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Ann Thorac Surg 2006;82:902-907
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Clinical Outcomes of Noninfectious Sternal Dehiscence After Median Sternotomy

Vanessa A. Olbrecht, BA, Christopher J. Barreiro, MD, Pramod N. Bonde, MD, Jason A. Williams, MD, William A. Baumgartner, MD, Vincent L. Gott, MD, John V. Conte, MD*

Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

Accepted for publication April 20, 2006.

* Address correspondence to Dr Conte, Division of Cardiac Surgery, Department of Surgery, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287-4618. (Email: jconte{at}csurg.jhmi.jhu.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Requirements for...
 Acknowledgments
 References
 
BACKGROUND: Infectious complications of median sternotomy carry significant morbidity and mortality. However, the outcomes of noninfectious sternal dehiscence have not been addressed. We have identified the preoperative characteristics, postoperative complications, and long-term functional outcomes of patients after reoperation for noninfectious sternal dehiscence and compared these patients with a control group to determine risk factors for dehiscence.

METHODS: Retrospective review of the cardiac surgery database identified 48 patients with noninfectious sternal dehiscence in a group of 12,380 median sternotomies between 1994 and 2004. The review included diagnosis, demographics, concomitant medical conditions, and surgical outcomes. Functional outcomes were assessed using the Short Form-12 questionnaire. One hundred fifty-six median sternotomy patients served as controls. Follow-up was 97.9% (47 of 48 patients) complete, for a total of 150.1 patient-years.

RESULTS: Mean age of patients at reoperation was 58.8 ± 12.8 years, with a male to female ratio of 45:3. Multivariate analysis determined that New York Heart Association class IV, obesity, and chronic obstructive pulmonary disease were preoperative risk factors for sternal dehiscence. The incidence of sternal dehiscence was 0.39% at a mean interval between initial operation and reoperation of 5.4 months. At a mean interval of 3.9 months, 14.6% (7 of 48) of patients required additional sternal procedures. Infectious complications after reoperation occurred in 12.5% (6 of 48). Functional outcomes demonstrated that 72.2% (26 of 36) had no or mild limitation of physical activities, with 90.5% (38 of 42) reporting no or mild sternal pain at follow-up.

CONCLUSIONS: Although patients undergoing surgical correction of noninfectious sternal dehiscence fare better than those with infectious complications, optimal sternal approximation during the initial procedure and sternal precautions during convalescence should be emphasized to prevent recurrent complications.


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Requirements for...
 Acknowledgments
 References
 
Dehiscence of the sternum is a serious and potentially devastating complication that can cause pulmonary dysfunction, chest wall discomfort, and superficial and mediastinal infections [1]. Sternal motion and instability may occur in the first days or weeks after median sternotomy owing to technical issues with the bone, wire, or surgical technique. This may resolve and heal normally, or it may lead to dehiscence because of fracture of the sternal bone or the sternal wires [2]. Sternal dehiscence can occur in 0.2% to 5% of patients as a result of primary nonunion, poor wound healing, or premature overexertion [2–7].

Certain patients are at a greater risk for experiencing sternal wound complications, and many studies have established both preoperative and operative risk factors. Previously reported preoperative risk factors for sternal dehiscence include obesity [2, 8], diabetes mellitus [9], chronic obstructive pulmonary disease [2, 9], chronic cough [10], smoking [2, 3], New York Heart Association functional class [11], osteoporosis [1, 2], use of angiotensin-converting enzyme inhibitors [10], use of ß-adrenergic drugs for respiratory problems [11], immunosuppression [2, 9], and previous sternotomy [9]. Operative risk factors include bilateral internal mammary artery harvest [9], excessive volumes of blood transfused [11], and prolonged cardiopulmonary bypass time [3].

Several previous studies have examined long-term outcomes of patients after muscle flap placement for mediastinal infection [12–16]. However, no significant efforts have been made to address long-term functional outcomes of patients experiencing sternal dehiscence in the absence of infection, making the long-term morbidity of this complication relatively unknown. The purpose of this study was to conduct a retrospective review of all patients experiencing noninfectious sternal dehiscence after median sternotomy at our institution during a 10-year period.


   Patients and Methods
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 Introduction
 Patients and Methods
Results
 Comment
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 Acknowledgments
 References
 
A retrospective review was performed of all patients undergoing median sternotomy for cardiac surgery at The Johns Hopkins Hospital from March 1994 to February 2004. A total of 12,380 median sternotomies were performed during the study period, and 48 patients (0.39%) underwent surgery to repair a noninfectious sternal dehiscence. Patients who experienced infectious complications of the sternal wound after sternotomy were excluded. Age, sex, race, and procedure-matched controls who underwent median sternotomy without dehiscence during the same period were used for comparison.

Medical records were used to obtain patient histories; demographics; preoperative, operative and postoperative data; and complications. Telephone interview with patients or family members was the primary mode of follow-up contact. Functional outcomes were evaluated using patient follow-up interviews and the Short Form-12 (SF-12) quality assessment tool. Institutional review board approval of the study was obtained on May 20, 2004, and each patient in the study gave informed consent before serving as a subject.

The SPSS statistical software (SPSS, Inc, Chicago, IL) was used to quantitatively analyze the collected data. Univariate analysis was done using {chi}2 analysis or Fisher's exact test for categorical data and the Mann-Whitney U test for continuous data. Multivariate analysis was conducted using binomial logistic stepwise regression, confirmed by forward and backward conditional method. Descriptive statistics are presented as mean ± standard deviation. Event-free curves and at-risk patients for sternal infection and additional sternal revisions were calculated using Kaplan–Meier analysis. Statistical significance was defined as a probability less than or equal to 0.05.


   Results
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 Introduction
 Patients and Methods
 Results
Comment
 Requirements for...
 Acknowledgments
 References
 
During this period, a total of 12,380 median sternotomies were performed, with an incidence of noninfectious sternal dehiscence of 0.39% (48 of 12,380). The incidence of infectious sternal dehiscence during the same period was 2.4% (298 of 12,380). Our patient cohort consisted of 48 patients (48 of 12,380, 0.39%) who suffered from noninfectious sternal dehiscence after median sternotomy, with a mean age of 58.8 ± 12.8 years (range, 30 to 79) at reoperation and a male to female ratio of 45:3 (Table 1). Follow-up was 97.9% complete (47 of 48) for a total of 150.1 patient-years, with a mean follow-up of 3.1 ± 2.4 years. The mean interval between the initial operation and sternal reoperation was 5.4 months. This patient group was compared with a group of 156 age-, sex-, race-, and procedure-matched control subjects who underwent median sternotomy during the same period but did not experience sternal dehiscence or undergo sternal revisions (Table 1). Multivariate analysis performed comparing our patient population with the matched control subjects identified New York Heart Association functional class IV, obesity, and chronic obstructive pulmonary disease as significant risk factors for sternal dehiscence in our patient population (Tables 1, 2).


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  		Table 1. Demographic, Preoperative, and Intraoperative Variables: Comparison Between Control Subjects and Sternal Revision Patients
 

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  		Table 2. Preoperative Variables: Odds Ratio and Multivariate Analysis
 
The majority of patients underwent coronary artery bypass grafting as the initial procedure requiring median sternotomy, with a small fraction undergoing heart transplantations (Table 3). Other initial procedures included aortic valve replacement, repair of aortic dissection, aortic root replacement, or a combination of these procedures. Three quarters of the patients underwent an internal mammary artery harvest, with only 10.8% (4 of 37) receiving a bilateral internal mammary artery graft (Table 1). Routine closure of the sternum until 2002 involved the placement of six to seven single sternal wires (no. 5 or no. 6) with a multitwist closure. The use of double loops of regular sternal wires (no. 5 or no. 6) became standard by 2002, and three to four double wires were placed in the sternum with two single wires placed in the manubrium. All wires were closed by multitwist closure. No patients had a prophylactic sternal weave in the group that experienced a dehiscence.


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  		Table 3. Initial Procedure Performed Through Median Sternotomy
 
Common postoperative findings included chronic ventilator dependence or intubation greater than 7 days (6.3%, 3 of 48), pneumonia (4.2%, 2 of 48), cough (12.5%, 6 of 48), pleural effusion (10.4%, 5 of 48), nausea or vomiting (6.3%, 3 of 48), and poor oxygen saturation (10.4%, 5 of 48).

Surgical treatment of sternal dehiscence included simple debridement and rewire; debridement, rewire, and placement of bilateral muscle flaps; debridement, rewire, and placement of sternal plates; debridement, rewire, and placement of sternal plates with bilateral muscle flaps; and sternal wire removal (Table 4). Rewire closure of the sternum, when uncomplicated, generally involved the use of a Robicsek weave as described by Robicsek and colleagues [2] using no. 5 or no. 6 wire. When bilateral pectoralis muscle flaps were used, both the pectoralis and rectus muscles were elevated off of the ribs to create a bipedicle flap. The flaps were then mobilized to cover the region of the sternal repair and sutured into place. Synthes sternal plate fixation systems (Synthes, Inc, West Chester, PA) were used in patients requiring sternal plates to stabilize the sternum. The types of plates varied in each of the patients, from parallel 2.7 mm or 3.0 mm, depending on the clinical situation.


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  		Table 4. Surgical Treatment of Sternal Dehiscence
 
The patient in which sternal wire removal was performed had significant nonunion of his sternum. However, on surgical examination, there was no evidence of infection and a small portion of the sternum did appear to have some bony union. Because of the patient's multiple chronic medical conditions and the lack of sternal instability by palpation, the decision was made to remove several of the sternal wires and to leave him with a relatively stable sternum in the attempt to help reduce his pain.

All patients were cultured for examination of infection at the time of reoperation and received standard antibiotic prophylaxis, which included 24-hour administration of a first-generation cephalosporin or vancomycin (in penicillin-allergic patients). At that time, all cultures were negative for infective microorganisms. In patients who experienced infectious complications after the initial reapproximation procedure, antibiotics were administered according to culture sensitivities for 6 weeks and only continued beyond that time if the wound remained frankly purulent.

Most patients were free from further sternal revisions and wound infections at the time of follow-up. However, 7 patients required further sternal revisions, and 6 patients exhibited wound infections confirmed by culture (Fig 1). As seen in Figure 2, freedom from additional sternal revisions was 86.6% ± 5.1%, 83.9% ± 5.6%, and 83.9% ± 5.6% at 1, 4, and 9 years, respectively, with a mean interval between revisions of 3.9 months. Figure 3 demonstrates an 85.6% ± 5.5% freedom from wound infection at 1, 4, and 9 years.


Figure 1
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  		Fig 1. Patient follow-up, showing further sternal revisions and infectious complications. (hatched bars = yes; solid bars = no.)

 

Figure 2
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  		Fig 2. Freedom from additional sternal revisions.

 

Figure 3
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  		Fig 3. Freedom from infection.

 
The majority of patients experiencing noninfectious sternal dehiscence presented with pain or instability of the sternum. Several patients also presented with drainage, nonunion, or completely asymptomatically (Table 5). After surgical revision, the majority of patients (57.1%, 24 of 42) experienced no pain at the time of follow-up, and 33.3% (14 of 42) experienced only mild pain. A small minority (9.5%, 4 of 42) did report constant pain at follow-up, and persistent sternal instability occurred in 19.5% (8 of 41) of patients after the sternal revision. Of the patients who had sternal plates placed, 3 continued to have sternal instability. However, 1 patient who had a sternal wire removed no longer experienced any sternal instability at follow-up.


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  		Table 5. Presenting Signs and Symptoms in Patients Experiencing Sternal Dehiscence
 
Approximately 75% (27 of 37) experienced no or mild limitations of their physical activities after revision, with 27.0% (10 of 37) experiencing either moderate or severe limitations due to sternal pain and/or instability. The majority of patients (54.1%, 20 of 37) ranked their overall level of general health as being excellent, very good, or good, although 13.5% (5 of 37) stated that they were experiencing poor health at the time of follow-up (Table 6).


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  		Table 6. Patient Follow-up: Persistent Pain, Instability, General Health, and Physical Limitations
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Requirements for...
 Acknowledgments
 References
 
The purpose of this study was to identify the preoperative characteristics, postoperative complications, and long-term functional outcomes of patients undergoing sternal reoperation from noninfectious causes and to compare these patients with a group of age-, sex-, race-, and procedure-matched control subjects to determine risk factors for noninfectious sternal dehiscence. Previous studies have addressed these issues for patients having sternal dehiscence from infectious causes. Although the presence of infection leads to poor results after debridement and rewiring [17], our study shows that patients undergoing sternal reoperation for dehiscence without infection have more favorable outcomes than those with infection. Nevertheless, approximately 20% of our patients experienced long-term complications, emphasizing the importance of optimizing sternal reapproximation during the initial median sternotomy.

Technical errors and misapproximation of the sternal halves often result in inadequate coaptation of the sternum [6, 7, 9, 18]. Despite a technically sound sternal approximation, mechanical analysis of median sternotomy closures demonstrates that the application of simple physiologic forces to the thorax can lead to significant sternal motion. In this cohort, 45.8% (22 of 48) of the patients experienced mechanical stresses on their wound that likely contributed to their sternal dehiscence, including premature overexertion, chest reexploration, intubation greater than 7 days, chronic ventilator dependence, and respiratory symptoms [3, 4, 12, 18]. Of note, 25 patients in this cohort experienced sternal dehiscence of undetermined causes.

Because of these physical problems, many studies describe the use of reinforced closure techniques to decrease the incidence of sternal dehiscence [7, 9, 19, 20]. Although these techniques are potentially effective in reducing the incidence of sternal dehiscence, they are more invasive, more technically cumbersome, and carry an increased risk of bleeding, making them less attractive options for use during routine closure of the initial midline sternotomy [2]. No studies have clearly identified a population of patients who are likely to benefit from a prophylactic sternal weave over standard sternal closure technique on a routine basis. The standard closure of the initial median sternotomy at our hospital from 1994 to 2002 involved the use of six to seven single sternal wires (no. 5 or no. 6) with a multitwist closure. In 2002, the use of double wires became standard, and closure then involved the use of three or four double wires in the sternum and two single wires placed in the manubrium with a multitwist closure of all wires. In general, this standard technique is replaced with a Robicsek sternal weave during the rewire procedure, in which peristernal single wire loops are placed around a continuous vertical pericostal weave [2]. Additionally, some patients with dehiscence and multiple sternal fractures received bilateral pectoralis muscle flaps both with and without sternal plates to further reinforce the sternum when clinically necessary. Allograft bone, Opteform (Exatech, Gainesville, FL) was used between the two sternal halves in 1 patient to help promote bone healing in the setting of chronic nonunion.

Our patient cohort demonstrated that the majority of patients were free from further sternal revisions and sternal wound infections at the time of follow-up. Cultures were routinely obtained at the time of sternal revision to ensure that infection did not cause the dehiscence, and all cultures were negative. However, 7 of 48 patients required additional sternal revisions, and 6 of 48 patients experienced wound infections after their initial sternal revision (Fig 1). Of the 7 patients who required an additional sternal procedure, 4 also experienced sternal infections. This means that of the 48 patients undergoing additional sternal reoperation procedures, 9 had long-term complications associated with their repeat procedure. Although this number is favorable compared with outcomes of patients after infectious sternal dehiscence and pectoralis flap reconstructions [14], it emphasizes the importance of adequate reapproximation of the sternum after the initial procedure. Despite patients with noninfectious sternal dehiscence faring better than those with infections, patient outcomes can be maximized by avoiding sternal rewire procedures.

The retrospective nature of this study leads to some limitations when analyzing our data. First, because this complication is rare and the study evaluated patients from one institution during a 10-year period, data could only be analyzed for a relatively small number of patients. In addition, our follow-up data were also somewhat subjective as they were based on individual patients reporting their postoperative experiences. We obtained consistency in our methods by having a single investigator interview all patients using a standard set of questions with the SF-12 quality assessment tool. One technical aspect that we could not specifically address was the role of opening of the sternum off-center. Although this would make intuitive sense to be a risk factor for dehiscence, we could not study this. It has been our practice to perform a partial weave on the thin side if there seems to be a significant disparity in the size of sternal bone on opposite sides. We did not find any patients who had such a partial weave who experienced a dehiscence. Despite the limitations of this study, these findings provide new insight into patient outcomes after noninfectious sternal dehiscence and support the hypothesis that patients generally do better than those experiencing infectious sternal dehiscence.

In conclusion, risk factors for noninfectious sternal dehiscence identified include obesity, chronic obstructive pulmonary disease, and New York Heart Association functional class IV. Patients undergoing surgical correction of noninfectious sternal dehiscence fared better than those patients who experienced complications after infectious sternal dehiscence. Although the majority was free from infectious complications and further sternal revisions, approximately 19% still experienced long-term complications, emphasizing the importance of adequate sternal reapproximation after the initial median sternotomy procedure to avoid recurrent complications. Our current recommendation is for patients who are morbidly obese (body mass index greater than 36), those with a chronic cough, or those with a sternum not divided in the midline to undergo a prophylactic sternal weave.


   Requirements for Recertification/Maintenance of Certification in 2006
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 Introduction
 Patients and Methods
 Results
 Comment
 Requirements for...
Acknowledgments
 References
 
Diplomates of the American Board of Thoracic Surgery who plan to participate in the Recertification/Maintenance of Certification process in 2006 must hold an active medical license and must hold clinical privileges in thoracic surgery. In addition, a valid certificate is an absolute requirement for entrance into the recertification/maintenance of certification process. if your certificate has expired, the only pathway for renewal of a certificate is to take and pass the Part I (written) and the Part II (oral) certifying examinations.

The American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified in the American Board of Medical Specialties directories. The Diplomate's name will be published upon successful completion of the recertification/maintenance of certification process.

The CME requirements are 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to application. SESATS and SESAPS are the only self-instructional materials allowed for credit. Category II credits are not allowed. The Physicians Recognition Award for recertifying in general surgery is not allowed in fulfillment of the CME requirements. Interested individuals should refer to the Booklet of Information for a complete description of acceptable CME credits.

Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed.

Candidates for recertification/maintenance of certification will be required to complete all sections of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS individually because it will be sent to candidates after their application has been approved.

Diplomates may recertify the year their certificate expires, or if they wish to do so, they may recertify up to two years before it expires. However, the new certificate will be dated 10 years from the date of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation.

Recertification/maintenance of certification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate.

The deadline for submission of applications for the recertification/maintenance of certification process is May 10 each year. A brochure outlining the rules and requirements for recertification/maintenance of certification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, 633 N St. Clair St, Suite 2320, Chicago, IL 60611; telephone: (312) 202-5900; fax: (312) 202-5960; e-mail: info{at}abts.org. This booklet is also published on the website: www.abts.org.


   Acknowledgments
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 Abstract
 Introduction
 Patients and Methods
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 Requirements for...
 Acknowledgments
References
 
The authors would like to thank Nishant D. Patel for his technical assistance in the creation of this manuscript. Christopher Barreiro, MD, is a Hugh R. Sharp Cardiac Surgery Research Fellow, and Jason Williams, MD, is an Irene Piccinini Investigator in Cardiac Surgery.


   References
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 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Requirements for...
 Acknowledgments
 References
 

  1. Katz NM. Pericostal sutures to reinforce sternal closure after cardiac surgery J Card Surg 1997;12:277-281.[Medline]
  2. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy Thorac Cardiovasc Surg 2000;48:1-8.[Medline]
  3. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomya comprehensive review. Eur J Cardiothorac Surg 2002;21:831-839.[Abstract/Free Full Text]
  4. Bryan AJ, Lamarra M, Angelini GD, West RR, Breckenridge IM. Median sternotomy wound dehiscencea retrospective case control study of risk factors and outcome. J R Coll Surg Edinb 1992;37:305-308.[Medline]
  5. El Oakley RM, Wright JE. Postoperative mediastinitisclassification and management. Ann Thorac Surg 1996;61:1030-1036.[Abstract/Free Full Text]
  6. Harjula A, Jarvinen A. Postoperative median sternotomy dehiscence Scand J Thorac Cardiovasc Surg 1983;17:277-281.[Medline]
  7. Casha AR, Yang L, Kay PH, Saleh M, Cooper GJ. A biomechanical study of median sternotomy closure technique Eur J Cardiothorac Surg 1999;15:365-369.[Abstract/Free Full Text]
  8. Antoinette MJ, Rockx BA, Fox SA, et al. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? Can J Surg 2004;1:34-38.
  9. Sharma R, Puri 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]
  10. Abid Q, Podila SR, Kendall S. Sternal dehiscence after cardiac surgery and ACE type I inhibition Eur J Cardiothorac Surg 2001;20:203-204.[Abstract/Free Full Text]
  11. Bitkover CY, Gardlund B. Mediastinitis after cardiovascular operationsa case-control study of risk factors. Ann Thorac Surg 1998;65:36-40.[Abstract/Free Full Text]
  12. Francel TJ, Kouchoukos NT. A rational approach to wound difficulties after sternotomyreconstruction and long-term results. Ann Thorac Surg 2001;72:1419-1429.[Abstract/Free Full Text]
  13. Yuen JC, Zhou AT, Serafin D, Georgiade GS. Long-term sequelae following median sternotomy wound infection and flap reconstruction Ann Plast Surg 1995;35:585-589.[Medline]
  14. Ringelman PR, Vander Kolk CA, Cameron D, Baumgartner WA, Manson PN. Long-term results of flap reconstruction in median sternotomy wound infections Plast Reconstr Surg 1994;93:1208-1214.[Medline]
  15. Castello JR, Centella T, Garro L, et al. Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgerya 10-year analysis. Scand J Plast Reconstr Surg Hand Surg 1999;33:17-24.[Medline]
  16. Netscher DT, Eladoumikdachi F, McHugh PM, Thornby J, Soltero E. Sternal wound debridement and muscle flap reconstructionfunctional implications. Ann Plast Surg 2003;51:115-122.[Medline]
  17. Cosgrove DM, Lytle BW, Loop FD, et al. Does bilateral internal mammary artery grafting increase surgical risk? J Thorac Cardiovasc Surg 1988;95:850-856.[Abstract]
  18. Shafir R, Weiss J, Herman O, Cohen N, Stern D, Igra Y. Faulty sternotomy and complications following median sternotomy J Thorac Cardiovasc Surg 1988;96:310-313.[Abstract]
  19. Totaro P, Lorusso R, Zogno M. Reinforced sternal closures for prevention of sternal dehiscence in high risk patients J Cardiovasc Surg 2001;42:601-603.[Medline]
  20. Randecker H. Median sternotomy closurea simple inexpensive effective technique. Ann Thorac Surg 2005;80:2393-2394.[Abstract/Free Full Text]

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