Ann Thorac Surg 2008;86:1384-1385. doi:10.1016/j.athoracsur.2008.03.039
© 2008 The Society of Thoracic Surgeons
How To Do It
Sternal Plating to Prevent Malunion of Transverse Sternotomy in Lung Transplantation
Kimberly L. Gandy, MD, PhD*,
Michael J. Moulton, MD
Division of Cardiothoracic Surgery, University Medical Center, Tucson, Arizona
Accepted for publication March 20, 2008.
* Address correspondence to Dr Gandy, Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, 9000 W. Wisconsin Avenue, MS715, Milwaukee, WI 53226 (Email: kgandy{at}mcw.edu).
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Abstract
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Sternal malunion can be a significant cause of morbidity in double-lung transplantation when it is performed through a thoracosternotomy or clamshell incision. Some patients experience increased pain with malunion and have delayed or decreased functional recovery. We propose a method of sternal plating to decrease the incidence of sternal malunion encountered with this incision. The transverse sternotomy can be rigidly fixed with two titanium interlocking plates during chest closure, a procedure that offers the potential for timely and consistent union of the sternum. The interlocking plate configuration also affords a unique quality to this closure; a pin securing the two plates can be quickly released allowing expedient access to mediastinal structures if emergent re-entry is necessary.
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Introduction
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Sternal malunion can be a significant cause of morbidity when bilateral lung transplantation is performed through a thoracosternotomy. Patient movement places a significant amount of torque on this incision. Sternal wires can break, and one edge of the sternum can be displaced over the other. Union is delayed or prevented, and oftentimes a significant cosmetic deformity results. The cause of these malunions is multifactorial. This population of patients is often malnourished, on chronic steroid therapy, and osteopenic. In addition, current fixation techniques sometimes fail to stabilize the bony structures, preventing tissue approximation sufficient for healing. Many patients experience increased pain with malunion, which may compromise functional recovery. In an effort to avoid this problem, some centers have resorted to performing bilateral thoracotomies without the sternotomy [1]. Despite recent innovative technical modifications [2], exposure through this approach can be compromised, especially if bypass is necessary.
Multiple closure techniques have been developed [3–5]. We report a method of sternal approximation that has uniformly promoted sternal union in a small high-risk group of patients with no noted complications. In addition, it affords the potential for rapid re-entry into the chest if the clinical need arises.
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Technique
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Three patients underwent bilateral lung transplantation with the use of the Synthes Titanium Sternal Fixation System (Synthes, Westchester, PA) for sternal reapproximation (Fig 1). All patients were considered high risk for sternal dehiscence; 1 patient for poor nutrition and 2 for chronic steroid use. The patient that underwent primary transplantation had cystic fibrosis and was nutritionally compromised. The other 2 patients had previously undergone single-lung transplantation through posterolateral thoracotomies and had been treated with steroids prior to the redo lung transplantation.
Each Synthes 12-hole titanium sternal plate (Synthes) is composed of two separable components that interlock and are secured with an emergency release pin. The pin can be easily removed, allowing the components to be quickly separated. At the time of chest closure, pericostal sutures were placed in the standard fashion. The sternum was then cleared of subcutaneous tissue for an area 3 cm above and 3 cm below the transverse sternotomy. The space that the plates were to span was measured, and the plates were cut to the appropriate lengths with a plate and rod cutter. The two plates were positioned in a vertical fashion across the sternotomy, approximately 0.5 to 1 cm apart (Fig 2). The plates were positioned such that the release pins were located laterally. The superior component of the plate was positioned to overlay the superior sternum, and the inferior component to overlay the inferior sternum, the plate being implanted with the components in the interlocking position. A bending template was used to mold the plate to the contour of the sternum. The depth of the sternum was assessed with a depth gauge; the superior and inferior edges of the sternotomy assessed separately since the depths could differ. This data was used to select the appropriate drill bit to pierce the anterior and posterior tables of the sternum. Space was left laterally so that a finger could be placed behind the sternum to assure no portion of the device protruded beyond the posterior plate of the sternum. At times, a sternal wire was placed to facilitate approximation of the sternum while the plates were being secured. Alternatively, rib approximators or the Synthes Reduction Forceps were used to facilitate sternal approximation during plate placement. After the holes were drilled in the sternum, the depth of the sternum at the regions of the holes was reassessed. Synthes 3.0-mm titanium locking screws (Synthes) of the appropriate length were chosen, 2 to 3 mm of depth being added to the measured depth of the sternum to account for the heights of the plates. The first screws to be secured were those immediately above and below the sternotomy. A finger was placed behind the sternum after the screws were secured to assure that no screw pierced the posterior sternal table. An effort was made during closure to cover the plates with both skin and subcutaneous tissue.
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Fig 2. A gross picture of a redo transsternal thoracotomy incision at the time of closure with two titanium plates.
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Comment
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Sternal malunion after a thoracosternotomy is a significant problem, and multiple closure methods have been proposed as a solution. We propose this method of rigid sternal fixation for its strength and flexibility, and for the rapid access it allows to cardiopulmonary structures. Rigid fixation of the sternum has been shown to be effective in closure of the high-risk median sternotomy [6–9]. We propose that this method can be equally effective in reducing sternal dehiscence of the high-risk thoracosternotomy.
The proposed method of closure has a unique feature that distinguishes it from other similarly used closure systems. It allows expedient access to mediastinal structures in the event of an emergency. The release pin of the Synthes system is removed at the time of re-exploration, and a new pin is placed at the time of re-closure. In the method of closure described, the pin does not extend beyond the depth of the posterior plate of the sternum. The drill and screw gauging system permits complete penetration of the posterior table while preventing the screws from extending beyond the posterior border.
Addition of the plates does add to the operative time and cost of the procedure. It may take between 15 to 30 minutes for placement of the plates and may add an additional 5% to the cost of the total procedure. However, we propose that in light of the discomfort and disappointment associated with sternal malunion for our patients, the benefits obtained with these fixation plates compensate for the additional operative time and cost.
The 3 patients who underwent sternal fixation after lung transplantation with this technique have had timely sternal union in the appropriate plane. No patients have noted increased pain in the region of the sternal plate. Discomfort with the incision has decreased, and there have been minimal complaints of sternal pain. There have been no infections in these devices. Use of a Synthes Titanium Sternal Fixation System can aid sternal closure and possibly decrease morbidity associated with sternal malunion.
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Acknowledgments
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The authors wish to acknowledge Brian Bertram and Brendan Huck of Synthes for their aid in developing the technique for placement of these devices; Orazio Amabile, MD and Quan Vo, MD for assistance in these cases; Steve Knoper, MD, Joan Wild, MT, Romana Coelho Anderson, RN, and Martha Moutray, LMSW for their unwavering and excellent care of these patients; and Martha Moutray for careful editing of the manuscript.
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References
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- Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications J Thorac Cardiovasc Surg 1999;117:358-364.[Abstract/Free Full Text]
- Lau CL, Hoganson DM, Meyers BF, Damiano Jr RJ, Patterson GA. Use of an apical heart suction device for exposure in lung transplantation Ann Thorac Surg 2006;81:1524-1525.[Abstract/Free Full Text]
- Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision J Thorac Cardiovasc Surg 1996;112:137-141.[Abstract/Free Full Text]
- McGiffin DC, Alonso JE, Zorn Jr GL, et al. Sternal approximation for bilateral anterolateral transsternal thoracotomy for lung transplantation Ann Thorac Surg 2005;79:e19-e20.[Abstract/Free Full Text]
- Oto T, Venkatachalam R, Morsi YS, et al. A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: from biomechanical test to clinical application J Thorac Cardiovasc Surg 2007;134:218-224.[Abstract/Free Full Text]
- Song DH, Lohman RF, Renucci JD, Jeevanandam V, Raman J. Primary sternal plating in high-risk patients prevents mediastinitis Eur J Cardiothorac Surg 2004;26:367-372.[Abstract/Free Full Text]
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Abstract
Introduction
