Ann Thorac Surg 2005;80:1537-1539
© 2005 The Society of Thoracic Surgeons
How to do it
Advanced Sternal Closure to Prevent Dehiscence in Obese Patients
Arndt-H. Kiessling, MD
a
,
*
,
Frank Isgro, MD
a
,
Udo Weisse, MD
a
,
Andreas Möltner, PhD
a
,
Werner Saggau, MD
a
,
Joachim Boldt, MD
b
a Department of Cardiac Surgery, Klinikum Ludwigshafen, Ludwigshafen, Germany
b Department of Anaesthesia and Operative Intensive Care Medicine, Klinikum Ludwigshafen, Ludwigshafen, Germany
Accepted for publication April 14, 2004.
* Address reprint requests to Dr Kiessling, Klinikum Ludwigshafen, Heart Institute Ludwigshafen, Bremserstrasse 73, D-67063 Ludwigshafen, Germany (Email: kiesslia{at}klilu.de).
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Abstract
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Sternal dehiscence is a frequent complication after cardiac surgical procedures. The objective was to evaluate a novel method for advanced sternal closure compared with standard techniques for preventing sternal dehiscence. Our investigation comprised 100 patients with a body mass index above 32. Patients were randomly assigned to receive either advanced sternal closure with three stainless steel double wires or standard techniques with stainless steel single wires. The incidence of sternal refixation was 6 of 50 patients in the standard techniques group and 1 of 50 in the advanced sternal closure group during a follow-up period of 6 months.
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Introduction
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Postoperative sternal dehiscences continue to be among the biggest problems in cardiac surgery. In the normal weight population, the incidence is estimated at 1% to 6%. The mechanisms of a sternal wound complication are manifold, however. These include, on the one hand, the instability caused by pulled out wires and also torn out bone fragments in the case of osteoporotically altered matrix. Osteomyelitis leads to an increased risk of 1% to 2%, especially in patients in whom the predisposing factors diabetes mellitus, steroid medication, overweight, osteoporosis, or bilateral preparation of the internal mammary arteries are present. Often the initial instability derives from the basic mechanism of an osteomyelitis. This is the ground upon which the feared infection develops. Mechanical techniques were developed that led to a reduction in morbidity. Where osteoporosis has altered the bone structure, paracostal longitudinal wiring on both sides has established itself. The tearing out of transverse wires is thus substantially reduced but the problem remains with seriously overweight patients. Through the strong interthoraxial forces, even strengthened USP 7 wires can tear out. The most common localization is the twisting point. Longitudinal wires (USP 5) do not offer any special protection in such cases (Fig 1).
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Fig 1. Standard wiring technique with the control group. Single wires were used in the area of the manubrium and figure-of-eight loops in the distal area. To ensure comparability of the groups, however, single wires were applied in the majority of cases.
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Double wire (USP 5-7) was developed by the company Fumedica GmbH (Herne, Germany), and this is applied through a special technique (Fig 6). Through the double wiring the forces acting on the sternum surfaces are spread out, resulting in an increased resistance to tearing out.
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Fig 6. The reverse cutting needle forms a puncture channel, which allows optimum uptake of the double wire. The soldering point between needle and wire is not produced homogenously. This step can be responsible for a forced bone passage.
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This prospective, randomized study was performed between January 2002 and September 2003 on 100 patients who underwent a cardiac procedure through a full sternotomy at the Klinikum Ludwigshafen Heartcenter. The demographic characteristics and concomitant diseases are presented in Table 1. For nominal variables, Fisher's exact test was used. In terms of continuous variables, a Mann-Whitney test was calculated with SAS 8.02 software. A p value less than 0,05 was considered as statistical significance. Informed consent was obtained before operation (24 hours) from each patient.
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Technique
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For applying the double wires, the needles are so directed through or around the sternum that the double wire loops are the same length on both sides (Fig 2). The needles are then parted directly above the loop connection by a wire cutter. After the double wires are in position, the hook of the twister is pushed through the noose of the double wires (Fig 5). Twisting then takes place by pulling up the hook with simultaneous consistent rotation of the wrist; that has the effect of turning the hook and twisting the double wire. A final twisting action is not yet applied at this phase (Fig 3). The same procedure than takes place with the next double wire. The sequence of wire twisting to give a consistent joining of sternum surfaces is up to the surgeon, to be decided upon according to the anatomical situation. During the rotation of the loops, the index finger can be used to simultaneously steady and direct the anterior sternum surfaces. For achieving the desired end stability, the hook is turned until the completely twisted line begins to bend several times and further twisting is hardly possible (Fig 4). The wires are then cut at 0.75 to 1 cm using a wire cutter. The end points of the twisted wires are tucked out of the way by being bent downward in the direction of rotation. The bent wire is then pressed flat against the anterior surface of the sternum with the blunt point of a needle forceps.
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Fig 2. The wiring technique with double wire. In the area of the upper manubrium, only single USP 7 wires were used; 3 to 4 double wires were applied parasternally. A further single wire was twisted in the distal sternum where required.
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Fig 3. Twisting double wires: to achieve a consistent and strong twisting result, it is important that the hook is pulled upward with simultaneous and consistent rotation of the wrist.
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Fig 4. The desired end stability is reached at the point when the completely twisted line begins to bend several times.
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Comment
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The described technique showed a high efficacy and success rate in the avoidance of postoperative sternal dehiscence with overweight patients (body mass index > 32). During a follow-up period of 6 months, one instability was evident in the double wire group (1 of 50). Six patients in the standard group had to be rewired (6 of 50; p = 0.05, one sided). While the patient selection included this high-risk collective, not included were in particular older, postmenopause patients. In such cases, there were fears that initial damage could be caused to the sternum through the greater forces applied with double wiring compared with standard wiring.
One problem with the double wire is caused by the soldered point at the end of the wire loop. That does not allow penetration of the manubrium. The optimum position for the most proximal wire is the second intercostal space. Important here, too, is a parasternal positioning to protect the internal mammary artery.
Before one can apply the wires clinically, the ability to correctly operate the twister is necessary. The movement for twisting of the wires must come from the wrist only. Only in this way is it possible to achieve a consistent pulling-together action. That is where the biggest mistake lies in applying this technique. To help practice this action, one should place the hook on the inner surface of the hand. The rotational movement of the wrist should lead to a rotational movement of the twister at the one point.
The application of double wires in the care of overweight patients represents a reliable method for reduction of sternal dehiscence [1–7].
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References
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- Zurbrugg HR, Freestone T, Bauer M, Hetzer R. Reinforcing the conventional sternal closure Ann Thorac Surg 2000;69:1957-1958.[Abstract/Free Full Text]
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Abstract
Introduction
