| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1997;64:888-889
© 1997 The Society of Thoracic Surgeons
Alliance Cardiac Surgery Ltd, 3337 N Miller Rd, Suite 105, Scottsdale Az 85251
To the Editor:
Sternal dehiscence, infection, and sternectomy with muscle flap inlay and skin closure remain a serious problem after sternotomy. The typical occurrence rate is about 2% to 8% annually depending on many factors including general nutritional status of the patient, length of the procedure, presence of osteoporosis, obesity, malalignment of the sternal division and reapproximation, medications that might impair sternal healing such as prednisone, postoperative arrest situations requiring external cardiac massage, persistent postoperative coughing, timing of prophylactic antibiotic administration, septic operations, and many other factors [1, 2].
I commenced a sternotomy procedure for bilateral lung volume reductions of remarkably impaired emphysema sufferers. Most of these severely short of breath patients suffered the markers listed above. Most were receiving oxygen, and the typical forced expiratory volume in 1 second was less than 30% of predicted. It is unlikely that any of these patients would have tolerated sternal dehiscence, infection, and sternectomy.
A simple method was employed to successfully prevent sternal problems to date. The number of sternal wires typically passed through the manubrium and sternal body was essentially doubled. Instead of six wires (two manubrial and four body), the manubrial wires were increased to three or four and the sternal body wires were increased from four to seven wires. The only additional change made was to use 7F wire. The success of the program was evident at 3 months and was immediately transferred to my cardiac surgical program.
More than 350 sternotomies have now been completed, 50 in emphysema patients and more than 300 in cardiac patients extending over 3.5 years. To date there have been no sternal problems: no clicks, no movements, no pain, no infections, no dicings, no sternectomies. Primary sternal healing together with primary skin healing occurred in 100% of patients.
Stronger 7F wire with more single loops (between eight and ten) to date has so far eliminated the 2% to 8% annual rate of dreaded sternal nonunion/infection/sternectomy problems. This simple technique is recommended, and may be expected to decrease sternotomy nonunion.
Addendum
Since this letter was submitted 1 patient has presented with sternal nonunion. The hospital did not have 7F wire so eight 6F wires were used. The patient broke two wires postoperatively. He was successfully repaired with 7F wires.
References
4230 Harding Rd Suite 501 Nashville Tn 37205
To the Editor:
Sternal dehiscence occasionally is merely a minor postoperative problem resulting in nonunion that may or may not require surgical intervention. More often, the instability breaks down the integrity of the incision and, if not corrected early, can progress to deep sternal wound infection. Doctor Opie proposes that this problem can be greatly reduced by increasing the number and size of sternal wires used for all patients.
Our experience suggests that the number of wires used for sternal closure should be adjusted upward according to the size of the patient and other considerations, including osteoporosis, long-term use of steroids, and off-center incision. Although six wires are enough for small patients (120 lb), the average patient (150 lb) should have seven or eight wires, and those weighing more than 250 lb require 12 to 14 wires [1]. The increase in the number of wires will decrease the load on each wire during cough or stress, thereby avoiding wires cutting through the sternum, the principal cause of sternal dehiscence. To estimate the risk of dehiscence, it can be helpful to divide the body weight of the patient by the number of wires used. In the range of 20 to 25 lb/wire, the probability of dehiscence is low, but in the range of 35 to 40 lb/wire, the risk of dehiscence increases.
The technique of weaving a wire along the lateral edge of the sternum as proposed by both Robicsek and associates [2] and Chlosta and Elefteriades [3] can be useful in preventing sternal dehiscence in patients who have extensive osteoporosis or an offset sternotomy. This prevents the horizontal wires from cutting into the sternum during cough or stress, the most common finding when dehiscence occurs.
Doctor Opie recommends increasing the diameter of the wires used. Probably this offers only a small advantage, as wire breakage is not a factor in sternal dehiscence. When wire breakage occurs, it is almost always due to metal fatigue produced by long-term repeated motion of the wire secondary to nonunion of the sternum.
Doctor Opie's report of no sternal complications in 350 patients using this technique is laudable. However, the incidence of sternal dehiscence should be rare, in the order of three or four episodes per thousand patients, so final judgment of any sternal closure technique should be based on at least that many patients.
Our experience would indicate that Dr Opie is correct: increasing the number of sternal wires reduces the chance of sternal dehiscence. Rather than using a fixed number of wires, we adjust the number according to the size of the patient and the condition of the sternum.
References
Doctor Stoney's concept is mathematically simplified if one wire per 10 kg is used. I have now completely abandoned 6F wires. I now only use 7F wires. The one primary healing failure with 6F wire might support my contention that 7F wire is better because it adds strength with perhaps less likelihood of a pull-through dicing effect.
This article has been cited by other articles:
|
|
 |
|
  L. C. Wu, J. Renucci, and D. H. Song Rigid-plate fixation for the treatment of sternal nonunion J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 623 - 624. [Full Text] [PDF]
|
|
|
|
 |
|
 U. K. Dasika and J. A. Magovern Lower sternal reinforcement to improve median sternotomy closure: Reply Ann. Thorac. Surg., June 1, 2004; 77(6): 2261 - 2262. [Full Text] [PDF]
|
|
|
|
 |
|
 R.S. Jutley, D.E.T. Shepherd, D.W.L. Hukins, and R.R. Jeffrey Calculating stress magnitude between sternotomy closures and sternum Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 1071 - 1071. [Full Text] [PDF]
|
|
|
|
|
|
A.R. Casha, M. Gauci, L. Yang, P.H. Kay, and G.J. Cooper Reply to Jutley et al. Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 1072 - 1073. [Full Text] [PDF]
|
|
|
|
|
|
A.R. Casha, M. Gauci, L. Yang, M. Saleh, P.H. Kay, and G.J. Cooper Fatigue testing median sternotomy closures Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 249 - 253. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. T. Ogus, M. Emir, S. Cicek, and O. Isik Prevention of recurrent osteomyelitis using cyanoacrylate gluing in mediastinitis Ann. Thorac. Surg., November 1, 2000; 70(5): 1761 - 1762. [Full Text] [PDF]
|
|
|
|
|
|
A.R. Casha, L. Yang, P.H. Kay, M. Saleh, and G.J. Cooper A biomechanical study of median sternotomy closure techniques Eur. J. Cardiothorac. Surg., March 1, 1999; 15(3): 365 - 369. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. C. Opie Reply Ann. Thorac. Surg., July 1, 1998; 66(1): 305 - 306. [Full Text] [PDF]
|
|
|
|
|
|
M. M. Demirtas, M. Akcar, and S. Sarikaya Avoidance of sternal nonunion with cyanoacrylate gluing Ann. Thorac. Surg., July 1, 1998; 66(1): 304 - 306. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
