bars and screws (Fig. 2C). The sternoclavicular junction was recreated using high-tension polyethylene sutures as previously described. 5,6 The reconstruction was cov- ered by advancing the bilateral pectoralis major muscle flap (Fig. 2D). The operation time was 134 minutes.