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Ann Thorac Surg 1996;62:320-321
© 1996 The Society of Thoracic Surgeons

Correspondence

Double-Loop Sternal Wiring Technique

Melih Erdinc, MD, Ahmet Ocal, MD, Husnu Sezer, MD, Ahmet Kuzgun, MD, Cuneyt Ozturk, MD

Baglan cad Orgen apt 18/3 16090 Cekirge, Bursa, Turkey

To the Editor:

We read the ingenious technique of Roux and colleagues [1] with great interest. The quality of osteosynthesis affects the consolidation of sternotomy, but one can achieve a good osteosynthesis without assistance, effort, or even a specially designed device, with the usual steel threads and a double-loop wiring technique. Two important causes of sternal dehiscence, sternal tearing or wire snapping, especially in elderly or obese patients, also could be minimized with this uncomplicated and effective method.

Usually we place two steel threads above the manibrium by simple and four below by a double-loop wiring technique (Fig 1Go). The technique resembles the closure of median sternotomy with transsternal figure-of-8 wires [2], but in this technique we use the same intercostal space when doubling the loop. It therefore is possible to place more threads with an easier method. Placing the wires intercostally below the manubrium improves the resistance against the tearing forces over the sternum. Intercostal wiring also maintains good matching of the sternotomy edges, and the wires slide more easily while approximating. After pulling the wires and turning the arms around each other two or three times, we twist them firmly with a needle-holder until appropriate tension is achieved. While the wires are twisted, the crossing arms should embrace each other spirally. At a certain point, if one continues twisting excessively, one of the wire arms turns as the axis and the other begins to coil around this axis. The arm in the axis usually breaks or weakens at the fastening site by excess torsion. Inspection might be more helpful than a subjective tightness feel to prevent this problem.



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  		Fig 1. . Application of double-loop wiring technique: the two cranially placed wires on the manubrium are placed with standard technique.

 
Between December 1994 and December 1995 we used this technique in 44 coronary artery bypass grafting procedures (left internal mammary artery was used in 43 of them) and 7 valvular procedures, a total of 51 open heart procedures, in patients suspected to be at risk for sternal complications. We did not use this technique in a randomized fashion that would allow us to make comparison with other techniques. The hospital records were investigated retrospectively. The mean age (+/- standard error) was 58.3 +/- 1.39 years (range, 29 to 72 years), and 39 (76.5%) of them were male. Even though most of them were obese or elderly patients, 3 had extended intubation (more than 48 hours), 2 had superficial wound infection, and 1 had hemiplegia; but we did not observe any sternal dehiscence or instability even in fractured and osteoporotic sternums on physical examination. There was no wire snapping or sternal gap in the chest roentgenograms either at discharge or 2 months postoperatively.

By double-looping the wires, one can achieve an easy and firm approximation of the sternal edges with half the traction force by doubling the pulling length, just like the principle used in a set of pulleys. The possibility of wire snapping is reduced to half by doubling the carrying forces. The double bundle of steel wire exerts half the cutting pressure over the sternum because the thickness of the cutting surface is doubled. It is possible to combine this technique with other reinforcement methods [3]. Another practical advantage of the technique is, if a thread breaks while twisting, you do not need to reopen the sternum; you simply take back one of the loops to extend the wire to reattach the arms.

In conclusion, the double-loop sternal wiring technique is effective, simple, and reproducible to achieve good osteosynthesis and minimize sternal dehiscence and instability.

References

  1. Roux D, Fournial G, Glock Y, Rottin N. New technique for sternal osteosynthesis. Ann Thorac Surg 1995;60:1132.[Abstract/Free Full Text]
  2. Goodman G, Palatianos GM, Bolooki H. Technique of closure of median sternotomy with trans-sternal figure-of-eight wires. J Cardiovasc Surg 1986;27:512–3.[Medline]
  3. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternal seperation following open heart surgery. J Thorac Cardiovasc Surg 1977;73:267–8.[Abstract]



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