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Ann Thorac Surg 2006;82:907-908
© 2006 The Society of Thoracic Surgeons
Department of Surgery, MC 5026, Room J 517, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637
(Email: jelosanoff{at}yahoo.com).
Olbrecht and coauthors [1] provide a detailed retrospective study of 48 patients who required reconstructive surgery for noninfectious sternal dehiscence. Although the work has the limitations of a retrospective analysis, it provides important insight into the risk factors of this relatively rarely discussed condition and its postoperative complications.
Olbrecht and colleagues' practice of routinely using single wires to close the sternotomy was changed to using double wires during the study period. The authors did not specify the exact closure method (peristernal versus transsternal), the factors that triggered the change, the type and manufacturer of the double wires, or whether the more recently used closure influenced the pattern of sternal dehiscence.
Most institutions favor the peristernal closure because it exploits the added stability of the cortical bone. A recent human cadaveric study of median sternotomy exploring various wire configurations found that closures with single peristernal wires proved superior in strength and stability [2]. Many surgeons in the United States claim that using commercially available looped double wire (DoubleWire, A & E Medical Corp, Farmingdale, NJ) is faster and more reliable compared with the standard stainless steel closures. Increased surface area, tensile strength, shear strength, and flexibility are among the product's claimed advantages (http://www.aemedical.com/Doublewire.htm). A recent prospective, randomized study from Germany that used looped double wires (Fumedica GmbH, Herne, Germany) showed significantly improved closures [3].
The reconstruction procedures used by Olbrecht and colleagues included a combination of a parasternal weave and overlying peristernal cerclage loops, also known as the Robicsek method [4]. More than 14% of the patients thus treated required further reconstructions, suggesting that additional technical modifications could potentially improve the results. Rigid fixation with a locking sternal plate/screw system (Sternalock, W. Lorenz Surgical, Inc, Jacksonville, FL) and reinforcement of the lower sternal segment where the separation is initiated [5] are among the recently published methods shown to enhance the stability of the closure.
The 12.5% incidence of surgical infection reported by the Olbrecht team reinforces that the septic risk associated with sternal reconstruction procedures is still very high. Their study found no positive preoperative sternal cultures, but they did not explore the intranasal pathogen carriage, a known major risk factor for surgical site infection after median sternotomy [6].
Olbrecht and colleagues should be commended for contributing to the understanding of why sternal dehiscence occurs and how it can be best treated. The conclusion that patients at risk for sternal separation should be identified and treated prophylactically with lateral support of the sternum reinforces the previously published recommendations [4]. Sternal dehiscence can occur under physiologic loads [7]; thus, closure techniques and materials should ensure stable repair, with avoidance of material migration through the bone [2–4, 7].
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