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Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery

Journal of Cardiothoracic Surgery volume 6, Article number: 141 (2011) Cite this article

Abstract

Purpose

A retrospective study to evaluate the effect of hyperbaric oxygen (HBO2) therapy on sternal infection and osteomyelitis following median sternotomy.

Materials and methods

A retrospective analysis of patients who received sternotomy and cardiothoracic surgery which developed sternal infection and osteomyelitis between 2002 and 2009. Twelve patients who received debridement and antibiotic treatment were selected, and six of them received additional HBO2 therapy. Demographic, clinical characteristics and outcome were compared between patients with and without HBO2 therapy.

Results

HBO2 therapy did not cause any treatment-related complication in patients receiving this additional treatment. Comparisons of the data between two study groups revealed that the length of stay in ICU (8.7 ± 2.7 days vs. 48.8 ± 10.5 days, p < 0.05), duration of invasive (4 ± 1.5 days vs. 34.8 ± 8.3 days, p < 0.05) and non-invasive (4 ± 1.9 days vs. 22.3 ± 6.2 days, p < 0.05) positive pressure ventilation were all significantly lower in patients with additional HBO2 therapy, as compared to patients without HBO2 therapy. Hospital mortality was also significantly lower in patients who received HBO2 therapy (0 case vs. 3 cases, p < 0.05), as compared to patients without the HBO2 therapy.

Conclusions

In addition to primary treatment with debridement and antibiotic use, HBO2 therapy may be used as an adjunctive and safe treatment to improve clinical outcomes in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery.

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Introduction

Patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery are uncommon, but these serious complications could increase postoperative mortality, morbidity and medical cost [1, 2]. Ischemia and hypoxia are postulated as the mechanism resulting in development of sternal infection and osteomyelitis [3, 4]; however, the current primary treatment only focuses on early debridement and antibiotic use [5].

Hypobaric oxygen (HBO2) therapy, the administration of 100% oxygen at 2 to 3 absolute atmosphere pressure (ATA), has been widely used in the treatment of various problem wounds and for refractory osteomyelitis [6, 7]. Mechanisms of HBO2 therapy include reversing hypoxia, reducing local edema, improving host immunity, enhancing antibiotic activity [8, 9]. There are only few reports about the additional HBO2 therapy for patients who develop sternal osteomyelitis after sternotomy. Most of the results are effective and successful [10, 11]. The aim of this retrospective study was to evaluate the efficacy of HBO2 therapy in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery.

Methods and materials

During January 1st, 2002 to December 31th 2009, twelve patients who developed sternal infection and osteomyelitis following sternotomy and cardiothoracic surgery at Taipei Veterans General Hospital were recruited. The study was approved by the Institutional Review Board of the Taipei Veterans General Hospital (approval number, 201009015IC). All study data were collected retrospectively, so informed consent was not required.

The diagnosis of organ/space sternal surgical site infection(SSI) was according to the Center for Disease Control (CDC) criteria: (1) the sternal SSI occurs after sternotomy and cardiothoracic surgery; (2) the infection appears to be related to the operation and could involve any part of the anatomy other than the incision which was opened or manipulated during the operation (organs or spaces). Furthermore, at least one of the following criteria is required: (1) purulent drainage from the organ/space of sternal surgical site; (2) organism isolated from an aseptically obtained culture of fluid or tissue in the organ/space of sternal surgical site; (3) an abscess or other evidence of infection involving the organ/space of sternal surgical site found on direct examination; (4) diagnosis of organ/space SSI by a surgeon or attending physician [12]. In addition, sternal osteomyelitis was documented by computer tomography of chest, surgical debridement pathology or osteomyelitis scans.

All patients were treated with empiric antibiotics initially and then guided by culture report and antibiotic susceptibility tests. Early debridement, daily antiseptic irrigation and dressing change were performed. After the infection was under control, reconstruction of the wound with pectoralis or rectus muscle and omental flap rotation was performed at the decision of the clinical physician. HBO2 therapy was performed in a multiplace chamber (HTK 1500/BS, Drägen, Siemens, Germany). Each session was 120 minutes long including three phases: compression, oxygen breath and decompression. Compression and decompression were performed with room air at a rate of 0.1 ATA per minute. At oxygen breath phase, all patients breathed 100% oxygen under 2.5 ATA for 90 minutes through a face mask that was fit well and secured with head straps. During the treatment period, patients were observed closely for acute illness or any complications. HBO2 therapy sessions were daily from Monday to Friday with a break of 2 days. The total number of sessions of HBO2 therapy performed based on clinical outcome and at the discretion of the clinical physician.

Statistical analysis

Statistical analysis was done using SPSS version 18.0 (SPSS Inc., Chicago IL). Continuous variables were expressed as the mean ± standard deviation (SD). Continuous variables were compared with Wilcoxon's rank sume test and categorical variables were compared by Fishers exact test. p < 0.05 was considered statistically significant.

Results

During the study period, 12 patients (mean age 59 ± 4.5 years) fulfilling the entry criteria were selected. Among these patients, 7 patients received coronary arterial bypass surgery, 3 patients received thymectomy, 1 patient received mitral valve replacement and 1 patient received type A aortic dissection repair. They received computer tomography of chest (n = 8), pathologic surgical debridement (n = 3) or osteomyelitis scans (n = 7) for the diagnosis of sternal osteomyelitis. All patients received primary treatments with debridement and empiric antibiotics treatment, and then guided by antibiotic susceptibility tests. Six of them received additional HBO2 therapy. The others did not received HBO2 therapy because of the insurance or risk of HBO2 therapy. The characteristics of the study population are presented in Table 1 and there was no significant difference between these two groups. The bacteriology data from sternal wound/pus, pleural effusion and blood are listed in Table 2. Staphylococcus species were the most common pathogens of sternal wound infection (11/12, 91.7%) and bacteremia (5/6, 83.3%). Mixed infection due to Gram-positive and Gram-negative pathogens was also identified in 2 patients (2/12, 16.7%). Mycobacterium tuberculosis was found in one sternal pus/wound pathogen. HBO2 therapy did not cause any treatment-related complication in the study patients who received this additional treatment. Besides, patients breathed with room air when initiation of HBO2 therapy and did not receive mechanical ventilation, sedative or inotropic medication during HBO2 therapy. Total and average debridement duration, debridement frequency, hospital admission frequency and length of hospital stay were not significantly different between HBO2 therapy and control group. Most importantly, length of ICU stay (8.7 ± 2.7 days vs. 48.8 ± 10.5 days, p < 0.05), duration of invasive mechanical ventilation (MV) (4 ± 1.5 days vs. 34.8 ± 8.3 days, p < 0.05) and duration of noninvasive positive pressure ventilation (NIV) (4 ± 1.9 days vs. 22.3 ± 6.2 days, p < 0.05) were significantly reduced in HBO2 therapy group (Table 3). In addition, hospital death (0 person vs. 3 persons, p < 0.05) w as significantly lower in HBO2 therapy group (Table 4). The causes of death in the control group were ischemic bowel disease (n = 1), acute pancreatitis (n = 1) and mediastinitis (n = 1).

Table 1 Characteristiscs of patients in HBO2 and control group
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Table 2 Causative organisms of patients in HBO2 and control group
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Table 3 Operative and postoperative details in HBO2 and control group
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Table 4 Outcome of patients in HBO2 and control group
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Discussion

The incidence of sternal infection and osteomyelitis in patients undergoing sternotomy for cardiothoracic surgery is not common- stated as being less than 4% in several reports; however, it is a serious complication that increases the length of hospital stay, short-term and long term mortality, and medical cost [4, 13]. In the current study, we demonstrated that in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery, HBO2 therapy could be an adjunctive treatment to improve clinical outcomes including the length of ICU stay, duration of MV and NIV support, complications during hospital stay, and hospital mortality.

Risk factors for deep sternal wound infection and osteomyelitis after median sternotomy have been reported that included: (1) preoperative factors: male, chronic obstructive pulmonary disease, diabetes, New York Heart Association congestive heart failure class, reoperation and obesity; (2) intraoperative factors: coronary artery bypass grafting, prolonged cardiopulmonary bypass time and duration of surgery; (3) postoperative factors: excessive postoperative bleeding, postoperative inotropic support and prolonged time (>48 hours) on mechanical ventilation [14–18]. In our study, although patients in the control group compared to HBO2 group had more above-mentioned risk factors, these differences did not reach statistical significance. However, the potential influence by these risk factors might still play a role on the patient outcome. Importantly, patients with the co-morbidity of congestive heart failure have been mentioned the risk for acute pulmonary edema after HBO2 therapy [19]. Therefore, HBO2 therapy should be cautious when be applied to these patients.

The pathophysiology of sternal wound infection and osteomyelitis is hypoxia and ischemia [3, 4]; therefore, the administration of HBO2 therapy has theoretical benefit for these patients. However, there are only few case reports and non-randomized studies about the use of HBO2 therapy in this patient population. Recently, Higuchi et al. presented 4 patients with sternal osteomyelitis after lung transplantation who received surgical debridement, antimicrobial treatment and adjunctive HBO2 therapy [10]. Three of them improved significantly and the authors concluded that HBO2 therapy was safe and effective for the management of infection complication. Barili et al also conducted a prospective nonrandomized study to investigate the effect of HBO2 therapy on organ/space sternal surgical site infection (SSI) following cardiothoracic surgery [20]. A total of 34 patients who developed organ/space sternal SSI after cardiac surgery were enrolled and divided into two groups according to whether HBO2 therapy was offered or not. The relapsing, infection rate, the duration of intravenous antibiotic use and total hospital stay were significantly lower in patients with HBO2 therapy than those without HBO2 therapy. In our study, we further identified that HBO2 therapy alleviated the burden of critical care by shortening the length of ICU stay, and duration of MV and NIV support. Furthermore, it also reduced complications during hospital stay and mortality in patients with sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery. Although the total length of hospital stay and total debridement frequency were not significantly different between the HBO2 therapy and control group, patients in HBO2 group tended to receive more debridement frequencies and have more hospital admissions that might contribute to longer length hospital stay and better outcome.

The current treatment for sternal infection and osteomyelitis includes early recognition, early debridement, collection of specimens for bacteria pathogen, use of broad-spectrum antibiotics and a change in antibiotics based on the culture result of the sensitivity test. When the patient's infection is under control, reconstruction of the wound should be instituted, including rewiring, and pectoralis or rectus muscle and omental flap rotation [21–23]. HBO2 therapy might offer additional biochemical and cellular effects. With the administration of HBO2 therapy, the partial oxygen pressure in the wound increases and promotes collagen matrix formation, angiogenesis, osteoclast/osteoblast activity and bone union [24–26]. Increased oxygen tension improves neutrophil ability to kill bacteria. Some antibiotics such as aminoglycosides, fluoroquinolones, vancomycin and sulfonamides have a synergistic effect when combined with HBO2 for the treatment of bacterial infection [9]. HBO2 itself also acts as an antibiotic agent against a broad spectrum of Gram-positive and Gram-negative bacteria [9]. These above-mentioned effects of HBO2 therapy might explain how adjunctive HBO2 therapy provides additional benefits to patients with sternal infection and osteomyelitis and improves the clinical outcomes of such patients.

The timing of HBO2 therapy for SSI and sternal osteomyelitis after sternotomy has been discussed. Higuchi et al. reported the initiation of HBO2 therapy for patients with persistent osteomyelitis after standard treatment [10]. Barili et al started early HBO2 therapy after the diagnosis of sternal surgical site infection [20]. Both studies demonstrated the adjunctive benefit of HBO2 therapy. In our study, the decision of HBO2 therapy was based on clinical physicians, range from 2 weeks to months after the diagnosis of sternal osteomyelitis. However, the timing of HBO2 therapy for sternal osteomyelitis to gain maximum benefit requires further investigation.

Although the microbiologic pathogens from the sternal pus/wound, pleural effusion and blood are diverse, Gram-positive cocci remain the most common pathogens in our retrospective study which is consistent with other studies [27, 28]. Interesting, mycobacterium tuberculosis was found in one sternal pus/wound pathogen. Reactivation of pulmonary or mediastinal lymph node tuberculosis, contamination of the operation field, and exogenous exposure persons with active pulmonary tuberculosis may hypothesize tuberculosis infection after cardiothoracic surgery [29, 30]. The patient with sternal wound infection of mycobacterium tuberculosis received surgical debridement, combination antituberculous agent treatment and HBO2 therapy and was finally discharged. It is important to note that some of the patients with sternal infection and osteomyelitis developed bacteremia (2/6 in HBO2 therapy group, 4/6 in control group) which might worsen the prognosis of patients. Based on our observations of this study, HBO2 therapy might improve sternal infection and reduce the occurrence of bacteremia.

Limitations

Our study had several limitations that are worth noting. This study was retrospective in nature; therefore certain data might have been missing or poorly documented. Second, the number of patients in this study was small. Third, we only focused on the clinical outcomes of the study patients; therefore, the local effects of HBO2 therapy, such as tissue oxygenation, angiogenesis, and osteoclast/osteoblast activity were not observed.

Conclusion

HBO2 counteracts tissue hypoxia by elevating tissue oxygen partial pressure, promotes wound healing, has the synergistic effect when combined with some antibiotics and prevents infection. In this study, all patients who received HBO2 therapy as an adjunctive treatment for post-cardiothoracic surgery related sternal infection and osteomyelitis achieved a favorable result. We suggest a combination of aggressive surgical debridement, antibiotic treatment and adjunctive HBO2 therapy for patients who develop sternal infection and osteomyelitis after cardiothoracic surgery.

References

  1. 1.

    Braxton JH, Marrin CA, McGrath PD, Ross CS, Morton JR, Norotsky M, Charlesworth DC, Lahey SJ, Clough RA, O'Connor GT, Northern New England Cardiovascular Disease Study Group: Mediastinitis and long-term survival after coronary artery bypass graft surgery. Ann Thorac Surg. 2000, 70: 2004-7. 10.1016/S0003-4975(00)01814-2.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Muñoz P, Menasalvas A, Bernaldo de Quirós JC, Desco M, Vallejo JL, Bouza E: Postsurgical Mediastinitis: A Case-Control Study. Clin Infect Dis. 1997, 25 (5): 1060-4. 10.1086/516068.

    Article  PubMed  Google Scholar 

  3. 3.

    Francel TJ, Dufresne CR, Baumgartner WA, O'Kelley J: Anatomic and clinical considerations of an internal mammary artery harvest. Arch Surg. 1992, 127: 1107-11.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Mills C, Bryson P: The role of hyperbaric oxygen therapy in the treatment of sternal wound infection. Eur J Cardiothorac Surg. 2006, 30: 153-159. 10.1016/j.ejcts.2006.03.059.

    Article  PubMed  Google Scholar 

  5. 5.

    De Feo M, Gregorio R, Della Corte A, Marra C, Amarelli C, Renzulli A, Utili R, Cotrufo M: Deep sternal wound infection: the role of early debridement surgery. Eur J Cardiothorac Surg. 2001, 19: 811-816. 10.1016/S1010-7940(01)00676-5.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Zamboni WA, Browder LK, Martinez J: Hyperbaric oxygen and wound healing. Clin Plastic Surg. 2003, 30: 67-75. 10.1016/S0094-1298(02)00068-8.

    Article  Google Scholar 

  7. 7.

    Undersea & Hyperbaric Medical Society. [http://membership.uhms.org/?page=Indications]

  8. 8.

    Hunter S, Langemo DK, Anderson J, Hanson D, Thompson P: Hyperbaric Oxygen Therapy for Chronic Wounds. Adv Skin Wound Care. 2010, 23 (3): 116-119. 10.1097/01.ASW.0000363517.55135.c2.

    Article  PubMed  Google Scholar 

  9. 9.

    Cimşit M, Uzun G, Yildiz S: Hyperbaric oxygen therapy as an anti-infective agent. Expert Rev Anti Infect Ther. 2009, 7 (8): 1015-1026. 10.1586/eri.09.76.

    Article  PubMed  Google Scholar 

  10. 10.

    Higuchi T, Oto T, Millar IL, Levvey BJ, Williams TJ, Snell GI: Preliminary report of the safety and efficacy of hyperbaric oxygen therapy for specific complications of lung transplantation. J Heart Lung Transplant. 2006, 25 (11): 1302-1306. 10.1016/j.healun.2006.08.006.

    Article  PubMed  Google Scholar 

  11. 11.

    Shields RC, Francis C, Nichols FC, Buchta WG, Claus PA: Hyperbaric oxygen therapy for chronic refractory osteomyelitis of the sternum. Ann Thorac Surg. 2010, 89: 1661-3. 10.1016/j.athoracsur.2009.10.018.

    Article  PubMed  Google Scholar 

  12. 12.

    Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR: Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Cont Hosp Ep. 1999, 20 (4): 247-278.

    Article  Google Scholar 

  13. 13.

    Kappstein I, Schulgen G, Fraedrich G, Schlosser V, Schumacher M, Daschner FD: Added hospital stay due to wound infections following cardiac surgery. Thorac Cardiovasc Surg. 1992, 40: 148-51. 10.1055/s-2007-1020134.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Culliford AT, Cunningham JN, Zeff RH, Isom OW, Teiko P, Spencer FC: Sternal and costochondral infections following open-heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg. 1976, 72: 714-726.

    CAS  PubMed  Google Scholar 

  15. 15.

    Demmy TL, Park SB, Liebler GA, Burkholder JA, Maher TD, Benckart DH, Magovern GJ, Magovern GJ: Recent experience with major sternal wound complications. Ann Thorac Surg. 1990, 49: 458-462. 10.1016/0003-4975(90)90256-6.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Borger MA, Rao V, Weisel RD, Ivanov J, Cohen G, Scully HE, David TE: Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 1998, 65: 1050-1056. 10.1016/S0003-4975(98)00063-0.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    The Parisian Mediastinitis Study Group: Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg. 1996, 111: 1200-1207.

    Article  Google Scholar 

  18. 18.

    Newman LS, Szczukowski LC, Bain RP: Suppurative mediastinitis after open heart surgery. Chest. 1988, 94: 546-53. 10.1378/chest.94.3.546.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Weaver LK, Churchill S: Pulmonary edema associated with hyperbaric oxygen therapy. Chest. 2001, 120 (4): 1407-1409. 10.1378/chest.120.4.1407.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Barili F, Polvani P, Topkara VK, Dainese L, Cheema FH, Roberto M, Naliato M, Parolari A, Alamanni F, Biglioli P: Role of hyperbaric oxygen therapy in the treatment of postoperative organ/space sternal surgical site infections. World J Surg. 2007, 31: 1702-1706. 10.1007/s00268-007-9109-0.

    Article  PubMed  Google Scholar 

  21. 21.

    Klesius AA, Dzemali O, Simon A, Kleine P, Abdel-Rahman U, Herzog C, Wimmer-Greinecker G, Moritz A: Successful treatment of deep sternal infections following open heart surgery by bilateral pectoralis major flaps. Eur J Cardiothorac Surg. 2004, 25: 232-3.

    Article  Google Scholar 

  22. 22.

    Oh AK, Lechtman AN, Whetzel TP, Stevenson TR: The infected median sternotomy wound: management with the rectus abdominis musculocutaneous flap. Ann Plast Surg. 2004, 52: 367-70. 10.1097/01.SAP.0000099710.38299.a3.

    Article  PubMed  Google Scholar 

  23. 23.

    Schroeyers P, Wellens F, Degrieck I, de Geest R, Van Praet F, Vermeulen Y, Vanermen H: Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery. Eur J Cardiothorac Surg. 2001, 20: 743-6. 10.1016/S1010-7940(01)00873-9.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Hopf HW, Gibson JJ, Angeles AP, Constant JS, Feng JJ, Rollins MD, Zamirul Hussain M, Hunt TK: Hyperoxia and angiogenesis. Wound Repair Regen. 2005, 13 (6): 558-564. 10.1111/j.1524-475X.2005.00078.x.

    Article  PubMed  Google Scholar 

  25. 25.

    Sawai T, Niimi A, Takahashi H, Ueda M: Histologic study of the effect of hyperbaric oxygen therapy on autogenous free bone grafts. J Oral Maxillofac Surg. 1996, 54: 975-981. 10.1016/S0278-2391(96)90396-1.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Godman GA, Chheda KP, Hightower LE, Perdrizet G, Shin DG, Giardina C: Hyperbaric oxygen induces a cytoprotective and angiogenic response in human microvascular endothelial cells. Cell Stress Chaperones. 2010, 15: 431-442. 10.1007/s12192-009-0159-0.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Mekontso Dessap A, Vivier E, Girou E, Brun-Buisson C, Kirsch M: Effect of time to onset on clinical features and prognosis of post-sternotomy mediastinitis. Clin Microbiol Infect. 2011, 17 (2): 292-9. 10.1111/j.1469-0691.2010.03197.x.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Brook I: Microbiology of postthoracotomy sternal wound infection. J Clin Microbiol. 1989, 27 (5): 806-807.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Sipsas NV, Panayiotakopoulos GD, Zormpala A, Thanos L, Artinopoulos C, Kordossis T: Sternal tuberculosis after coronary artery bypass graft surgery. Scand J Infect Dis. 2001, 33: 387-388. 10.1080/003655401750174147.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Achouh P, Aoun N, Hagege A, Fabiani JN: Mediastinitis due to Mycobacterium tuberculosis after a redo open heart surgery. J Cardiovasc Surg. 2005, 46 (1): 93-94.

    CAS  Google Scholar 

Download references

Acknowledgements

The authors are grateful to Steven R. Kaufman, a marketing director of Scandinavian Health Limited Group, for his help in language editing.

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Affiliations

  1. Department of Respiratory Therapy, Taipei Veterans General Hospital, Taipei, Taiwan

    Wen-Kuang Yu, Yen-Wen Chen, Huei-Guan Shie, Te-Cheng Lien, Hsin-Kuo Kao & Jia-Horng Wang

  2. National Yang-Ming University School of Medicine, Taipei, Taiwan

    Yen-Wen Chen, Te-Cheng Lien & Hsin-Kuo Kao

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  1. Wen-Kuang Yu
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Authors' contributions

WKY and YWC both participated in the design of the study and drafted the manuscript. HGS and TCL both obtained data and performed the statistical analysis. HKK and JHW both participated in critical revision of the manuscript. All authors read and approved the final manuscript

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Yu, W., Chen, Y., Shie, H. et al. Hyperbaric oxygen therapy as an adjunctive treatment for sternal infection and osteomyelitis after sternotomy and cardiothoracic surgery. J Cardiothorac Surg 6, 141 (2011). https://doi.org/10.1186/1749-8090-6-141

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Keywords

  • hyperbaric oxygen
  • sternal infection
  • osteomyelitis
  • sternotomy
  • Cardiothoracic surgery

Journal of Cardiothoracic Surgery

ISSN: 1749-8090

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