| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1999;67:1209-1210
© 1999 The Society of Thoracic Surgeons
a Dostlar Sitesi C-36, 06520 Balgat, Ankara, Turkey
b Soleyman Demirel Universitesi, Kalp ve Damar Cerrahisi Klinigi, Isparta, Turkey
c International Hospital, Istanbul cad. no: 82, 34800 Yesilkoy, Istanbul, Turkey
e-mail: eerdinc{at}superonline.com
To the Editor
We have recently read an outstanding paper from Chu and colleagues with interest [1]. They described a novel one-stage sternal stenting technique with bone homograft in pediatric patients. Homologous bone is an ingeniously proposed graft material in this setting; it seems conceivable that it may also have growth potential besides its many other virtues. However, we would like to draw attention to a sternal growth restriction risk of their fixation method—not mentioned in the text but seen in their figure as being a figure-of-eight (x-suture) wiring technique [2].
Two attributes of x-suture wiring appear to be the main factors behind its wide acceptance among surgeons. The wrapping effect is one of them; this is namely a pulley effect, by running doubly between the sternal halves, the loops of an individual x-suture imitate the mechanical properties of a set of pulleys. This mechanism provides easy approximation of the sternal halves with less traction force, and additionally maintains a firmer grasp and captures the bone stent in place more stably in this particular use.
The second is its architectural design counteracting more effectively the diverse separatory forces. Physiologically, lateral traction forces are the prominent vectors over the sternum working to detach the sternal halves with respiratory dynamics. Of lesser importance, body movements also add some burden in various directions. Although maintaining horizontal (lateral to medial) tension on one side, this crisscross geometry exerts diagonally oriented forces toward the center of the crossing arms on the other side of the sternum as well. Thus, by countervailing the separatory forces from a variety of directions more efficiently, it provides a more immobile closure. Although this is an extra bonus for adults, it may restrain sternal growth within the boundaries of individual x-sutures along the longitudinal axis in infants and children.
To eliminate the risk of longitudinal growth restriction, simple interrupted wiring can be used, but to save the x-suture’s useful wrapping effect, our previously described double-loop sternal wiring technique [3] also could be a good alternative in such cases. We use the same intercostal space when doubling the loop in this method; therefore, it is possible to place more threads, but with an easier and less crowded manner than figure-of-eight wiring. By increasing the number of carrying threads with the double-loop wiring technique, you could gain an even firmer reconstruction, but longitudinal growth restriction would not be a risk at this time.
The use of resorbable materials for closure of median sternotomy in children would be another viable option, which may eliminate the risk of growth restriction in width as well. Even complex secondary sternal repairs after median sternotomy using myocutaneous flaps and refixation of the sternum in cases of aseptic instability have been shown to be feasible with absorbable sutures [4, 5]. Similarly, we do have satisfactory results in a small group of pediatric patients with polyglyconate monofilament (Maxon, Davis and Geck, Gosport, UK), which has become our suture of choice for median sternotomy closure in children for some time. Tight knot tying of the sternum seems to be troublesome with nonwire threads, but doubling—as in double-loop wiring—or even tripling the suture loops in an individual suture almost totally eliminates this disadvantage, while improving the strength of the suture material.
We admit that sternal growth restriction risk of x-suture wiring is anecdotal and needs to be documented with objective data. What would be the incidence and severity of probable deformities? Could it lead to any adverse effects on cardiopulmonary physiology? Is it possible that the unrestricted segments between the individual x-sutures partially ease this risk by overgrowing, or the steel wire, at least to some extent, gradually cuts through and becomes embedded into the sternum in time without hampering growth? Such questions also have not been fully answered yet, and deserve reappraisal of untouched data and future investigation.
In summary, we agree that homologous bone appears to be an appropriate stent for median sternotomy closure. However, we have reservations about x-suture wiring in pediatric patients; thus, like some colleagues—although not standing firmly on scientific grounds—we would recommend using another sternal fixation technique that would not cause growth restriction.
References
This article has been cited by other articles:
|
|
 |
|
  H. Nishimori, A. Hata, and S. Sasaguri Optimal application of gelatin-resorcin-formaldehyde glue with special reference to the quality of mixing Ann. Thorac. Surg., April 1, 2000; 69(4): 1299 - 1299. [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 |
