{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T06:34:46Z","timestamp":1781073286070,"version":"3.54.1"},"reference-count":55,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2025,10,2]],"date-time":"2025-10-02T00:00:00Z","timestamp":1759363200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["Life"],"abstract":"<jats:p>Background: Late sternocutaneous fistulas (SCFs), secondary to chronic sternal osteomyelitis, are uncommon sequelae of median sternotomy and present significant therapeutic challenges. They are frequently linked to low-virulence microorganisms forming biofilms on retained foreign materials. While antibiotic-impregnated polymethylmethacrylate (PMMA) beads are established in managing chronic osteomyelitis in other anatomical locations, reports describing their use for post-sternotomy SCFs are limited to two early postoperative cases. Case Presentation: We describe a 62-year-old man with a history of triple-vessel coronary artery disease who underwent coronary artery bypass grafting via median sternotomy. Two months postoperatively, he developed an SCF in the upper sternum, initially treated with wire removal, negative pressure wound therapy, and intravenous vancomycin. Recurrence occurred one month later without systemic signs of infection. Imaging revealed inflammatory changes at the level of the manubriosternal junction. Definitive surgery included extensive sternal and costosternal debridement, bilateral anterior arthrolysis of the second ribs, and pulse lavage with 10 L of Microdacyn. The remaining defect was filled with vancomycin- and gentamicin-loaded PMMA beads. The patient had an uneventful recovery with no recurrence at six months. Conclusions: This case suggests that local antibiotic delivery via PMMA beads can be a valuable adjunct in the surgical management of recurrent, late-presenting SCFs after cardiac surgery.<\/jats:p>","DOI":"10.3390\/life15101547","type":"journal-article","created":{"date-parts":[[2025,10,2]],"date-time":"2025-10-02T10:22:32Z","timestamp":1759400552000},"page":"1547","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Antibiotic-Loaded PMMA Beads for Recurrent Sternocutaneous Fistula: Expanding the Surgical Armamentarium in Post-Sternotomy Osteomyelitis: Case Report and Literature Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3599-129X","authenticated-orcid":false,"given":"Mircea","family":"Robu","sequence":"first","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Irina Maria","family":"Margarint","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrei","family":"Draganita","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Giurgiu Emergency Hospital, 080302 Giurgiu, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miruna","family":"Guzu","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, \u201cProf. Dr. C. C. Iliescu\u201d Emergency Institute for Cardiovascular Diseases, 022328 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vlad Anton","family":"Iliescu","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1910","DOI":"10.1016\/j.athoracsur.2009.07.012","article-title":"Sternocutaneous fistulas after cardiac surgery: Incidence and late outcome during a ten-year follow-up","volume":"88","author":"Gustafsson","year":"2009","journal-title":"Ann. Thorac. Surg."},{"key":"ref_2","first-page":"e20240137","article-title":"Treatment of Sternocutaneous Fistula Due to Cardiac Surgery Using Extracellular Matrix Patch","volume":"40","year":"2025","journal-title":"Braz. J. Cardiovasc. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"623","DOI":"10.3109\/00365548.2012.669842","article-title":"Incidence of sternocutaneous fistulas following open heart surgery in a nationwide cohort","volume":"44","author":"Gudbjartsson","year":"2012","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1270","DOI":"10.1016\/j.athoracsur.2005.04.010","article-title":"The impact of vacuum-assisted closure on long-term survival after post-sternotomy mediastinitis","volume":"80","author":"Nilsson","year":"2005","journal-title":"Ann. Thorac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1422","DOI":"10.1056\/NEJMra035415","article-title":"Treatment of infections associated with surgical implants","volume":"350","author":"Darouiche","year":"2004","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1053\/jhin.2001.1052","article-title":"Implant infections: A haven for opportunistic bacteria","volume":"49","author":"Schierholz","year":"2001","journal-title":"J. Hosp. Infect."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1093\/ejcts\/ezs449","article-title":"Post-sternotomy chronic osteomyelitis: Is sternal resection always necessary?","volume":"43","author":"Tocco","year":"2013","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_8","first-page":"934","article-title":"Gentamycin-PMMA-Kugeln in der Behandlung abszedierender Knochen- und Weichteilinfektionen [Gentamicin-PMMA-beads in treating bone and soft tissue infections (author\u2019s transl)]","volume":"104","author":"Klemm","year":"1979","journal-title":"Zentralbl. Chir."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"265","DOI":"10.3109\/17453678508993010","article-title":"Gentamicin-PMMA beads in the treatment of chronic osteomyelitis","volume":"56","author":"Majid","year":"1985","journal-title":"Acta Orthop. Scand."},{"key":"ref_10","first-page":"338","article-title":"Langfristige Therapieergebnisse der chronischen, posttraumatischen Osteomyelitis mit Gentamycin-PMMA-Ketten [Results of long-term therapy of chronic, post-traumatic osteomyelitis with gentamycin PMMA chains]","volume":"98","author":"Jerosch","year":"1995","journal-title":"Unfallchirurg"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"518","DOI":"10.3109\/17453679808997790","article-title":"Osteomyelitis treated with gentamicin-PMMA beads: 100 patients followed for 1\u201312 years","volume":"69","author":"Walenkamp","year":"1998","journal-title":"Acta Orthop. Scand."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e41","DOI":"10.1177\/021849230601400233","article-title":"Managing sternal osteomyelitis with antibiotic bead implantation","volume":"14","author":"Chiu","year":"2006","journal-title":"Asian Cardiovasc. Thorac. Ann."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/S0003-4975(10)61173-3","article-title":"Management of chronic sternal osteomyelitis","volume":"40","author":"Johnson","year":"1985","journal-title":"Ann. Thorac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"583","DOI":"10.1097\/00000658-199106000-00008","article-title":"Long-term results of pectoralis major muscle transposition for infected sternotomy wounds","volume":"213","author":"Pairolero","year":"1991","journal-title":"Ann. Surg."},{"key":"ref_15","first-page":"422","article-title":"Case report. Successful treatment of two cases of post-surgical sternal osteomyelitis, due to Candida krusei and Candida albicans, respectively, with high doses of triazoles (fluconazole, itraconazole)","volume":"44","author":"Petrikkos","year":"2001","journal-title":"Mycoses"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1016\/j.ajic.2008.03.002","article-title":"CDC\/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting","volume":"36","author":"Horan","year":"2008","journal-title":"Am. J. Infect. Control"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1016\/S0003-4975(10)62920-7","article-title":"Median sternotomy dehiscence","volume":"26","author":"Stoney","year":"1978","journal-title":"Ann. Thorac. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"633","DOI":"10.3109\/00365549009027114","article-title":"Serious infectious complications of midsternotomy: A review of bacteriology and antimicrobial therapy","volume":"22","author":"Shafir","year":"1990","journal-title":"Scand. J. Infect. Dis."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1177\/096721090301100306","article-title":"Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications","volume":"11","author":"Peivandi","year":"2003","journal-title":"Cardiovasc. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"341","DOI":"10.1080\/14017431.2016.1180427","article-title":"Sternal wound infections following open heart surgery\u2014A review","volume":"50","author":"Gudbjartsson","year":"2016","journal-title":"Scand. Cardiovasc. J."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1016\/j.bjps.2009.01.057","article-title":"Reconstruction for sternal osteomyelitis at the lower third of sternum","volume":"63","author":"Lee","year":"2010","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1050","DOI":"10.1016\/S0003-4975(98)00063-0","article-title":"Deep sternal wound infection: Risk factors and outcomes","volume":"65","author":"Borger","year":"1998","journal-title":"Ann. Thorac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"766","DOI":"10.1097\/00000658-199706000-00014","article-title":"Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience","volume":"225","author":"Jones","year":"1997","journal-title":"Ann. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/S0924-8579(97)00375-0","article-title":"Management of osteomyelitis","volume":"9","author":"Gentry","year":"1997","journal-title":"Int. J. Antimicrob. Agents"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1080\/00015458.2001.12098640","article-title":"Chronic osteomyelitis after sternotomy","volume":"101","author":"Thijssens","year":"2001","journal-title":"Acta Chir. Belg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1097\/00000637-198104000-00010","article-title":"Complete sternectomy for chronic osteomyelitis with reconstruction using a rectus abdominis myocutaneous island flap","volume":"6","author":"Neale","year":"1981","journal-title":"Ann. Plast. Surg."},{"key":"ref_27","first-page":"433","article-title":"Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery","volume":"80","author":"Lee","year":"1976","journal-title":"Surgery"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1097\/00000658-198006000-00012","article-title":"Infected median sternotomy wound successful treatment by muscle flaps","volume":"191","author":"Jurkiewicz","year":"1980","journal-title":"Ann. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e151","DOI":"10.1016\/j.jinf.2005.08.007","article-title":"Recurrent post-sternotomy mediastinitis","volume":"52","author":"Falagas","year":"2006","journal-title":"J. Infect."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"176","DOI":"10.14503\/THIJ-17-6239","article-title":"Use of an Extracellular Matrix Patch for Sternal Wound Dehiscence after Cardiac Surgery in a Neonate","volume":"45","author":"Boulemden","year":"2018","journal-title":"Tex. Heart Inst. J."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Aramini, B., Masciale, V., Radaelli, L.F.Z., Sgarzani, R., Dominici, M., and Stella, F. (2022). The sternum reconstruction: Present and future perspectives. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.975603"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1016\/j.jtcvs.2009.07.030","article-title":"Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function","volume":"140","author":"Iarussi","year":"2010","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"4057","DOI":"10.21037\/tlcr-21-935","article-title":"Expert consensus on resection of chest wall tumors and chest wall reconstruction","volume":"10","author":"Wang","year":"2021","journal-title":"Transl. Lung Cancer Res."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Raheem, A.A., Hameed, P., Whenish, R., Elsen, R.S., G, A., Jaiswal, A.K., Prashanth, K.G., and Manivasagam, G. (2021). A Review on Development of Bio-Inspired Implants Using 3D Printing. Biomimetics, 6.","DOI":"10.3390\/biomimetics6040065"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1007\/s42242-020-00108-1","article-title":"Next generation surgical meshes for drug delivery and tissue engineering applications: Materials, design and emerging manufacturing technologies","volume":"4","author":"Corduas","year":"2021","journal-title":"BioDesign Manuf."},{"key":"ref_36","first-page":"666","article-title":"Advancing application of mesenchymal stem cell-based bone tissue regeneration","volume":"6","author":"Shang","year":"2020","journal-title":"Bioact. Mater."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1016\/0007-1226(83)90120-0","article-title":"Mediastinal cutaneous fistulae arising as a complication of major cardiac surgery: The value of sinography and injection of methylene blue in their radical excision and immediate repair","volume":"36","author":"Herrera","year":"1983","journal-title":"Br. J. Plast. Surg."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1097\/00006534-199802000-00012","article-title":"Clinical-radiological evaluation of poststernotomy wound infection","volume":"101","author":"Gur","year":"1998","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1194","DOI":"10.2214\/AJR.18.19782","article-title":"Poststernotomy Complications: A Multimodal Review of Normal and Abnormal Postoperative Imaging Findings","volume":"211","author":"Hota","year":"2018","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Horch, R.E., Willy, C., and Kutschka, I. (2016). Radiological Diagnostics of Postoperative Sternal Osteomyelitis. Deep Sternal Wound Infections, Springer.","DOI":"10.1007\/978-3-662-49766-1"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1981","DOI":"10.1016\/S0142-9612(00)00082-X","article-title":"Surface roughness, porosity and wettability of gentamicin-loaded bone cements and their antibiotic release","volume":"21","author":"Neut","year":"2000","journal-title":"Biomaterials"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1093\/jac\/dkh032","article-title":"Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty","volume":"53","author":"Benini","year":"2004","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1016\/S0883-5403(98)90179-6","article-title":"Long-term elution of antibiotics from bone-cement: An in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system","volume":"13","author":"Masri","year":"1998","journal-title":"J. Arthroplast."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"1615","DOI":"10.1002\/jor.20214","article-title":"High concentration and bioactivity of vancomycin and aztreonam eluted from Simplex cement spacers in two-stage revision of infected hip implants: A study of 46 patients at an average follow-up of 107 days","volume":"24","author":"Hsieh","year":"2006","journal-title":"J. Orthop. Res."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"332","DOI":"10.1128\/AAC.50.1.332-335.2006","article-title":"In vivo and in vitro studies of antibiotic release from and bacterial growth inhibition by antibiotic-impregnated polymethylmethacrylate hip spacers","volume":"50","author":"Kelm","year":"2006","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1002\/jbm.a.30253","article-title":"Gentamicin-loaded bone cement with clindamycin or fusidic acid added: Biofilm formation and antibiotic release","volume":"73","author":"Neut","year":"2005","journal-title":"J. Biomed. Mater. Res. A"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"791","DOI":"10.1093\/jac\/30.6.791","article-title":"Growth-rate-independent killing by ciprofloxacin of biofilm-derived Staphylococcus epidermidis; evidence for cell-cycle dependency","volume":"30","author":"Duguid","year":"1992","journal-title":"J. Antimicrob. Chemother."},{"key":"ref_48","doi-asserted-by":"crossref","unstructured":"Salvati, E.A., Callaghan, J.J., Brause, B.D., Klein, R.F., and Small, R.D. (1986). Reimplantation in infection: Elution of gentamicin from cement and beads. Clin. Orthop. Relat. Res., 83\u201393.","DOI":"10.1097\/00003086-198606000-00015"},{"key":"ref_49","first-page":"804","article-title":"Liquid gentamicin in bone cement spacers: In vivo antibiotic release and systemic safety in two-stage revision of infected hip arthroplasty","volume":"66","author":"Hsieh","year":"2009","journal-title":"J. Trauma"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1490","DOI":"10.1016\/j.arth.2013.02.035","article-title":"Two-stage arthroplasty for prosthetic joint infection: A systematic review of acute kidney injury, systemic toxicity and infection control","volume":"28","author":"Luu","year":"2013","journal-title":"J. Arthroplast."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"102","DOI":"10.3892\/etm.2020.9534","article-title":"Dyselectrolytemia-management and implications in hemodialysis","volume":"21","author":"Timofte","year":"2021","journal-title":"Exp. Ther. Med."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"Verras, G.I., and Mulita, F. (2024). Butyrylcholinesterase levels correlate with surgical site infection risk and severity after colorectal surgery: A prospective single-center study. Front. Surg., 11.","DOI":"10.3389\/fsurg.2024.1379410"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1055\/s-0038-1624562","article-title":"Successful Salvage of an Extracardiac Fontan in the Setting of Purulent Mediastinitis using Antibiotic-Impregnated Beads","volume":"7","author":"Coghill","year":"2018","journal-title":"J. Pediatr. Intensive Care"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1177\/1708538116630859","article-title":"Bio-absorbable antibiotic impregnated beads for the treatment of prosthetic vascular graft infections","volume":"24","author":"Genovese","year":"2016","journal-title":"Vascular"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1706","DOI":"10.1016\/j.jvs.2011.12.037","article-title":"Antibiotic-loaded polymethylmethacrylate beads for the treatment of extracavitary vascular surgical site infections","volume":"55","author":"Stone","year":"2012","journal-title":"J. Vasc. Surg."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/10\/1547\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,2]],"date-time":"2025-10-02T10:27:10Z","timestamp":1759400830000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/10\/1547"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,2]]},"references-count":55,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["life15101547"],"URL":"https:\/\/doi.org\/10.3390\/life15101547","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,2]]}}}