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Correspondence

Reply

Clinic for Cardiovascular Surgery, University Hospital Zurich Rämistr. 100, Zurich 8091, Switzerland

(Email: andre.plass{at}usz.ch).

To the Editor:

Dr Plass discloses a financial relationship with Synthes.

 

We read with interest the letter by Avlonitis and colleagues [1] and have to bring different comments into this discussion.

We did not mean that plate osteosynthesis is a simple technique, because there is no need for retrosternal dissection. The handling and the principle of the plate system is easy to learn, although it has to be used very carefully because serious injury to the heart and the lungs is possible [2]. However, the fact that no dissection retrosternally is necessary represents a huge advantage compared with other sternal closure systems currently available, including the thermoreactive clips. In this operative technique the required dissection and lifting of both pectoral muscles is the reason for the most frequent complications like seromas and bleeding.

However, it can be kept minimal depending of the bone quality and also the experience of the surgeon in this technique. The tendency is clearly to shorter plates and less soft tissue dissection as possible.

We used the thermoactive clips in 3 patients instead of the stainless steel wires in clinical routine. The patients showed no special risk factors for complicated sternal healing. One of these 3 patients showed a complication where the left sided parts of the clips completely tore out and ripped through the bone of the left sternal halve.

The question is the indication. The authors mentioned that they used these thermoactive clips for sternal dehiscence. Not only the dehiscence but also the bone quality of the sternum is important (especially in strong osteoporosis or multiple fractures). Certainly the contact surface of the clips is larger compared to the wires [3], but this is still not enough for complete stabilization. The efficacy of the clips is reduced due to the fact that they can not be placed complete circumferentially around the sternal body, which enhances the danger for shifting of the clips. With the sternal plates "bridging" over missing bones structures is only possible with this technique. In addition the presence of retrosternal adhesions is important. There is no information as to how many days postoperatively the second closure with thermoactive clips was performed. In 6 patients, the dehiscence was due to deep sternal infection. Because of that it can be assumed that the primary surgery was only a few days before and the substernal adhesions were only minimal. In addition, it is important which kind of surgery the patients received: coronary bypass grafting or valve surgery. The thermoactive clips partially encompass the sternal body. If strong adhesions are present, the efficacy of clips could be reduced and the insertion of the clips can cause serious retrosternal bleeding if bypass grafts are injured or adhesions are impaired. In case of sternal pseudarthrosis we already treated 7 patients with plate osteosynthesis where quite strong forces were necessary to approximate and stabilize both sternal halves. We do not believe that thermoreactive clips are able to develop the necessary force in these cases.

However, the thermoreactive clips may be used in patients with a normal sternum or in patients with slight osteoporosis and dehiscence, or both, where stainless steel wires are normally used. An advantage of this technique might be the timesaving aspect wires and more gentle handling of the sternal bone compared with installation of the sternal plates. On the other hand, the cost factor will eventually influence the decision against the clips because they are significantly more expensive then steel wires. However, sternal plate osteosynthesis is the most expensive closure material.

In our opinion, there is no comparison between the thermoreactive clips and the sternal plates, because the indication to best treat sternal complications are different for both closure techniques.

	References

Top References

 

1. Avlonitis VS, Shrivastava V, Wallis J, et al. Thermoreactive clips for sternotomy closure in sternal dehiscence Ann Thorac Surg 2008;85:2164-2165(letter).[Free Full Text]
2. Plass A, Grunenfelder J, Reuthebuch O, et al. New transverse plate fixation system for complicated sternal wound infection after median sternotomy Ann Thorac Surg 2007;83:1210-1212.[Abstract/Free Full Text]
3. Negri A, Manfredi J, Terini A, et al. Prospective evaluation of a new sternal closure method with thermoreactive clips Eur J Cardiothorac Surg 2002;22:571-575.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jurg Grunenfelder Michele Genoni Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Plass, A. Articles by Genoni, M. Search for Related Content PubMed Articles by Plass, A. Articles by Genoni, M. Related Collections Chest wall Related Article