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Ann Thorac Surg 2001;71:1682-1684
© 2001 The Society of Thoracic Surgeons

Case report

Intravascular migration of fractured sternal wire presenting with hemoptysis

Andrew J. Schreffler, MDa, John D. Rumisek, MDa

a Department of Surgery, University of Kansas School of Medicine, Wichita, Kansas, USA

Accepted for publication July 15, 2000.

Address reprint requests to Dr Rumisek, Department of Surgery Education, University of Kansas School of Medicine-Wichita, Via Christi Regional Medical Center, 929 N St Francis, Wichita, KS 67214
e-mail: kesimur{at}aol.com


   Abstract
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 Abstract
Introduction
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 References
 
We present a rare complication of median sternotomy in which a segment of fractured sternal wire punctured the heart, embolized to the right lung, and eroded into a bronchus causing massive hemoptysis. It was safely removed through a median sternotomy. Sternal wire fracture or migration is diagnosed easily on chest roentgenograms, but frequently goes unnoticed. Sternal wire failure can be managed nonoperatively; however, repair is indicated if fractured wires are displaced or potentially migratory.


   Introduction
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Injury caused by disruption of wire suture is a rare, but potentially devastating, complication of median sternotomy [1–3]. We describe a patient in which poor wound healing, strenuous activity, and fractured sternal wiring led to chronic sternal nonunion, progressive wire deterioration, and the migration of a fractured wire through the heart and right pulmonary artery to the lung where erosion into an adjacent bronchus caused massive hemoptysis.

A 53-year-old man with diabetes and chronic renal failure presented with massive, painless hemoptysis. A chest roentgenogram (CXR) showed a segment of fractured sternal wire in the hilum of the right lung (Fig 1). The patient, a bilateral lower extremity amputee, had undergone triple-vessel coronary artery bypass grafting 2 years previously, but maintained an active lifestyle with aggressive wheelchair use. A superficial sternal wound infection resolved postoperatively with antibiotics and wound care; however, fractured wiring and nonunion developed 6 months later. Serial CXRs before the development of hemoptysis showed progressive deterioration of the sternal closure with increasing wire fracture and displacement. The patient had tolerated this well and had refused operative intervention.



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  		Fig 1. Anterioposterior (A) and lateral (B) chest roentgenograms taken on admission demonstrating a segment of fractured sternal wire in the right hemithorax.

 
Fluoroscopy and computed tomography localized the wire to the right middle pulmonary artery, and erosion into the right middle bronchus was confirmed at bronchoscopy. After resuscitation, mediastinal exploration revealed multiple fractures of all sternal wires with fragmentation and pseudoarthrosis of the sternum. Dissection of the right hilum under cardiopulmonary bypass allowed retrieval of the wire (Fig 2) through a small arteriotomy. The sternum was reconstructed using a modified Robicsek weave and the patient was discharged 5 days later without further sequelae.



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  		Fig 2. Segment of fractured sternal wire (measuring 4.5 cm) removed from the right middle pulmonary artery.

 

   Comment
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Although generally regarded as an insignificant finding [1, 4], sternal wire fracture may result in serious morbidity and death. Cardiac tamponade and massive hemothorax have been attributed to fractured wires [1, 3] and puncture of the ascending aorta by a migratory segment has been reported as well [2]. In our patient, migration of a fractured wire into the right ventricle allowed embolization to the right middle pulmonary artery resulting in massive hemoptysis as it eroded into an adjacent bronchus. Although safely removed, the outcome easily could have been less favorable.

The incidence of sternal wire fracture after median sternotomy is unknown, but it is not an uncommon radiologic finding, even as early as the first postoperative day [1, 2]. The mechanism of wire fracture is attributed to mechanicochemical cracking secondary to cold-working (bending, twisting) and body fluids. Even the twisting used in sternal closure causes damage to wire suture making it susceptible to fracture [1, 5, 6].

Migration of a broken sternal wire has been reported only once before [2], but the literature is replete with reports of intrathoracic injury from the migration of other types of surgical wire. The mechanism of wire migration in the chest is thought to be attributable to the repetitive movement of the thorax with respiration, and upper body activity [7]. Kirschner wires are particularly troublesome when applied to bones around the thorax and are no longer used as reinforcement of sternotomy closure [8].

The progressive wire fracture and migration seen in our patient was likely caused by the constant sternal motion allowed by the development of sternal nonunion, aggravated by the patient’s heavy wheelchair use [1, 5, 7]. In addition to strenuous upper body activity, several other risk factors associated with sternal wound complications were present in our patient, including diabetes, obesity, chronic obstructive pulmonary disease, and postoperative wound infection.

The diagnosis of wire fracture, displacement, or migration is made easily on CXR, although more than one view may be required [4, 6]. Despite this, the integrity and location of sternal sutures on CXRs commonly is not given due attention by radiologists or surgeons [1, 4]. In our patient, the progressive disruption of the sternal wires was never documented in the interpretation of numerous CXRs, nor was its potential morbidity recognized until hemoptysis occurred.

Careful surgical technique in opening and closing the sternum is important in preventing sternal wound complications. Alternative methods of mediastinal access may avoid some of the morbidity of traditional median sternotomy. Several variations of Robicsek’s reinforcement of the standard wire closure [8] are currently used to prevent wire pull-through, and methods using conventional suture materials, steel bands, and metal plates have all been used effectively for sternal closure, avoiding wire altogether.

Treatment of sternal nonunion or wire fracture should be individualized. Some patients may be incapacitated by the discomfort associated with fractured wires or nonunion and eagerly seek repair, whereas others may be willing to tolerate varying degrees of discomfort to avoid further operation. For patients with minimally symptomatic nonunion, fractured wiring, or both, frequent monitoring is indicated to insure continued wire integrity. If increasing wire fracture develops or nonunion worsens, repair is indicated to prevent progressive deterioration and possible injury, as occurred in our patient. If such a patient is reluctant to undergo operation, is inactive, or has serious comorbidities, strict sternal surveillance may be acceptable; however, if the fractured ends are displaced or a potentially migratory segment is present, operative repair is indicated, particularly in active patients.

In conclusion, injury from fracture or migration of sternal wire is a rare but potentially devastating complication of median sternotomy. Sternal movement from nonunion and upper body activity may hasten wire failure and migration. Although not all patients with fractured sternal wires or chronic sternal nonunion require rewiring, the presence of a displaced wire fracture, or a potentially migratory segment is a strong indication for operative repair. If patients are treated conservatively, close surveillance is mandatory and changes in wire integrity must be carefully assessed on every chest roentgenogram.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Brantigan C.O., Brown R.K., Brantigan O.C. The broken wire suture. Am Surg 1979;45:38-41.[Medline]
  2. Hazelrigg S.R., Staller B. Migration of sternal wire into ascending aorta. Ann Thorac Surg 1994;57:1023-1024.[Abstract]
  3. Mimbs J.W., Weiss A.N. Spontaneous cardiac tamponade due to sternotomy wire suture. Am Heart J 1976;92:630-633.[Medline]
  4. Hayward R.H., Knight W.L., Baisden C.E., Reiter C.G. Sternal dehiscence: early detection by radiography. J Thorac Cardiovasc Surg 1994;108:616-619.[Abstract/Free Full Text]
  5. Soroff H.S., Hartman A.R., Pak E., Sasvary D.H., Pollak S.B. Improved sternal closure using steel bands: early experience with three-year follow-up. Ann Thorac Surg 1996;61:1172-1176.[Abstract/Free Full Text]
  6. Weber L.D., Peters R.W. Delayed chest wall complications of median sternotomy. South Med J 1986;79:723-727.[Medline]
  7. Liu H.P., Chang C.H., Lin P.J., et al. Pulmonary artery perforation after Kirschner wire migration: case report and review of the literature. J Trauma 1993;34:154-156.[Medline]
  8. Robicsek F., Daugherty H.K., Cook J.W. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]



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This Article
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