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Ann Thorac Surg 2003;76:975-976
© 2003 The Society of Thoracic Surgeons

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Correspondence

Double criss-cross sternal wiring and chest wound infections

^a Istituto di Cardiochirurgia, Università di Padova, Via Giustiniani 2, Padova, Italy

e-mail: tomaso.bottio{at}unipd.it

To the Editor:

We read with great interest the article by Risnes and associates [1] and the letter to the editor from Hirose and Takahashi [2]. Risnes and coauthors followed 300 patients who underwent operation for coronary artery disease, valvular disease, or both and were assigned randomly to either intracutaneous or transcutaneous suture technique for chest closure after median sternotomy. The authors concluded that the transcutaneous technique guarantees a greater freedom from infection than the intracutaneous method (incidence of infection, 3% versus 8%). In their experience with 2,560 patients operated on for coronary artery disease, Hirose and Takahashi observed a lower incidence of deep and superficial wound infection with the intracutaneous technique than that reported by Risnes and colleagues. In commenting on these results, the Japanese authors concluded that the lower rate of wound infection in their population was related to the reduction in dead space between the skin and the underlying tissue obtained with a three-layer closure technique and was not due to either intracutaneous or transcutaneous skin suturing.

Between January 1999 and December 2001, we performed 1,845 heart operations in adult patients. Of these patients, 6.7% had a redo procedure, 7% had a low ejection fraction (< 0.30), and 5.3% underwent reexploration for bleeding. Patients having coronary artery bypass grafting accounted for 52.6% (off-pump coronary artery bypass grafting in 24%) of the study population. The left internal mammary artery was used in 99%, and both internal mammary arteries were used in 6%. An emergency operation was necessary in 6% of patients. The remaining patients were operated on for valvular disease (31%), combined coronary artery and valvular disease (11%), cardiomyopathy requiring heart transplantation (4%), and miscellaneous reasons (1.4%). The superficial and deep wound infection rates were 1.8% and 1.2%, respectively.

At our institution, the policy for chest wound closure after sternal wiring is to use a triple layer technique up to the intracutaneous skin closure. Like Hirose and Takahashi [2], we think that this technique combines the best cosmetic results with a low rate of wound infection.

In 300 of our patients (190 with coronary artery disease, 70 with valvular heart disease, and 40 with both conditions) followed personally and prospectively, we used a double criss-cross technique for sternal wiring (Fig 1). No patient experienced either a superficial or a deep wound complication. We believe these results are related to the improved chest and wound stability created by the double criss-cross closure.

View larger version (28K): [in this window] [in a new window]   Fig 1. (A) The four wires used to close the sternal body are placed as follows: The first runs from the fifth intercostal space (V) through the opposite third intercostal space (III) and then from the other third intercostal space to the opposite fifth (black solid and broken line). Likewise, the second wire goes from the fourth intercostal space (IV) to the opposite intercostal space (II) and from the other second intercostal space to the opposite fourth space (red solid and broken line). The last two wires are each passed singly through the sternal bone and control the remaining part of the sternum. (B) Closed chest. The wires on one side of the sternum (*) exert force from up to down, and those (#) on the other side counter with an opposite force. Together, the wires in the double criss-cross sternal closure provide a great stability to the chest.

References

1. Risnes I., Abdelnoor M., Baksaas S.T., Lundblad R., Svennevig J.L. Sternal wound infections in patients undergoing open heart surgery: randomized study comparing intracutaneous and transcutaneous suture techniques. Ann Thorac Surg 2001;72:1587-1591.[Abstract/Free Full Text]
2. Hirose H., Takahashi A. Sternal suturing technique and chest wound complication. Ann Thorac Surg 2002;74:634-635.[Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gino Gerosa Dino Casarotto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bottio, T. Articles by Casarotto, D. Search for Related Content PubMed PubMed Citation Articles by Bottio, T. Articles by Casarotto, D. Related Collections Cardiac - other