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\begin{document}

\title{Pectoralis major muscle turnover flap reconstruction for treatment of
deep sternal wound infection in infants and children}



\author[1]{Gang Wang}%
\author[2]{Yongshun Gao}%
\author[1]{Gengxu Zhou}%
\author[1]{Zhichun Feng}%
\affil[1]{Southern Medical University}%
\affil[2]{Bayi Children's Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objective}: The aim of the study is to assess the therapeutic
effect and applicability of pectoralis major muscle turnover flap
reconstruction for treatment of deep sternal wound infection after
cardiac surgery in infants and children. \textbf{Methods:} From march
2013 to october 2021, 23 patients with deep sternal wound infection
after cardiac surgery underwent pectoralis major muscle turnover flap
reconstruction.The data and outcomes of the patients were
retrospectively analyzed. \textbf{Results:} 20 patients were treated
with unilateral pectoralis major muscle turnover flap reconstruction,3
patients were treated by bilateral pectoralis major muscle turnover
flap. All of the sternal wounds healed successfully. All patients
survived and were discharged without evidence of infection. In a
follow-up period, ranging from 15 to 83 months (mean 32.6 months), all
patients demonstrated normal development with no limitations to limb
movements. There were no signs of chronic sternal infection in all of
them. \textbf{Conclusion:}Pectoralis major muscle turnover flap
reconstruction is a simple,feasible and effective treatment of deep
sternal wound infection after cardiac surgery in infants and
children,with minimal developmental problems.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Deep sternal wound infection(DSWI) after cardiac surgery is a rare but
severe complication, with a reported rate of 0.5-7.5\% in the pediatric
population{[}1,2{]}. The infection is defined as deep or severe, when
the sternum or mediastinal structures are involved, and it demands
effective surgical and antimicrobial therapy{[}3{]}. In adult patients,
various techniques have been used to treat DSWI with good results, such
as vacuum-assisted closure\textbf{,} vascularized muscle flaps\textbf{.}
However,only limited information are available concerning the treatment
of DSWI in infants and children{[}4-6{]}. The optimal treatment of DSWI
is still controversial in infants and children, due to the
pathophysiological characteristics and developmental problems.

In this report, we present our experience in treating DSWI following
cardiac surgery with pectoralis major muscle turnover flap(PMMTF)
reconstruction in infants and children, including immediate and mid-term
outcomes.

\textbf{Materials and methods}

\textbf{Patients}

A retrospective review of 23 patients with DSWI following cardiac
surgery were treated in the Department of Pediatric Cardiac Surgery, The
Seventh Medical Center of the PLA General Hospital from March 2013 to
October 2021.Patients' data were retrospectively obtained from the
hospital records.International Review Board approval, consent statement,
and clinical trial registration are not applicable to our study.

The patients' characteristics,surgical management and outcomes were
retrospectively analyzed. Follow up was completed with outpatient review
and by telephone interviews

\textbf{Surgical technique}

DSWI is defined as infection involving fascia or deeper with at least
one of the following: evidence of infection seen at re-operation or
spontaneous dehiscence, positive culture of mediastinal fluid and/or
positive blood culture and/or chest pain with sternal instability and
temperature higher than 38 degrees Celsius{[}7{]}. All patients with
DSWI are well prepared preoperatively, including early wound exploration
and drainage, antibiotic therapy, nutritional support and
cardiopulmonary function.

All patients are anesthetized with tracheal intubation. The infected
tissue is resected in full layer along the edge of the incision and all
sternal wires are removed. Use a rongeur to remove the infected sternum
until healthy solid bone with briskly bleeding margins is found. If the
bone is obviously necrotic, the entire sternum is resected. Explore the
posterior sternum space to thoroughly remove infected tissue and foreign
materials, such as residual pacemaker wires. If infection involves
extracardiac conduit and patch, they must also be removed.Mediastinal
secretions and infected tissue are sent for culture. The wound is
irrigated with hydrogen peroxide and normal saline.

According to the size of the wound defect decide whether unilateral or
bilateral pectoralis major flap. If an unilateral pectoralis major flap
is used, the right pectoralis major is usually chosen because muscles
are more developed on this side. Dissect the overlying skin off the
pectoralis major muscle from medial to the anterior axillary line.Cut
off the muscle at the junction of medial 2/3 and the lateral 1/3 by
using electrotome.Dissect the medial muscle from lateral to medial until
the perforating vessels are visible. Flip muscles to fill the
mediastinum as a turnover flap. The turnover muscle flap is fixed with
double-stranded no.7 silk sutures by methods of relieving tension. The
drainage tube is placed in the mediastinum. skin is closed with
interrupted silk sutures.Postoperatively,chest wall is pressurized with
elastic bandage. The drainage tube is left in place for 4-7 days based
on the amount of drained fluid. Postoperative antibiotic therapy was
performed for 2-3 weeks according to culture results.

\textbf{Table 1} Preoperative characteristics of patients\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Case No.\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Sex\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Age (months)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Weight (kg)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Diagnosis\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Initial operation\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Time from surgery to infection(days)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
DORV,VSD\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Intraventricular tunnel repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PA,VSD,PDA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Melbourne shunt\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
51\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TOF\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Complete repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
15\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TAPVC\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TAPVC correction\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
23\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
33\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
PA,VSD\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD repair,extracardiac valved conduit\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
16\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
52\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
16.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
MR\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
MVP\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9.3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
BDG\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
IAA,VSD,PDA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
One stage correction\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TOF\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Complete repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5.1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TAPVC\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TAPVC correction\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5.3\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TGA,VSD,PDA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Switch,VSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
DORV,VSD,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Intraventricular tunnel repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
8.7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD ,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
VSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
19\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
7.3\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PAS,TS\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
PAS repair, slide tracheoplaty\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TGA,VSD,PDA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Switch,VSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
13.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
TOF\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Complete repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
19\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
M\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Coa,VSD\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
One stage correction\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
23\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
F\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
9.8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD,PH\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CAVSD repair\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
17\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

DORV: double outlet of right ventricle; VSD: ventricular septal defect;
PA: pulmonary atresia; PDA:patent ductus arteriosus; TOF:tetralogy of
Fallot; TAPVC:total anomalous pulmonary venous connection; CAVSD:
complete atrioventricular septal defect; PH: pulmonary hypertension; MR:
mitral regurgitation; MVP: mitral valvuloplasty; TA: tricuspid atresia;
IAA: interrupted aortic arch; TGA: transposition of great artery; PAS:
pulmonary artery sling; TS: tracheal stenosis; CoA: coarctation of aorta

\textbf{Statistical analysis}

Data were analyzed with SPSS 25 software. Continuous data are expressed
as mean\selectlanguage{ngerman}±SD. Inferential comparisons were made using the two-sample mean
comparison t test. \emph{p} values of less than 0.05 were considered
significant.

\textbf{Results}

A total of 23 patients with DSWI following cardiac surgery were treated
in our center from March 2013 to October 2021, including 14 patients who
underwent initial cardiac operation at other hospitals. During the same
period, 2079 consecutive pediatric cardiac procedures via median
sternotomy were performed in our center and 9 patients were diagnosised
DSWI(0.4\%). The patients' preoperative characteristics are summarized
in Table 1. Postoperative DSWI developed an average of 14 days after the
initial operation. The average interval between diagnosis of DSWI and
PMMTF reconstruction was 4.7 days(Table 2).

\textbf{Table 2} postoperative characteristics of patients\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
Case No. & Time from DSWI to PMMTF(days) & Time from DSWI to PMMTF(days)
& Culture & Reconstruction technique & Hospital stay after
reconstruction(days)\tabularnewline
\midrule
\endhead
1 & 3 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
20\tabularnewline
2 & 7 & (-) & (-) & Right PMMTF & 17\tabularnewline
3 & 5 & Pseudomonas aeruginosa & Pseudomonas aeruginosa & Bilateal PMMTF
& 9\tabularnewline
4 & 6 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
12\tabularnewline
5 & 7 & Acinetobacter baumannii & Acinetobacter baumannii & Right PMMTF
& 14\tabularnewline
6 & 7 & (-) & (-) & Right PMMTF & 11\tabularnewline
7 & 7 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
26\tabularnewline
8 & 6 & Staphylococcus epidermidis & Staphylococcus epidermidis &
Bilateal PMMTF & 16\tabularnewline
9 & 4 & Staphylococcus epidermidis & Staphylococcus epidermidis & Right
PMMTF & 21\tabularnewline
10 & 5 & (-) & (-) & Right PMMTF & 20\tabularnewline
11 & 8 & Pseudomonas aeruginosa & Pseudomonas aeruginosa & Right PMMTF &
17\tabularnewline
12 & 4 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
13\tabularnewline
13 & 4 & Staphylococcus epidermidis & Staphylococcus epidermidis & Right
PMMTF & 28\tabularnewline
14 & 7 & (-) & (-) & Right PMMTF & 13\tabularnewline
15 & 5 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
19\tabularnewline
16 & 6 & (-) & (-) & Bilateal PMMTF & 10\tabularnewline
17 & 5 & Staphylococcus epidermidis & Staphylococcus epidermidis & Right
PMMTF & 15\tabularnewline
18 & 3 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
21\tabularnewline
19 & 3 & Staphylococcus aureus & Staphylococcus aureus & Right PMMTF &
18\tabularnewline
20 & 5 & (-) & (-) & Right PMMTF & 22\tabularnewline
21 & 5 & Staphylococcus epidermidis & Staphylococcus epidermidis & Right
PMMTF & 12\tabularnewline
22 & 6 & Pseudomonas aeruginosa & Pseudomonas aeruginosa & Right PMMTF &
29\tabularnewline
23 & 4 & (-) & (-) & Right PMMTF & 11\tabularnewline
\bottomrule
\end{longtable}

Wound cultures were positive in 16 patients (69.6\%). Staphylococcus
aureus in 7 patients (30.4\%), Staphylococcus epidermidis in 5 patients
(21.7\%), Pseudomonas aeruginosa in 3 patients(13.0\%), Acinetobacter
baumannii in 1 patient (4.3\%). There were no statistically significant
differences in clinical characteristics between patients with and
without wound culture positive(Table 3).

20 patients were treated with unilateral(right) pectoralis major muscle
turnover flap,3 patients were treated by bilateral pectoralis major
muscle turnover flap. All of the sternal wounds healed successfully in
one stage. All patients survived and were discharged without evidence of
infection.The mean hospital stay from PMMTF reconstruction was 17.1
days.

Follow-up ranged from 15 to 83 months with an average of 32.6 months.
During the follow-up, there were no signs of chronic sternal infection,
and all wounds healed well. All patients were between 25 to 75
percentile in their weight and height nomograms and appropriately
developed for their age according to the Denver development
scale{[}8{]}. In 3 patients,chest wall were mild asymmetry.There were no
limitations in upper trunk or limb movements in all patients.

\textbf{Table 3} comparision of clinical characteristics of wound
culture negative and positive\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Characteristic\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Wound culture negative (n=7)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Wound culture positive (n=16)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
Wound culture positive (n=16)\strut
\end{minipage} & \begin{minipage}[b]{0.19\columnwidth}\raggedright\strut
\emph{P}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age(month)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12.42\selectlanguage{ngerman}±10.34\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16.56\selectlanguage{ngerman}±15.92\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.537\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.537\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Weight(kg)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
7.56\selectlanguage{ngerman}±3.27\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
9.36\selectlanguage{ngerman}±5.12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.404\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.404\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Time from surgery to infection(d)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
13.29\selectlanguage{ngerman}±5.38\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14.31\selectlanguage{ngerman}±4.67\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.647\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.647\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Time from DSWI to PMMTF(d)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.86\selectlanguage{ngerman}±1.21\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
5.06\selectlanguage{ngerman}±1.53\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.238\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.238\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hospital stay after reconstruction(d)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14.86\selectlanguage{ngerman}±4.81\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
18.13\selectlanguage{ngerman}±5.86\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.211\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.211\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Discussion}

Median sternotomy is the most frequently used incision for pediatric
cardiac operation. However,DSWI after cardiac surgery is a severe
complication that not only increases mortality and morbidity{[}9,10{]},
but also prolongs hospital stays and increases treatment
costs{[}11,12{]}. Risk factors for sternal wound infection in infant
include low gestational age,prolonged ICU stay and open chest, cyanotic
congenital heart diseases, high complexity of the surgical treatment,
quality of the operative field treatment and surgical team
experience{[}13-16{]}.

The principles of treatment for DSWI are adequate debridement,removal of
all infected tissue and foreign materials, a well-vascularized tissue
transfer to promote wound healing, anterior mediastinal protection, and
chest wall stability{[}3{]}. If the wound infection is suspected, early
wound exploration and drainage are necessary, empirical broad spectrum
intravenous antibiotics should be initiated. when culture results are
available, targeted antibiotics should be used. once deep sternal
infection is definite, surgical debridement should be performed as soon
as possible. During debridement, the presence of residual foreign
materials and infection involving implants should be carefully
examined.In our study, 4 patients were found to have residual pacemaker
wires and one patient was found to have infection involving the
extracardiac conduit.we removed residual pacemaker wires,replaced the
extracardiac conduit.

There is no consensus as to the best specific treatment for close the
sternum after thorough surgical debridement.At present,the main
treatment methods include sternal rewiring after debridement,
Vacuum-assisted closure(VAC) therapy and flap reconstruction. For deep
sternal wound infections, part of the sternum is often resected,
resulting in unsatisfactory outcomes with the method of sternal
rewiring. VAC can improve wound healing by increasing parasternal blood
flow, reducing bacterial loads, enhancing formation of granulation
tissue {[}17,18{]}.But, using a vacuum system over an open sternum has
raised concerns that the strong negative pressure could cause right
ventricle rupture and other bleeding complications{[}19{]},and for
sternum necrosis and severe infection, the failure rate of VAC is still
high{[}20,21{]}.

Currently, flap reconstruction is regarded as the gold standard in DSWI
where there is inadequate sternum following debridement or uncertainty
whether the infectious process has been controlled{[}22{]}. There has
been a variety of flap choices for reconstructing sternal wounds, such
as the pectoralis major flap, rectus abdominis flap and omental flap.
The pectoralis major is a broad flat muscle that lies close to the
sternum, allowing for easy dissection and providing adequate coverage.
It has rich blood supply from thoracoacromial artery, segmental pedicles
from the internal thoracic artery and some branches of the lateral
thoracic and intercostals arteries. Based on the above advantages,
pectoralis major muscle flap is the most commonly used flap and has
achieved good results in adult patients {[}23{]}.However, there are only
a few reports about these techniques in pediatric patients.In this
study, we used the pectoralis major muscle turnover flap technique. This
technique preserves the lateral one third of the muscle with its
dominant vascular pedicle and motor nerves, and preserves the contour of
the chest wall, producing a better cosmetic result{[}24{]}. We consider
the technique is easy and unilateral flap can completely fill stermal
defect in most patients.It may be related to the relatively short
sternum in infants. If unilateral flap does not completely close the
defect, the residual sternal defect can be filled by splitting the
opposite pectoralis major muscle turnover flap. Zahiri demonstrated the
turnover flap to be associated with less postoperative complications
when compared to the advanced pectoralis major flap{[}25{]}. Many
studies suggest the use of VAC therapy to bridge definitive primary
closure or flap reconstruction. However, we consider that immediate flap
reconstruction after debridement may improve outcomes and shorter
treatment time. In our study,all patients underwent one-stage
debridement and flap reconstruction,and all of the sternal wounds healed
successfully.

In pediatric patients, long-term development and limb function should be
of special concern. During the follow-up,we found no evidence of any
upper limb or upper trunk movements disorder,and chest walls were stable
in all patients.Erez and colleagues {[}3{]} reported similar results in
5 neonates who were treated with unilateral PMMTF reconstruction. In
female patients, the use of pectoralis major flap may have potential
impact on breast development, should be long-term follow-up.

The study is subject to the usual limitations of a retrospective,
uncontrolled study design. Our experience with pectoralis major turnover
flap reconstruction over the past 10 years and have achieved good
therapeutic results. Therefore, pectoralis major turnover flap
reconstruction is our first choice for the treatment of DSWI. This is
one of the reasons we did not have a control group. Another limitation
of this study is the number of cases is small, so further large-scale
controlled studies are needed.

\textbf{Conclusion}

DSWI after cardiac surgery is a potentially life-threatening
complication. Early recognition and thorough debridement are important
for the management of DSWI. Pectoralis major muscle turnover flap
reconstruction is simple,feasible and effective treatment of DSWI in
infants and children,with satisfactory mid-term outcomes, almost no
complications. Developmental problems require long-term follow-up.

\textbf{Competing interests}

The authors declare that they have no competing interests.

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\selectlanguage{english}
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