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Ann Thorac Surg 1996;61:215-216
© 1996 The Society of Thoracic Surgeons

Case Report

Primary Sternal Closure and Mediastinal Decompression by Inlay Autologous Rib Grafts

James P. Geiger, MD, Carol A. Tabak, MD, Elmore M. Aronstam, MD

St. Mary's Hospital and Medical Center, San Francisco, California

Accepted for publication July 17, 1995.


   Abstract
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Hemodynamic instability and arrhythmia after cardiopulmonary bypass occasionally requires delayed sternal closure or placement of a stenting device. A primary sternal closure with autologous inlay rib grafts can ensure a secure, stable sternal repair and avoids prolonged ventilator support and the concerns, risks, and expense associated with a secondary sternotomy repair.


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The problem of post-cardiac bypass hemodynamic instability that precludes sternotomy closure has confronted most cardiac surgeons. The altered physiologic parameters and presumed etiology with a variety of methods of restoring cardiac function have been reviewed extensively [1–5].

Most solutions have involved delayed sternal closure and occasional use of some device to maintain separation of the sternal edges [6, 7]. Delayed sternal closure has been a life-saving technique but usually requires prolonged ventilatory support and a second operative procedure for sternal approximation with removal of any prostheses or stents. There is an associated delay in patient recovery, additional exposure to risks of anesthesia, infection, or sternal wound complications, and considerable additional expense.

A single-stage procedure of primary sternal osteoplasty with inlay rib grafting has been used successfully in a hemodynamically unstable patient after aortic valve replacement and coronary bypass. This procedure was considered an appropriate application of a technique we originally devised for decompression of life-threatening superior vena caval obstruction syndrome [8].

The patient is a 58-year-old man with unstable angina after a recent myocardial infarction. The presence of mixed aortic stenosis and insufficiency required aortic valve replacement at the time of double coronary bypass grafting. There were no untoward events during operation, but inotropic support and intraaortic balloon pump support were required to wean from cardiopulmonary bypass. Arrhythmia and hypotension accompanied each attempt at sternal closure.

Sternal osteoplasty with autologous inlay rib grafts was elected as a method of primary wound closure to avoid reoperation and increased possibility of infection. A 12- to 13-cm segment of the left fifth rib was removed subperiosteally, divided in two, and then bisected longitudinally to form four ``strut grafts'' 6 cm long. The four inlay grafts were spaced appropriately and wedged between the inner and outer tables of the sternum; the repair was secured with peristernal no. 6 wire (Fig 1Go). Partial mobilization of the pectoral fascia and subcutaneous tissue was required to permit otherwise standard closure technique. There was no further arrhythmia or hemodynamic instability.



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  		Fig 1. . (A) The segment of rib is divided in two and bisected longitudinally. The grafts are then spaced appropriately and wedged between the inner and outer tables of the sternum. (B) Peristernal wires are placed, and pectoral fascia and subcutaneous tissue are mobilized as required for closure in otherwise routine technique.

 
The stable sternal repair permitted extubation and removal of the intraaortic balloon pump in less than 36 hours. Recovery and wound healing were uneventful, and the patient was discharged on the seventh postoperative day. Normal wound healing, a stable sternum, and an uncomplicated recovery permitted return to work 3 months after operation. The chest wall was solid on evaluation 1 year after operation, and routine electrocardiography and chest roentgenography showed no unusual findings. A requested computed tomographic scan of the chest to evaluate the sternum and rib grafts was declined by the patient.


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The procedure as described required minimal extension of the usual operation time. The inlay grafts maintained 6-cm separation of the sternal edges, and hemodynamic stability was achieved by decompressing the dilated or edematous heart and lungs.

The bony defect between the inlay grafts has not been studied extensively, but autologous rib grafts have been used effectively in a variety of reconstructive spinal and other orthopedic procedures. Healing was uneventful in our previous cases; the sternum remained stable and secure to examination and without paradoxical motion or palpable defect on coughing during 12 to 18 months of follow-up. Sternal closure with autologous inlay bone grafts appears to be a reasonable alternative to other delayed sternal closure techniques for hemodynamically unstable patients, but may not be applicable in patients with coagulation disorders.

Significant cost reduction is an additional benefit of this single-stage sternal repair procedure by avoiding the need for extended ventilator support, decreasing the intensive care unit and hospitalization time, and avoiding additional anesthesia and operating room expense.

In conclusion, sternal osteoplasty with inlay rib grafts should be considered as a method of wound closure in those patients who are hemodynamically unstable on attempting sternal closure after a cardiac operation because it can avoid the undesirable risks and expense of a second operation. Our patient maintained excellent cardiopulmonary function, had primary and stable wound healing, and returned to his usual occupation in a timely fashion.


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Address reprint requests to Dr Geiger, 2001 Union St, San Francisco, CA 94123.


   References
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  1. Ott DA, Cooley DA, Norman JC, Sandiford FM. Delayed sternal closure: a useful technique to prevent tamponade or compression of the heart. Cardiovasc Dis (Bull Tex Heart Inst) 1978;5:15–8.[Medline]
  2. Gielchinsky I, Parsonnet V, Krishnan B, Silidker BS, Abel RM. Delayed sternal closure following open-heart operation. Ann Thorac Surg 1981;32:273–7.[Abstract/Free Full Text]
  3. Fanning W, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg 1987;44:169–72.[Abstract/Free Full Text]
  4. Mestres CA, Pomar JL, Acosta M, et al. Delayed sternal closure for life-threatening complications in cardiac operations: an update. Ann Thorac Surg 1991;51:773–6.[Abstract/Free Full Text]
  5. Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992;54:233–9.[Abstract/Free Full Text]
  6. Shore DF, Capuani A, Lincoln C. Atypical tamponade after cardiac operation in infants and children. J Thorac Cardiovasc Surg 1982;83:449–52.[Abstract]
  7. Baumgart D, Herbon G, Borowski A, deVivie ER. Primary closure of median sternotomy with interposition of hydroxyapatite blocks. Eur J Cardiothorac Surg 1991;5:383–5.[Abstract/Free Full Text]
  8. Little A, Golomb HM, Ferguson MK, Skosey C, Skinner DB. Malignant superior vena cava obstruction reconsidered. The role of diagnostic surgical intervention. Ann Thorac Surg 1985;40:285–8.[Abstract/Free Full Text]



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