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Ann Thorac Surg 1999;68:2388-2389
© 1999 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig Maximilian University of Munich, Wolkerweg 16, 81375 Munich, Germany
e-mail: lamm{at}lrz.uni-muenchend.de
To the Editor
We thank Dr Szerafin and associates for their interest in our recent article. Unlike most hospitals, in which the majority of patients are in the surgical ward where they can be attended to by surgeons for a limited period of time before being transferred to other wards, our hospital functions on the basis of combined medical and surgical wards whereby most patients are seen on a daily basis by cardiologists and surgeons for a minimum of 2 to 3 weeks, thus allowing close observation over a longer period. Based on the comparatively lengthy observation of the patients, we realized that there is a noticeable percentage rate of superficial sternal wound healing problems (inflammation, suppuration, and others) [1]. Most of these problems are easily treatable and are usually not brought to the attention of a surgeon under normal circumstances due to the patients being transferred or discharged often before the complications arising. We noticed, however, that most of our severe sternal infections had prodromi such as superficial wound healing problems. This is not necessarily problematic if there is a stable osteosynthesis of the sternum. Such a stable closure, however, is often counteracted by the traction of large breasts and, in the case of osteoporosis, by the use of steel wire, which can cut through the sternum. In this context, we fear the risk of sternal instability in patients with postoperative neurological disorders. As Dr Szerafin mentions, we too make use of supportive brassiere or corset postoperatively. In our experience, however, there is often an unwillingness of the patients to wear a corset. Similarly, we would also expect an aversion in our extubated patients to using wide adhesive tapes to fix one breast to the other. In addition, one must beware of signs of impaired respiratory function depending on the device used.
In regard to Dr Szerafin’s routine usage of the butterfly wire fixation technique, we abandoned this technique in 1998 due to our observation of an increased rate of sternal instability and are of the opinion that a stable osteosynthesis is easier to achieve with a wire that runs in a 90° angle to the fracture line. If the sternum is osteoporotic, we use a modified Robicsek technique with good results.
With regard to preoperative weight reduction, we are also aware that it can reduce the rate of sternal instability and wound complication. It is our experience, however, that the clinical application of it can be problematic. Our concern being that approximately 1% of coronary heart disease patients die if they have to wait for more than 3 weeks to be scheduled for an operation [2]. Due to this alarming statistic, we believe that even in the case of obese patients, cardiac operations should not be delayed. In the case of an aortocoronary bypass operation, it should be performed immediately if possible. As our data show, this can be done with an acceptable complication rate for sternal wound healing problems. In this context, the use of retention sutures can be very helpful.
References
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