Closure of median sternotomy: an overview of different sternal closure techniques

Objectives: Sternal dehiscence and subsequent mediastinitis are among the most severe complications of median sternotomy. Sternal dehiscence usually occurs when the wire cuts through the bone and causes multiple fractures of the sternum. This occurs in 0.3% to 5% of all cases and is associated with a mortality rate of 14% to 47%, especially if mediastinitis supervenes. Stabile fixation is particularly crucial in the growing population with several risk factors for sternal instability.

Methods: This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The method of sternal closure technique in conventional and risk-patients, the parameters considered as risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. Furthermore, we summarize the pros and cons of the different sternal closure techniques and their principles by concentrating on their clinical and biomechanical aspects.

Results: Conventional closure of primary sternotomy is done in multiple fashions: trans/peristernal (64%), figure-of-eight (11%), pericostal (5%), alternatives (20%). An osteoporotic or fractured sternum (70 x), and obesity (31 x) were the most often considered risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method by Robicsek.

Conclusions: There is no uniform osteosynthetic method for primary sternal closure in conventional and risk-patients; there are substantial variation in the perception of risk factors for sternal instability. There are no consensus among biomechanical studies on the optimal sternal model and the effectiveness of different methods for sternal closure.