Primary Closure of Median Sternotomy: A Survey of all German Surgical Heart Centers and a Review of the Literature Concerning Sternal Closure Technique

Abstract

Background: Sternal instability and mediastinitis are rare but serious complications following cardiac surgery with median sternotomy. Methods: This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The conventional sternal closure technique, the parameters considered to be risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. In addition, a literature research with the key words “sternal closure technique” and “sternal dehiscence” was performed. Results: Conventional closure of primary sternotomy is done using many different methods, most often with surgical steel sutures (87 %) passed trans/peristernally (64 %). An osteoporotic or fractured sternum (70 ×), and obesity (31 ×) were the most frequently cited risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method of Robicsek (48 ×). Conclusion: There is no uniform osteosynthetic method for primary sternal closure and there is substantial variation in the perception of risk factors for sternal instability and possible surgical consequences among the surgical heart centers in Germany.

Key words

Sternal instability - mediastinitis - risk patient - Robicsek sternal closure

References

• 1 Losanoff J E, Collier A D, Wagner-Mann C C, Richmann B W, Huff H, Hsieh F, Diaz-Arias A, Jones J W. Biomechanical comparison of median sternotomy closures.  Ann Thorac Surg. 2004;  77 203-209
• 2 Negri A, Manfredi J, Terrini A, Rodella G, Bisleri G, El Quarra S, Muneretto C. Prospective evaluation of a new sternal closure method with thermoreactive clips.  Eur J Cardiothorac Surg. 2002;  22 571-575
• 3 Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy.  Thorac Cardiov Surg. 2000;  48 1-8
• 4 McGregor W E, Payne M, Trumble D R, Farkas K M, Magovern J A. Improvement of sternal closure stability with reinforced steel wires.  Ann Thorac Surg. 2003;  76 1631-1634
• 5 Pai S, Gunja N J, Dupak E L, McMahon N L, Roth T P, Lalikos J F, Dunn R M, Francalancia N, Pins G D, Billiar K L. In vitro comparison of wire and plate fixation for midline sternotomies.  Ann Thorac Surg. 2005;  80 962-968
• 6 Losanoff J E, Jones J W, Richmann B W. Primary closure of median sternotomy: techniques and principles.  Cardiovasc Surg. 2002;  2 102-110
• 7 Fowler V G, O'Brien S M, Muhlbaier L H, Corey G R, Ferguson T B, Peterson E D. Clinical predictors of major infections after cardiac surgery.  Circul. 2005;  112 358-365
• 8 Casha A R, Yang L, Kay P H, Saleh M, Cooper G J. A biomechanical study of median sternotomy closure technique.  Eur J Cardiothorac Surg. 1999;  15 365-369
• 9 Casha A R, Gauci M, Yang L, Saleh M, Kay P H, Cooper G J. Fatigue testing median sternotomy closure.  Eur J Cardiothorac Surg. 2001;  19 249-253
• 10 Cohen C DJ, Griffin L V. A Biomechanical comparison of three sternotomy closure techniques.  Ann Thorac Surg. 2002;  73 563-568
• 11 Bruhin R, Stock U A, Drücker J P, Azhari T, Wippermann J, Albes M A, Hintze D, Eckardt S, Könke C, Wahlers T. Numerical simulation techniques to study the structural response of the human chest following median sternotomy.  Ann Thorac Surg. 2005;  80 623-630
• 12 Jutley R S, Watson M A, Shepherd D E, Hukins D W. Finite element analyses of stress around a sternum screw used to prevent sternal dehiscence after heart surgery.  Proc Inst Mech Eng. 2002;  216 315-321
• 13 Sharma R, Puri D, Panigrahi B P, Virdi I S. A modified parasternal wire technique for prevention and treatment of sternal dehiscence.  Ann Thorac Surg. 2004;  77 210-213
• 14 Molina J E, Lew R S, Hyland K. Postoperative sternal dehiscence in obese patients: incidence and preventation.  Ann Thorac Surg. 2004;  78 912-917
• 15 Song D H, Lohmann R F, Renucci J D, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis.  Eur J Cardiothorac Surg. 2004;  26 367-372
• 16 Riess F C, Awwad N, Hoffmann B, Bader R, Helmold H Y, Loewer C, Riess A G, Bleese N. A steel band in addition to 8 wire cerclages reduces the risk of sternal dehiscence after median sternotomy.  Heart Surg Forum. 2004;  7 387-392
• 17 Bottio T, Rizzoli G, Vida V, Casarotta D, Gerosa G. Double crisscross sternal wiring and chest wound infections: a prospective randomised study.  J Thorac Cardiovasc Surg. 2003;  126 1352-1356
• 18 Kiessling A H, Isgro F, Weisse U, Möltner A, Saggau W, Boldt J. Advanced sternal closure to prevent dehiscence in obese patients.  Ann Thorac Surg. 2005;  80 1537-1539
• 19 Khasati N, Sivaprakasam R, Dunning J. Is the figure-of-eight superior to the simple wire technique for closure of the sternum?.  Interactive Cardiovasc Thorac Surg. 2004;  3 191-194
• 20 Peivani A A, Kasper-König W, Quinkenstein E, Loos A H, Dahm M. Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications.  J Cardiovasc Surg. 2001;  42 601-603