| Background and PurposeThe median sternal incision is the most commonly used approach for cardiac surgery because of the advantages of its sufficient exposure and simple operation.But the sternal wound infection often happens after operation.It could make the incision hard to be healed normally and form the refractory wounds,which may lead to very severe consequences.This study is based on a large sample of clinical data before analyzing the risk factors of SWI.The R language is adopted to construct a prediction model of nomogram and evaluate the degree of differentiation,calibration and clinical effectiveness,which could help to establish an efficient and accurate visual prediction model of SWI.Then the model could further provide clinical prediction tools for early,timely and effective intervention to reduce the incidence of SWI.At the same time,the effectiveness of plastic surgery repair and reconstruction technology in SWI clinical treatment is discussed,and our experience in diagnosis and treatment is summarized for improving the diagnosis and treatment efficiency of SWI.MethodsPart one:construction of nomogram model of sternal wound infection.This thesis gives a retrospective analysis of the clinical data of 23182 patients who underwent median sternal incision thoracotomy from August 1,2009,to July 31,2019,in the Department of Cardiovascular surgery,second affiliated Hospital of Army Medical University.The patients were divided into the observation group and the controlling group according to whether or not they progressed to SWI.The statistical screening process includes:firstly,the factors with statistical differences were screened out by univariate logistics regression analysis of the two groups of data,and the selected factors were diagnosed by collinearity with Spearman correlation coefficient.The factors that do not have collinear relationships are included in the multi-factor Logistic regression model to screen out independent risk factors into the nomogram.The rms packet in R language is used to draw the nomogram,and the model is evaluated by the degree of differentiation,calibration,and clinical effectiveness.The differentiation degree is evaluated by the receiver operating characteristic cur ve(ROC)and the C-Statistics;the calibration degree is evaluated by calibration curve(Calibration plot)and Hosmer-Lemeshow test,and the clinical effectiveness is evaluated by decision curve analysis.Part two:The strategy of plastic surgery in the diagnosis and treatment of sternal wound infection.The detailed clinical data of 35 patients with SWI after median sternal incision in our department from March 2017 to March 2019 were analyzed retrospectively.According to the diagnostic criteria,superficial sternal wound infection(SSWI)was mainly tr eated by debridement,vacuum sealing drainage,and skin grafting,while deep sternal wound infection(DSWI)was treated with mixed reality(MR)technique to localize the infected lesions accurately.Meanwhile,the plastic surgical repair and reconstruction techniques such as muscle flap transfer and no foreign body retained in the wound were adopted.The clinical effect was evaluated according to the incision recovery,hospital stays,cure rate,and follow-up visit.ResultsPart one:the construction of the nomogram prediction model of sternal wound infection.1.The results of univariate analysis showed that the influencing factors of SWI were age,body mass index(BMI),obesity(BMI≧28),intensive care unit time,secondary operation,diabetes,cardiogenic shock,hypertension,hyperlipidemia,hypoproteinemia,renal failure,myocardial infarction,and angina pectoris,which have statistical differences.Collinear diagnosis showed that there was no linear relationship.It is showed that BMI,intensive care unit time,diabetes and secondary operation were independent risk factors according to the further multivariate logistics regression analysis.2.The prediction model of SWI was established based on four independent risk factors:BMI,intensive care unit time,diabetes,and secondary operation.The C-Statistics of ROC curve of the model was 0.705(95%CI:0.746-0.803),which proved that the model was useful,and the best cut-off point of ROC curve was 0.018,the sensitivity and specificity of the model were 0.702 and 0.739,respectively,and it was further proved that the model was reliable and effective.The calibration curve showed that there was good consistency between the calibration curve and the ideal curve;the Hosmer-Lemeshow goodness-of-fit test showed that the calibration curve was?~2=6.987,P=0.538,which further indicated that the model had good fitting validity and high predictive value.The clinical decision-making curve shows that the net benefit rate of the prediction model is greater than 0 i n the range of cut-off points,indicating that it has good clinical effectiveness.Part two:the strategy of plastic surgery in the diagnosis and treatment of sternal wound infection.The vacuum sealing drainage device was changed for an average of 3 times for 27patients with SSWI.The time range of treatment in the hospital was from 5 to 126 days,the average treatment time was 57 days,and the cure rate was 92.6%.Among th em,25 cases were healed in the first stage after direct suture,2 cases were not cured and discharged from the hospital.The range of treatment time in the hospital was from 10 to 96 days,the average treatment time was 32 days,and the cure rate was 100%.Among them,7 cases were healed in the first stage when they were discharged from the hospital,and the activity of the limbs in the donor area was not significantly affected.1 case had partial skin necrosis at the cutting edge and healed under the scab actively after active treatment.There is no recurrence among the patients during the 2 months to 2 years follow-up.Conclusion1.BMI,intensive care unit time,secondary operation,and diabetes were independent risk factors for SWI.The nomogram prediction model based on independent risk factors could be used to predict the risk of SWI after median sternotomy.It has good differentiation,accuracy and high clinical application value,and has guiding significance for early screening of high-risk groups and early formulation of intervention strategies.2.The accurate diagnosis and classified treatment are given based on the severity of the disease.Therefore,SSWI was mainly treated with debridement,vacuum-sealing drainage,skin graft,while DSWI was treated with plastic surgical repair and reconstruction techniques such as muscle flap transfer and no foreign body in the wound,which improved the cure rate of the patients.In addition,MR technology in the diagnosis and treatment of DSWI helps to accurately locate the focus of infection before the operation and help guide the scope of intraoperative debridement,which ensures thorough debridement and reduces the probability of recurrence.At the same time,it also plays a positive role in preoperative doctor-patient communication and postoperative follow-up. |
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