Ann Thorac Surg 2005;79:1096-1097
© 2005 The Society of Thoracic Surgeons
Correspondence
Parasternal Wire Technique and Sternal Dehiscence
Tomaso Bottio, MD, PhD,
Vincenzo Tarzia, MD,
Claudio Muneretto, MD
Department of Cardiovascular Surgery, University of Brescia Medical School, Piazza Spedali Civili 1, Brescia, Italy
(E-mail: tomaso.bottio{at}unipd.it).
To the Editor:
Sharma and associates [1] devised and assessed a new method of sternal closure to prevent sternal dehiscence. Based on the concept that the pathogenesis of sternal wound dehiscence may be due to sternal instability after a technical pitfall, as already suggested by Kirklin and Barrat-Boyes [2], Sharma randomly allocated 776 high-risk patients to a conventional group using six stainless steel wires (390 patients; group IIa) or to a group using a modified parasternal wire technique (386 patients; group IIb). Patients were considered at high risk when older than 65 years or when they had diabetes mellitus, bilateral internal thoracic artery harvesting, reoperation, eccentric sternotomy, previous mediastinitis or dehiscence, obesity, or chronic obstructive pulmonary disease. According to the excellent results obtained (in group IIb, only 1 patient of 386 had sternal dehiscence), the authors concluded that by adopting the longitudinal parasternal wire technique it is possible to reduce and prevent sternal wound complications.
We have recently published a prospective randomized study to assess the efficiency of two different sternal wiring techniques in preventing sternal dehiscence [3]. We concluded that when improved stability is achieved by a specific wiring technique, this technique produces superior results and accomplishes real prophylaxis. According to Sharma and associates, we routinely used parasternal reinforcement in subgroups of high-risk patients. In fact, in these patients we used two previously published sternal reinforcing techniques: namely, the Robicsek technique [4] and the simplified parasternal Sutherland technique [5]. In these patients, regardless of the sternal wiring technique we used, no signs of superficial or deep wound infections were evident [3]. We concluded, as did Sharma and associates, that sternal stability and reinforcement by parasternal wires appears to be the most important determinant for reducing sternal wound complications in high-risk patients.
We have two comments regarding the Sharma paper: the first is that the simplified Robicsek technique, namely, a one-way longitudinal parasternal wire, has been already published by Sutherland; the second is that we do not consider it clinically ethical to randomize patients at high risk, such as those with a paramediam sternotomy, to a conventional sternal closure, omitting parasternal wire reinforcement.
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References
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- Sharma R, Ouri D, Panigrahi BP, Virdi IS. A modified parasternal wire technique for prevention and treatment of sternal dehiscence Ann Thorac Surg 2004;77:210-213.[Abstract/Free Full Text]
- Kirklin JW, Barrat-Boyes BG. Cardiac surgery2nd ed. New York: Churchill Livingstone; 1993225–6.
- Bottio T, Rizzoli G, Vida V, Casarotto D, Gerosa G. Double crisscross sternal wiring and chest wound infections: a prospective randomized study J Thorac Cardiovasc Surg 2003;126:1352-1356.[Abstract/Free Full Text]
- Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]
- Sutherland RD, Martinez HE, Guynes WA. A rapid, secure method of sternal closureCardiovascular diseases. Bull Texas Heart Inst 1981;8:54-55.
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References