Primary Closure of Median Sternotomy: Techniques and Principles

Abstract

Understanding the biomechanics of midline sternotomy repair is important to successful surgical outcome. High-risk patients, particularly those with immunosuppression, diabetes, and osteoporosis, should be identified. Details of technique should be monitored, and closure should incorporate lateral support of the sternum in patients at risk. Sternal dehiscence can occur under physiologic loads. Closure techniques and materials should insure stable repair, with avoidance of material migration through the bone.

A new cable-tie-based sternal closure device: infectious considerations†

“…We performed a retrospective descriptive and comparative study at the University Hospital Basel, Switzerland with the objective of assessing the frequency of wound infection and sternal dehiscence post-sternotomy with regard to the closure technique itself. At our institution, sternotomies are usually closed with five stainless steel wires placed trans-sternally in a figure-of-eight interrupted transverse fashion [6]. Two senior surgeons started to use the sternal ZF closing device in February 2011.…”

“…Nosocomial wound infections after sternotomy are a multifactorial and complex problem, and risk factors for the development of infections have been emphasized by several authors [4,5]. Sternal dehiscence has been discussed for years to be a reason for infection [6] that can be potentially prevented using sternal ZF that surrounds the sternum through the intercostal space, providing a larger implant-to-bone contact and avoiding bone cut-through especially in patients at risk [7]. We report our clinical experience and the possible related infectious considerations of the cable-tie-based device.…”

Biomechanical comparison of canine median sternotomy closure using suture tape and orthopedic wire cerclage

“…[2][3][4][5] Postoperative complications reported include pain, lameness, seroma formation, infection, dehiscence, draining tracts, perforated internal thoracic artery, osteomyelitis, sternal fracture, and implant failure. [2][3][4]6 In human medicine, adequate reduction and stabilization of the median sternotomy site are imperative to avoid complications related to instability, such as pain, incisional dehiscence, and implant failure. [7][8][9][10] Clinical research supports rigid fixation for sternotomy closures in people using plates and screws 11,12 but sternal plate fixation is not currently possible in veterinary medicine due to lack of optimized available implants.…”

“…A high rate of postoperative complications, reported to be between 14% and 78%, has led to investigation of various methods of surgical closure 2–5 . Postoperative complications reported include pain, lameness, seroma formation, infection, dehiscence, draining tracts, perforated internal thoracic artery, osteomyelitis, sternal fracture, and implant failure 2–4,6 . In human medicine, adequate reduction and stabilization of the median sternotomy site are imperative to avoid complications related to instability, such as pain, incisional dehiscence, and implant failure 7–10 .…”

Morphometry of The Sternum in Osteosynthetic Reconstruction

“…Common indications for sternal reconstruction are fractures due to thoracic trauma, congenital sternal cleft and median sternotomy in the context of cardiothoracic surgery [1,2] Various methods for sternal reconstruction and closure after median sternotomy have been developed and are available in clinical use -with the most common being the application of wire cerclage and titanium plates [3]. Anatomically, the adult sternum is divided into three parts [4,5] the manubrium ("handle") with the incisures for clavicula and the 1st rib, the corpus or gladiolus with the incisures of the 3rd to 6th rib and the processus xiphoideus ("swordlike"). The three parts are separated by cartilage zones: at the symphysis manubriosternalis (angulus sterni, "Angle of Louis") articulates the 2nd rib; at the symphysis xiphosternalis articulates the 7th rib involving both connected bone parts (see also Figure 1).…”