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Ann Thorac Surg 2007;83:1210-1212
© 2007 The Society of Thoracic Surgeons
a Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
b Clinic for Cardiac Surgery, City Hospital Triemli, Zurich, Switzerland
c Department of Experimental Surgery, University Hospital Zurich, Zurich, Switzerland
Accepted for publication March 27, 2006.
* Address correspondence to Dr Plass, Clinic for Cardiovascular Surgery, University Hospital Zürich, Rämistr. 100, Zürich, CH-8091 Switzerland (Email: andreplass{at}aol.com).
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Abstract |
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Introduction |
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Despite the named advantages and the widespread use of wire fixation, it is still associated with potential complications such as wound infection, including dehiscence and bony nonunion. A complication rate of less than 1% (range, 0.4% to 5.1%) is low; however it is connected to an increased morbidity and mortality [2]. Because of the risk of these complications, there is a continuous search for alternative sternal closure techniques.
In cases of complicated sternal infections the referral to plastic surgeons is not unusual [3]. They use different pectoralis major flap techniques including turnover and rotational flaps. Besides the lost of the whole sternum, many of these patients require prolonged postoperative ventilatory support and suffer from chronic pain due to severe anterior chest instability [4].
This report describes the first rigid fixation technique with plates (Titanium Sternal Fixation System, Synthes, Oberdorf, Switzerland) and preservation of the sternum performed by cardiac surgeons for treatment of sternal dehiscence and complicated sternal infection after median sternotomy.
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Technique |
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After debridement of devitalized bone, which is sent for microbiological gram staining and cultures to rule out osteomyelitis, an irrigation lavage with saline containing antibiotics is followed. Then exposure of the ribs laterally approximately 10 to 15 cm on both sides of the sternum is performed by dissection of the major pectoral muscle with the overlying soft tissue from the medial with electrocautery.
The accurate length of the screws was determined by measurements with the depth gauge from the sternal edges next to the ribs. Then approximation of the sternal edges is achieved with two or three reduction forceps on the superior and inferior aspect of the sternum.
By using a bending template the length and contour of the plate is prepared to best fit the shape of the ribs. The plates are formed and positioned transversely across the two sternal halves. The emergency release pin should be parallel to the midline of the sternum and cranially oriented.
Through a drill guide, holes are drilled of the planned lengths into the rib bones under avoidance of the inferior margin of the rib to preserve the intercostal nerves and vessels, as well as the pleura and the lungs. Then 3.0-mm sternal unilock screws with the measured lengths are inserted through the plate and tightened until secure. The screws are available in the range of 12 to 20 mm in length. At least four screws should be inserted in each side of the plate (Fig 1). In addition a manubrium plate can be placed for extra support.
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This sternal closure technique was applied to 3 patients who suffered from serious sternal wound infections and sternal instability. Because this new titanium osteosynthesis system has been officially approved for the Communauté Européenne (CE) market of the European Union it represents an additional option for complicated sternal wound infections. However, the patients gave written consent for the surgical procedure.
The surgical procedure was successfully performed in the 3 patients. In all of them the sternum could be preserved and showed stable conditions after plate installation.
The detailed description of 1 of the 3 patients is as follows. A 76-year-old man with a history of myocardial infarction and several interventional procedures underwent a coronary artery bypass grafting. After an uneventful postoperative stay in the hospital he was sent to rehabilitation. Three weeks after surgery the patient was readmitted with fever and a purulent sternal infection. To control the infection a sternal revision with insertion of a Vac-dressing (KCL Inc, San Antonio, TX) combined with antibiotics was carried out. Approximately 2 weeks after the initial revision, a sternal closure with the new titanium sternal fixation system (Synthes, Oberdorf, Switzerland) was performed.
Three 20-hole plates, one 12-hole plate, and one manubrium plate were fixed with 44 screws to the sternum (Fig 2). The operating time was 190 minutes. The patient was extubated 1 hour postoperatively and was mobilized the following day without problems and with minimal pain. The roentgenogram control showed good positioning of the plates (Figs 3A, 3B). The drains were removed on the fourth postoperative day, and we were able to discharge the patient to rehabilitation 6 days after the procedure.
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Comment |
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If a sternal infection with concomitant dehiscence necessitates a revision and the re-closure done by cardiac surgeons, then steel wires are used again. In cases of an instable sternum or distinctive infections, cardiac surgeons refer these patients to plastic surgery for a complete debridement of the sternum and a concomitant pectoral muscle flap reconstruction. After this procedure, patients may still suffer from different problems like chronic pain of the sternal separation and interminable wound healings [4, 6].
We believe that this is the first report of cardiac surgeons using a titanium plate system with an emergency release pin combined with simple bilateral major pectoral muscle flaps to close the complicated sternal dehiscences with infections. The cases with excellent short-term results may represent a promising new option for the cardiac surgeon to deal with the problem of sternal instability dehiscences and infections that could make the referral to the plastic surgeon unnecessary.
A significant advantage for using the plate system is that it makes adhesiolysis of the substernal area unnecessary. In our described case, massive adhesions were visible under the sternum, and in addition the right side of the sternum was fractured. Closure by wires would only be possible by using the Robicsek technique and inserting additional wires in a longitudinal direction. This would need an extensive dissection of tissue underneath the sternum, which could cause exhausting dissections with the constant risk of damaging any bypasses. With this technique the plates can be placed over the fractured part without any adhesiolysis beforehand, and with unilock screws a stable sternal condition can be achieved. All sternums could be preserved and the patients showed improved ventilation and reduced pain after surgery.
Special attention has to be paid to any bypasses that are not squeezed or kinked after the approximation of the sternum edges. Also bi-cortically placed screws may represent a potential risk in the region of underlying bypasses where the tip of the screw may damage the graft. If there are doubts, the screws should only be placed mono-cortically in the region where bypass grafts are expected.
With more experiences in this technique, the used material in form of the number and length of the plates, as well as the screws, can be certainly optimized. After frequent applications, the time of the procedure could be decreased.
The technique of transverse plate fixation broadens the spectrum for closure of complicated sternal wound infections or dehiscence by cardiac surgeons.
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  L. S. Levin, A. S. Miller, A. H. Gajjar, K. D. Bremer, J. Spann, C. A. Milano, and D. Erdmann An Innovative Approach for Sternal Closure Ann. Thorac. Surg., June 1, 2010; 89(6): 1995 - 1999. [Abstract] [Full Text] [PDF]
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V. S. Avlonitis, V. Shrivastava, J. Wallis, S. Hunter, A. Goodwin, A. Owens, and S. Kendall Thermoreactive Clips for Sternotomy Closure in Sternal Dehiscence Ann. Thorac. Surg., June 1, 2008; 85(6): 2164 - 2165. [Full Text] [PDF]
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A. Plass, J. Grunenfelder, I. Guber, and M. Genoni Reply. Ann. Thorac. Surg., June 1, 2008; 85(6): 2165 - 2165. [Full Text] [PDF]
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