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Ann Thorac Surg 2008;86:1897-1904. doi:10.1016/j.athoracsur.2008.08.071
© 2008 The Society of Thoracic Surgeons
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Christoph Schimmer
Wilko Reents
Peter Eigel
Hans Scheld
Brigitte Gansera
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Rainer Leyh
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Original Articles: Adult Cardiac

Prevention of Sternal Dehiscence and Infection in High-Risk Patients: A Prospective Randomized Multicenter Trial

Christoph Schimmer, MDa,*, Wilko Reents, MDa, Silvia Berneder, MDb, Peter Eigel, MDb, Oemer Sezer, MDc, Hans Scheld, MDc, Kerim Sahraouid, Brigitte Gansera, MDd, Oliver Deppert, MDe, Alvaro Rubiof, Richard Feyrer, MBAf, Cathrin Sauerg, Olaf Elert, MDa, Rainer Leyh, MDa

a Universitätsklinik Würzburg, Klinik für Thorax-, Herz- und Thorakale Gefäbchirurgie, Würzburg, Germany
b Klinikum Passau, Klinik für Herzchirurgie, Passau, Germany
c Universitätsklinik Münster, Klinik und Poliklinik für Thorax-, Herz- und Gefäbchirurgie, Münster, Germany
d Städt. Klinikum München GmbH, Klinikum Bogenhausen, Abteilung für Herzchirurgie, München, Germany
e Zentralklinik Bad Berka GmbH, Klinik für Herzchirurgie, Bad Berka, Germany
f Universitätsklinikum Erlangen, Herzchirurgische Klinik, Erlangen, Germany
g Center of Clinical Trial Würzburg (ZKSW), Würzburg, Germany

Accepted for publication August 1, 2008.

* Address correspondence to Dr Schimmer, Universität Würzburg, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäbchirurgie, Oberdürrbacherstrabe 6, Wurzburg, 97080, Germany (Email: schimmer_c{at}klinik.uni-wuerzburg.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: One factor for the development of sternal wound infection (SWI) is bony instability after sternotomy. This study compares two surgical techniques with respect to the occurrence of SWI in patients with an increased risk.

Methods: In this multicenter study, 815 consecutive patients with an increased risk for SWI were prospectively randomly assigned to a conventional osteosynthesis (transsternal or peristernal wiring; n = 440) or to an osteosynthesis with additional lateral reinforcement (Robicsek; n = 375). Primary endpoints were the rate of sternal dehiscence as well as the occurrence of superficial sternal wound infections and deep sternal wound infections.

Results: Both groups were comparable concerning preoperative and intraoperative variables. The rate of sternal dehiscence, superficial sternal wound infections, and deep sternal wound infections (conventional technique 2.5%, 3.4%, 2.5%; and Robicsek 3.7%, 5.6%, 3.7%) did not differ between the groups. Logistic regression analysis found independent risk factors for the development of sternal dehiscence: body mass indes greater than 30 kg/m2 (odds ratio [OR]: 2.9; p = 0.05), New York Heart Association class more than III (OR: 2.4; p = 0.07), impaired renal function (OR: 3.9; p = 0.01), peripheral arterial disease (OR: 3.6; p = 0.001), immunosuppressant state (OR: 3.3; p = 0.001), sternal closure performed by an assistant doctor (OR: 2.5, p = 0.004), postoperative bleeding (OR: 4.2; p = 0.03), transfusion of more than 5 red blood units (OR: 3.7, p = 0.01), reexploration for bleeding (OR: 6.9, p = 0.001), and postoperative delirium (OR: 3.5, p = 0.01). There was an inverse relation between the numbers of wires and DSWI in patients with conventional sternal closure (p = 0.008).

Conclusions: In patients with an increased risk for sternal instability and wound infection after cardiac surgery, sternal reinforcement according to the technique described by Robicsek did not reduce this complication.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
In cardiac surgery, the most commonly used approach to the heart is the median sternotomy. The incidence of sternal wound complications such as sternal dehiscence or superficial sternal wound infections (SSWI), or deep sternal wound infections (DSWI) range from 0.3% [1] to 8% [2]. Sternal wound complications result in increased morbidity and mortality, reaching 10% to 40% [3]. The only cohesive force acting upon the reunited sternum in the initial early postoperative period is the holding power of the sternal sutures. This holding power is determined by several factors: strength, number and location of the sutures, tightness, and applied stress exerted. The counterforce's invoking sternal disruption includes the action of the respiratory muscles and the negative intrathoracic pressures associated with the volume of normal respiration. Vigorous coughing can exacerbate this process [4]. Tight fixation and sufficient blood circulation are the essential factors for a successful healing. Prior studies have identified risk factors for the development of sternal dehiscence and infection (Table 1).


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  		Table 1 Preoperative and Intraoperative Risk Factors for Sternal Dehiscence and Subsequent Deep Sternal Wound Infection
 
There is a direct relation between sternal dehiscence and the development of sternal wound infection [4]. Given the assumption that surgical technique is a key component for the prevention of sternal dehiscence, we hypothesized that in patients with an increased risk for sternal dehiscence and sternal wound infection, a reinforced osteosynthesis—like the technique described by Robicsek—could reduce the rate of sternal wound complications.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
Between January 2006 and August 2007, all patients undergoing cardiac surgery at six German cardiac surgical departments were included if they had an increased risk for sternal wound complications (Table 2). At least one criterion had to be met to be included in the trial.


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  		Table 2 Inclusion Criteria
 
Exclusion criteria were urgent operations precluding informed consent, nonmidline sternotomy, transverse fracture from the sternal retractor, and age less than 18 years or missing consent. The study was approved by the local ethics committees of each participating institution (Würzburg, Passau, Bad Berka, Münster, München-Bogenhausen, and Erlangen). Randomization was done by card allocation according to a predefined randomization scheme. Patients were allocated to either a conventional osteosynthesis with transsternal or peristernal wiring (group 1, conventional treatment group) or to an osteosynthesis with lateral reinforcement (group 2, Robicsek treatment group). The primary endpoints were the incidence of sternal dehiscence requiring reosteosynthesis as well as the rate of SSWI and DSWI. The DSWI were defined according to the criteria proposed by the Centers for Disease Control as follows: (1) bacteria can be isolated from cultures of mediastinal tissue or fluid; (2) evidence of mediastinitis is seen during surgery; and (3) one of the following conditions: chest pain, sternal instability, or fever (>38°C) are present, and there is either purulent discharge from the mediastinum or bacteria can be isolated from a blood culture of drainage originating from the mediastinal area [5].

Secondary endpoints included a composite of postoperative clinical variables and in-hospital mortality related to DSWI. Baseline characteristics and perioperative variables were recorded. The technique of wound closure and disinfection protocol was regulated by the study protocol and was performed as follows: In the operating room, the skin is disinfected with polyvinylpyrrolidone (iodine solution). We changed the gloves after the disinfection and before the sternal closure. The method for wound suturing was the same for both groups, namely double-layer sutures up to the intracutaneous skin using Vicryl (Ethicon Inc, Somerville, NJ) sutures. Going from deep up to the surface, the presternal fascia was closed with 1-0 Vicryl sutures in a continuous type. The subcutaneous tissue was closed with 0 Vicryl sutures in a single knot type, and the skin was closed with 3-0 Vicryl sutures in continuous stitches. All patients received prophylactic antibiotic treatment with a second-generation cephalosporin for 48 hours postoperatively adapted to individual weight.

Group 1 conventional treatment group
The conventional closure of the sternum was defined as six or more sutures passed transsternally or peristernally. Transsternal sutures passed approximately 1 cm on each side. Peristernal wires reinforce the lateral table of the sternum, permitting tighter closure with less likelihood of the wires cutting through. The suture wires were then crossed, pulled, and twisted. Care was taken that knotting only occurs at the point where desired, and is not tied under tension. The surplus wire was cut so that the remaining twisted ends of the sutures were bent to lie flat over the sternum [1]. No figure-of-eight or other techniques were used, only single sutures. In every patient, six or more steel wires were used according the axiom "one wire per 10 kg body weight."

Group 2 robicsek treatment group
The method consists of placing continuous, heavy atraumatic wire sutures parasternally on both sides. The suture begins at the upper end of the sternum and is passed alternating anteriorly and posteriorly to the costal cartilages down to the xiphoid process. The suturing is then reversed and led in the cranial direction, passing the cartilages posteriorly where it had been anterior and vice versa. At the upper end of the first rib, the two ends of the suture are then tied together. After the two sides of the sternum are so reinforced, a number of peristernal sutures are passed and tied in the usual manner. Attention was given to pass these sutures laterally to the parasternal continuous sutures but still medial enough to avoid the injury of the mammary vessels [6].

Statistical Analysis
The SPSS statistical software package 15.0 for Windows (SPSS Inc, Chicago, IL) was used. The continuous and normally distributed data are presented as means ± SD. Categorial data were expressed as percentages. Univariate analysis of categorical data was carried out by using the {chi}2 and Fisher exact tests for categorical variables, and unpaired t test or Mann-Whitney U test for continuous variables. Multivariate analysis was assessed with logistic regression to identify risk factors for sternal dehiscence, SSWI, and DSWI. Standard statistical tests were used to calculate odds ratio (OR) and 95% confidence interval (CI). A p value less than 0.05 was considered to indicate statistical significance.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
During the study period, 815 patients were included and prospectively randomly allocated to one of the two treatment groups. Patients were recruited at the cardiac surgical centers in Würzburg (n = 251 patients), Passau (n = 169 patients), Münster (n = 137 patients), Bad Berka (n = 102 patients), München-Bogenhausen (n = 79 patients), and Erlangen (n = 77 patients). The cardiac surgical centers in Münster, München, and Erlangen started later so fewer patients could be included at these centers. Baseline and operative data were comparable in both groups (Table 3). Both groups were well balanced except for the distribution between the sexes and the New York Heart Association (NYHA) classification.


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  		Table 3 Preoperative and Intraoperative Demographic Data
 
In all, 440 patients (54%) received a conventional osteosynthesis; and in 375 patients (46%), chest closure was done according to the Robicsek technique. Thus, no significant difference with respect to the primary endpoints was seen between the two treatment groups. Isolated sternal dehiscence without evidence of infection was observed in 26 patients, 12 patients (2.7%) in the conventional treatment group and 14 patients (3.7%) in the Robicsek treatment group (p = 0.43). Superficial sternal wound infections occurred in 36 patients, 15 patients (3.4%) in the conventional treatment group and 21 patients (5.6%) in the Robicsek treatment group (p = 0.17). Twenty-five patients suffered from DSWI, 11 patients (2.5%) in the conventional treatment group and 14 patients (3.7%) in the Robicsek treatment group (p = 0.32; Table 4).


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  		Table 4 Primary Endpoints
 
According to the secondary endpoints, there were also no differences between the two compared groups (mechanical ventilation, p = 0.95; blood loss in intensive care unit, p = 0.55; transfusions, p = 0.54, 0.87, 0.35; reexploration for bleeding, p = 0.77; postoperative delirium, p = 0.27; intensive care unit stay, p = 0.49; hospital stay, p = 0.42; mortality related to DSWI, p = 0.90). The incidence of in-hospital mortality related to DSWI was 3.0% for all patients (Table 5).


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  		Table 5 Secondary Endpoints
 
Patients with sternal dehiscence were more likely to have a body mass index greater than 30 kg/m2 (OR: 2.9; p = 0.05), NYHA class greater than III (OR: 2.4; p = 0.07), impaired renal function (OR: 3.9; p = 0.01), peripheral arterial disease (OR: 3.6; p = 0.001), immunosuppressant state (OR: 3.3; p = 0.001), sternal closure performed by an assistant doctor (OR: 2.5, p = 0.004), postoperative bleeding (OR: 4.2; p = 0.03), transfusion of more than 5 red blood units (OR: 3.7, p = 0.01), reexploration for bleeding (OR: 6.9, p = 0.001), and postoperative delirium (OR: 3.5, p = 0.01). The impact of Robicsek (p = 0.43, 0.17, 0.32) or conventional sternal closure (p = 0.11, 0.08, 0.19) reached no significant correlation on sternal dehiscence, SSWI, and DSWI, respectively (Table 6).


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  		Table 6 Univariate Analyses of Risk Factors for Sternal Dehiscence and Superficial and Deep Sternal Wound Infections
 
There was an inverse relation between the numbers of wire circlages and the rate of DSWI in the conventional treatment group; more wires were associated with a reduced incidence of DSWI (p = 0.008). Logistic regression analysis found independent risk factors for the development of sternal dehiscence. Further analysis of clinical characteristics and the occurrence of SSWI and DSWI are reported in Table 7.


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  		Table 7 Logistic Regression Analyses for Sternal Dehiscence and Superficial and Deep Sternal Wound Infections
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The key factor in preventing sternal dehiscence and infection is a stable sternal approximation. All sternal closure techniques claim to maximize sternal stability, but it is difficult to differentiate between the merits of various techniques. In 2005, a survey at all German cardiac surgical departments revealed that there was no uniform osteosynthetic method for primary sternal closure in high-risk patients. Furthermore, if the usual sternal closure technique was abandoned in patients who were supposed to be at risk for sternum instability and subsequent DSWI, the most commonly mentioned preventive technique was the sternal closure technique described by Robicsek (48 times), followed by the use of more wire cerlages (29 times) (Fig 1) [7].


Figure 1
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  		Fig 1. In a 2005 survey, osteosynthetic procedures used if the standard osteosynthesis technique was not performed were as follows: 1 = Robicsek (used 48 times), 2 = more steel/bands (29 times), 3 = bands, 4 = figure-of-eight (19 times), 5 = combination of steel and bands (10 times), 6 = PDS-sutures (8 times), 7 = double loop steel (7 times), 8 = pectoralis muscle flap (5 times), 9 = sternal plating (3 times), 10 = special clips (1 time), 11 = no bands, no Robicsek (1 time), and 12 = pioneer steel (1 time).

 
As a consequence, this prospective randomized multicenter trial was initiated to investigate the influence of the two most commonly applied surgical techniques on the rate of sternal wound complications in high-risk patients. Sternal dehiscence, wound infection, osteomyelitis, and dehiscence are related [3]. The question of whether sternal instability or infection is the primary underlying problem can not be answered with certainty. Circlage fixation under normal physiologic loads can prove to be inadequate and can lead to separation. Bacterial contamination in the face of sternal separation and instability can then progress to DSWI [8]. On the other hand, the initial instability derives from the basic mechanism of an osteomyelitis. This is the ground upon which the feared infection develops [9]. Biomechanical studies establish the anatomic features of particular closure methods. Bioengineering techniques and mathematical modeling analyze the properties of bone fixation materials and devices but these models are weak reflections of clinical events; they represent a step toward understanding the etiology of failed sternal repair, and permit direct comparison of data [10–17]. The clinical studies on sternal closure techniques and sternal dehiscence focused either on risk factors for such complications or on different surgical procedures and modifications and different materials. All these studies have in common that the lower incidence of mediastinitis in many series with improved sternal closure seemed to support the belief that wound infection is largely technique dependent [1].

The current standard for sternotomy closure remains the method of wire circlage (here defined as conventional technique). Many authors described that sternal halves fixed with wire fixation techniques have proved to be more stable biomechanically than other methods of sternal closure [8, 18]. Losanoff and colleagues [16] found in a fresh adult human cadaveric model that mechanical stability of peristernal and alternating peristernal and transsternal wires were significantly greater than pericostal and figure-of-eight closure technique. Friberg and associates [19] could prove that the use of seven or more sternal fixation wires was associated with a marked reduction in DSWI (0.4%) compared with employing six or fewer wires (4.2%; p = 0.001). The authors described growing evidence that an additional wire at the caudal sternum substantially reinforces sternal fixation and has a preventive effect on the incidence of DSWI [19]. Studies on embalmed cadavers and clinical experience suggest that, in most cases, the wire would likely cut through the bone before suture breaking or unwinding due to increased stress [20]. Depending on the amount of movement and tension placed on the point of contact, the bone will often fracture before the period of healing is complete. These considerations led to the adoption of surgical techniques in patients with an increased risk for sternal instability to decrease morbidity, mortality, and hospital costs.

The technique described by Robicsek and coworkers in 1977 has several advantages: it stabilizes the sternum if it is fragile or broken; if subsequent instability develops, it prevents the wires cutting through the bone; it changes the site of pressure and provides wider support, especially if the sternum has been mishandled with the sternum retractor. This technique changes the point of contact from metal to bone to contact of metal to metal. The disadvantage of this technique is that it produces a constrictive weave that can disrupt the collateral blood supply of the sternum, and effective approximation of the top and bottom of a gaping sternum cannot be obtained [4, 18]. In a study by Molina and colleagues [21], 123 obese patients were prospectively divided into two groups (Robicsek technique, n = 54, versus standard sternal closure, n = 69). The Robicsek technique group had no dehiscence (0%) versus the standard closure group with 6 dehiscences (8.7%) [21]. The technique described by Robicsek was modified by Sutherland and colleagues and Sharma and coworkers, who placed a line of continuous wire suture on either side of the sternum and tied both lines cranially and caudally. This technique has an added advantage over the conventional Robicsek closure in that the blood supply of the sternum is not "strangulated" by the ring formed by encircling wires around the costal cartilages by anterior and posterior longitudinal wires [10, 18]. Sharma and colleagues [18] showed in 776 high-risk patients (390 conventional closure versus 386 modified Robicsek technique) that the incidence of postoperative sternal wound complications was significantly higher, 16 patients, compared with 1 patient among patients treated with the new technique [18].

Although several methods of sternal closure have been described in literature, for example, additional steel band at the third intercostal space [22], double crisscross [23], and double wires [9]. Khasati and colleagues [24] compared on the basis of 111 papers two different sternal closure techniques (simple wire and figure-of-eight technique). The authors concluded that the figure-of-eight technique revealed no significant advantage over the simple wire technique [24]. Nowadays, many other authors described the benefits of rigid plate fixations. These authors conclude that rigid plate fixation showed a significant decrease in the incidence of postoperative mediastinitis when compared with a similar population of patients whose sternums were closed with wire [2, 8, 12, 25, 26]. Song and associates [15] described rigid plate fixation and showed a significant (p = .006) decrease in the incidence of DSWI when compared with a similar population whose sternums were closed with wire. Pai and associates [12] compared the stability provided by sternal plates with standard wires using an in vitro model, and the authors concluded that plating increased stability at the midline compared with wires. Raman and coworkers [25] used this device even in high-risk patients for primary closure of the sternum after cardiac surgery. This increased stability may facilitate recovery and reduces the substrate for bony infections. Application of this technique in high-risk patients showed a decrease in the incidence of DSWI when compared with similar patients whose sternums were closed with wire. In the wire group (n = 207), 28 patients (14.8%) had mediastinitis. In the rigid plate fixation group (n = 215), there was no mediastinitis [25], but rigid plate fixation of the sternum has not been embraced as the method of choice for primary sternal osteosynthesis for various reasons. Drilling near and around the heart, added time and expense, the difficulty of emergent reentry, and the availability of a simple and effective plating system have all been obstacles to the development and institution of proven technology to the cardiac surgical arena [8]. However, Sharma and colleagues [18] pointed out that none of the alternative techniques like titanium-H-plates, thermoactive clips, and others offers an objective advantage over steel wire encircling [18].

This multicenter trial could not demonstrate that the Robicsek technique results in less sternal dehiscence or sternal infection, nor did this technique positively influence clinical postoperative factors such as mechanical ventilation, blood loss in the intensive care unit, transfusions, reexploration for bleeding, postoperative delirium, intensive care unit stay, hospital stay, and mortality related to DSWI. It was not our intent to establish multiple preoperative, intraoperative, and postoperative risk factors associated with an increased risk for sternal wound complications; these have been done by several other authors and could even be confirmed in this study [1, 18, 27-30]. This study contains the obvious limitations of missing documentation concerning the internal mammary artery preparartion (skelletonized versus nonskelletonized). Furthermore, we only evaluated those cases of sternal dehiscence, SSWI, and DSWI identified before hospital discharge.

In conclusion, the key factor in preventing sternal dehiscence and sternal wound infection is a stable sternal approximation. Careful attention to hemostasis and meticulous surgical technique remain the mainstays of prevention and must include precise sternal alignment and stable closure. The methodologic strength of this trial is that the influence of the surgical performance in a multicenter approach leads to an obvious consideration of the individual surgical influence. Especially if a more complex technique seems theoretically to be superior (one surgeon's results), it is not able to achieve the requirements under "real life" conditions. Therefore, in this setting, we did not observe any benefit of a reinforced osteosynthesis according to the Robicsek technique in patients with an increased risk for sternal wound complications.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Losanoff JE, Jones JW, Richmann BW. Primary closure of median sternotomy: techniques and principles Cardiovasc Surg 2002;10:102-110.[Medline]
  2. Negri A, Manfredi J, Terrini 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]
  3. Shih CC, Shih CM, Su YY, Lin SJ. Potential risk of sternal wires Eur J Cardiothorac Surg 2004;25:812-818.[Abstract/Free Full Text]
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  5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee Guideline for prevention of surgical site infection Infect Control Hosp Epidemiol 1999;20:424-429.
  6. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separartion following open-heart surgery J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]
  7. Schimmer C, Reents W, Elert O. Primary closure of median sternotomy: a survey of all German surgical heart centers and a review of the literature concerning sternal closure techniques Thorac Cardiovasc Surg 2006;54:1-6.[Medline]
  8. Song DH, Lohmann 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]
  9. Kiessling AH, Isgro F, Weisse U, Möltner A, Saggau W, Boldt J. Advanced sternal closure to prevent dehiscence in obese patients Ann Thorac Surg 2005;80:1537-1539.[Abstract/Free Full Text]
  10. Losanoff JE, Collier AD, Wagner-Mann CC, et al. Biomechanical comparison of median sternotomy closures Ann Thorac Surg 2004;77:203-209.[Abstract/Free Full Text]
  11. McGregor WE, Payne M, Trumble DR, Farkas KM, Magovern JA. Improvement of sternal closure stability with reinforced steel wires Ann Thorac Surg 2003;76:1631-1634.[Abstract/Free Full Text]
  12. Pai S, Gunja NJ, Dupak EL, et al. In vitro comparison of wire and plate fixation for midline sternotomies Ann Thorac Surg 2005;80:962-968.[Abstract/Free Full Text]
  13. 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]
  14. Casha AR, Gauci M, Yang L, Saleh M, Kay PH, Cooper GJ. Fatigue testing median sternotomy closure Eur J Cardiothorac Surg 2001;19:249-253.[Abstract/Free Full Text]
  15. Cohen CDJ, Griffin LV. A biomechanical comparison of three sternotomy closure techniques Ann Thorac Surg 2002;73:563-568.[Abstract/Free Full Text]
  16. Bruhin R, Stock UA, Drücker JP, et al. Numerical simulation techniques to study the structural response of the human chest following median sternotomy Ann Thorac Surg 2005;80:623-630.[Abstract/Free Full Text]
  17. Jutley RS, Watson MA, Shepherd DE, Hukins DW. Finite element analysis of stress around a sternum screw used to prevent sternal dehiscence after heart surgery Proc Inst Mech Eng 2002;216:315-321.
  18. 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]
  19. Friberg Ö, Dahlin LG, Söderquist B, Källman J, Svedjeholm R. Influence of more than six sternal fixation wires on the incidence of deep sternal wound infection Thorac Cardiovasc Surg 2006;54:468-473.[Medline]
  20. McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure J Thorac Surg 1999;117:1144-1150.[Abstract/Free Full Text]
  21. Molina JE, Lew RS, Hyland K. Postoperative sternal dehiscence in obese patients: incidence and preventation Ann Thorac Surg 2004;78:912-917.[Abstract/Free Full Text]
  22. Riess FC, Awwad N, Hoffmann B, et al. A steel band in addition to 8 wire circlages reduces the risk of sternal dehiscence after median sternotomy Heart Surg Forum 2004;7:387-392.[Medline]
  23. Bottio T, Rizzoli G, Vida V, Casarotta D, Gerosa G. Double crisscross sternal wiring and chest wound infections: a prospective randomized study J Thorac Cardiovasc Surg 2003;126:1352-1356.[Abstract/Free Full Text]
  24. Khasati N, Sivaprakasam R, Dunning J. Is the figure-of-eight superior to the simple wire technique for closure of the sternum? Interact Cardiovasc Thorac Surg 2004;3:191-194.[Abstract/Free Full Text]
  25. Raman J, Song DH, Bolotin G, Jeevanandam V. Sternal closure with titanium plate fixation—a paradigm shift preventing mediastinitis Interact Cardiovasc Thorac Surg 2006;5:336-339.[Abstract/Free Full Text]
  26. Cicilioni OJ, Stieg FH, Papanicolaou G. Sternal wound reconstruction with transverse plate fixation Plast Reconstr Surg 2005;115:1297-1303.[Medline]
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