Orthoplastic management of delayed sternal osteomyelitis and non-union: a retrospective case series applying fracture-related infection principles.

BACKGROUND

Sternal osteomyelitis (OM), particularly in the context of late-presenting non-union following cardiothoracic surgery, remains a poorly understood and inconsistently managed condition. Delayed presentations involve established infection, sternal instability, and biofilm formation, requiring a multidisciplinary approach. BOAST guidelines for fracture-related infection (FRI) recommend a combined orthoplastic approach to manage these complex cases.

METHODS

This retrospective case series identified all patients referred to a specialist bone infection unit with delayed onset sternal OM from March 2015 to March 2025. All patients were managed through a multidisciplinary pathway involving cardiothoracic surgery, orthopaedics, plastic surgery, and microbiology. Each case involved planning through a bone infection MDT, radical debridement, multiple deep tissue sampling, removal of infected foreign material, skeletal stabilisation where indicated, definitive soft tissue reconstruction, and culture-directed antimicrobial therapy. Clinical outcomes, microbiological findings, and recurrence were assessed.

RESULTS

Fourteen patients were included (mean age 63·7 years), all with significant comorbidity burden. The interval from index cardiac surgery to definitive debridement ranged from 25 to 3,251 days. Eleven patients underwent single-stage debridement with immediate reconstruction: three required staged procedures. The most commonly isolated organisms were Staphylococcus epidermidis (7/14), Cutibacterium acnes (5/14), and Staphylococcus aureus (4/14); mixed infections were frequent. Mean length of stay following single-stage procedures was 10·5 days. During a mean follow-up of 410 days, one patient experienced recurrence requiring further surgery.

CONCLUSION

This case series demonstrates that delayed sternal OM and non-union can be effectively managed through an orthoplastic approach aligned with FRI principles. Isolated soft tissue coverage, which has historically been the default management, fails to address the underlying pathology. Approaches focused solely on soft tissue reconstruction risk, persistent infection, and instability. This study supports the application of fracture-related infection principles to delayed sternal osteomyelitis, emphasising radical debridement, hardware removal, multidisciplinary decision-making, and definitive reconstruction as key components of successful treatment.