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Ann Thorac Surg 2002;73:1661-1662
© 2002 The Society of Thoracic Surgeons

How to do it

Repair of transverse sternal nonunions using metal plates and autogenous bone graft

Kim C. Bertin, MD*a, Robert S. Rice, BAb, Donald B. Doty, MDc, Kent W. Jones, MDc

a Department of Orthopedic Surgery, Salt Lake City, Utah, USA
b Department of Cardiac Surgery, Latter-Day Saints Hospital, Salt Lake City, Utah, USA
c Tulane University School of Medicine, New Orleans, Louisiana, USA

Accepted for publication December 28, 2001.

* Address reprint requests to Dr Bertin, Utah Bone and Joint Center, 2490 South State St, Suite 100, Salt Lake City, UT 84115 USA
e-mail: kbertin{at}utahhipandknee.com


   Abstract
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 Abstract
Introduction
 Technique
 Results
 Comment
 References
 
Transverse sternal nonunion is a complication of sternal fracture or partial sternotomy, and requires surgical treatment. Three patients with repeated failure of standard sternal repair were treated with a technique using metal plates and autogenous bone graft, which resulted in bone union in all patients. Metal plating of the sternum, accompanied by autogenous bone graft, is an effective method of treating transverse sternal nonunion.


   Introduction
Top
 Abstract
 Introduction
Technique
 Results
 Comment
 References
 
Sternal nonunion is a complication encountered in patients after treatment for sternal fracture or after sternotomy. The incidence of sternal wound complications is 0.5% to 3% of all patients undergoing median sternotomy [1–5]. Minimally invasive surgery using a transverse sternotomy may be more commonly associated with transverse nonunion than is open surgery associated with median sternal nonunion.

All nonunions reported to date have been vertical nonunions associated with sternotomy. There is no standardized treatment of sternal nonunion; and because all nonunions have been vertical, all techniques of surgical repair reported in the literature are for this specific problem. Chase and colleagues [1], Smoot and Weiman [5], Eich and Heinz [6], and Hendrickson and colleagues [3] have reported success in treating vertical nonunions.

In this article we report a method used to repair transverse nonunions, along with clinical results of this technique. The technique involves plating and using cancellous bone graft procured from the iliac crest. This technique has resulted in marked sternal stability, and all patients treated by this method have been able to resume physical activity that was previously impossible due to pain and discomfort.


   Technique
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 Abstract
 Introduction
 Technique
Results
 Comment
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All three patients treated for transverse sternal nonunion by plating and autografting at our institutions were included in our report. These three patients underwent the described procedure for transverse sternal nonunion. Two of these patients had previous partial sternotomy and 1 a remote fracture. The 2 patients with previous sternotomy were among 164 patients treated between January 1996 and December 2000 who had received partial lower half sternotomy for cardiac surgery at our institution. The 3 patients treated by our technique were male and aged 46, 65, and 67 years, respectively. One patient previously underwent ministernotomy for coronary artery bypass surgery, 1 previously underwent ministernotomy for mitral valve repair, and 1 had experienced blunt trauma to the anterior chest wall from a snowmobile accident.

The 2 patients with previous cardiac surgery had had initial repair of the sternotomy and subsequent attempt to repair a nonunion. The fracture patient had had initial surgical repair of the fracture, which resulted in nonunion. All three patients experienced sternal instability and painful sternal motion. Thus, the indication for this surgical treatment was failure of other repair methods, sternal instability, painful sternal motion, or a combination of these. The interval between initial surgery and repair was from 60 to 120 days. All 3 patients were discharged from the hospital after their initial surgery before the dehiscence was diagnosed.

The sternum is adequately exposed for placing two parallel fracture fixation plates. The nonunion is debrided to expose bleeding viable bone. Two metal plates, either narrow, large-fragment, dynamic compression or semitubular plates (Synthes USA, West Chester, PA), were selected and contoured to fit the sternum. We believed that plates of adequate length would be needed to achieve excellent primary stability that would resist the forces of breathing and upper extremity movement. The plates that were used had six to nine holes each and were made of either titanium or stainless steel. The length of the plates allowed the nonunion site to be bridged and left adequate holes over bone for screw insertion. The plates were fixed in a parallel fashion on either side of the sternal midline. A minimum of three screws was placed proximal and distal to the nonunion in each plate, requiring good purchase in both sternal tables. Each hole was individually drilled and measured to determine the length of screw required. The 6.5-mm cancellous screws ranged in length from 20 mm to 45 mm, depending on the thickness of the sternum. Shortening of some screws was required to prevent significant penetration of the back of the sternum. These large-fragment, 6.5-mm, cancellous screws were chosen to maximize the fixation in the sternum, which tended to be osteoporotic due to age, previous surgery, and limited stress.

Once the proximal screws were in place, the distal fragment was brought to the proximal fragment using tenaculum bone-reducing clamps. The fragments could never be brought completely together because of the ribs and other structures holding them apart. This always resulted in a gap of 10 to 25 mm, which had to be packed with cancellous bone graft obtained from the iliac crest. The fragments were held as close together as possible. Leaving the bone clamps in place, the distal screws were then inserted by the above method with at least three screws distal to the nonunion site. The bone clamps were then removed, and the wound was irrigated and closed.


   Results
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 Technique
 Results
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 References
 
Postoperative radiographs showed sternal healing to have taken place by 6 to 8 weeks after repair (Fig 1). In all 3 patients activity was limited for 6 weeks during recovery from the operation, but all patients have since returned to full activity. In no patient has there been failure or removal of the hardware. One patient experienced two upper abdominal hernias secondary to musculature weakening, which was caused by the multiple procedures required to repair the nonunion. One patient experienced slight localized pain in his chest upon reaching across his body. One patient had experienced pain and tenderness of the iliac crest caused by a hematoma of the donor site, which completely resolved by 6 weeks after the operation.



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  		Fig 1. Radiograph showing two large metal plates and 6.5-mm screws with bone graft filling the nonunion space.

 

   Comment
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 Abstract
 Introduction
 Technique
 Results
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Symptomatic nonunion is a rare complication of sternal fractures, and symptomatic transverse dehiscence of a sternotomy with subsequent nonunion requiring reoperation is even more rare. Minimally invasive surgery through a ministernotomy is advantageous in that it is associated with decreased morbidity and rapid recovery; unfortunately, however, it exposes the patient to potential transverse nonunion of the sternum. Because of the elasticity and movement of the chest wall during breathing, surgical repair of transverse sternal nonunions can be very challenging. With every breath and movement, the sternal fracture or sternotomy is subjected to forces that tend to distract the fragments. This may be the factor that leads to nonunion, and it certainly must be overcome to create an environment in which the nonunion can heal. The substantial anterior plates with at least three screws above and below the nonunion accomplish this objective with this technique. The lack of quality bone in the sternum is another obstacle that must be overcome to achieve effective repair of the injury. This limitation in quantity and quality of bone is addressed by using multiple 6.5-mm cancellous screws; use of smaller screws has been consistently unsuccessful. Even after attempts to approximate the upper and lower ends of the sternum, there was always a space or gap between the two ends of the bone. The addition of cancellous autogenous bone graft stimulated rapid and complete union. Factors that lead to failure of primary surgical repair include use of bone plates that are too small, placement of wires placed in inadequate or weakened bone, and resumption of patient activity before ossification of the repair occurs.

The use of large plates and screws and the introduction of new bone into the sternum have proved effective for the treatment of transverse sternal nonunions. This technique implements hardware sufficient to withstand the tension of the chest wall, and allows for effective healing of the fracture and recovery of the patient.


   References
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 Abstract
 Introduction
 Technique
 Results
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  1. Chase C.W., Franklin J.D., Guest D.P., Barker D.E. Internal fixation of the sternum in median sternotomy dehiscence. Plast Reconstr Surg 1999;103:1667-1672.[Medline]
  2. Demmy T.L., Park S.B., Liebler G.A., et al. Recent experience with major sternal wound complications. Ann Thorac Surg 1990;49:458-462.[Abstract]
  3. Hendrickson S.C., Kroger K.E., Morea C.J., et al. Sternal plating for the treatment of sternal nonunion. Ann Thorac Surg 1996;62:512-518.[Abstract/Free Full Text]
  4. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
  5. Smoot E.C., Weiman D. Paramedian sternal bone plate reinforcement and wiring for difficult sternotomy wounds. Ann Plast Surg 1998;41:464-467.[Medline]
  6. Eich B.S., Heinz T.R. Treatment of sternal nonunion with the Dall-Miles cable system. Plast Reconstr Surg 2000;106:1075-1078.[Medline]



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