# Antibiotic-Loaded PMMA Beads for Recurrent Sternocutaneous Fistula: Expanding the Surgical Armamentarium in Post-Sternotomy Osteomyelitis: Case Report and Literature Review

## TL;DR

This case report shows how antibiotic-loaded PMMA beads helped treat a recurring sternocutaneous fistula after heart surgery.

## Contribution

The paper expands the use of PMMA beads for late-presenting, recurrent sternocutaneous fistulas, a rare and challenging condition.

## Key findings

- Local antibiotic delivery via PMMA beads led to successful recovery without recurrence after six months.
- The case highlights PMMA beads as a valuable adjunct in managing complex, recurrent sternocutaneous fistulas.
- Extensive debridement and antibiotic-loaded PMMA beads were effective after prior treatments failed.

## Abstract

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.