Abstract
Background: Sternal instability and mediastinitis are rare but serious complications following cardiac surgery with median sternotomy. Methods: This study presents the results of a questionnaire, which was sent to all 79 German surgical heart centers. The conventional sternal closure technique, the parameters considered to be risk factors for sternal instability, and the surgical strategy in the presence of risk factors were determined. In addition, a literature research with the key words “sternal closure technique” and “sternal dehiscence” was performed. Results: Conventional closure of primary sternotomy is done using many different methods, most often with surgical steel sutures (87 %) passed trans/peristernally (64 %). An osteoporotic or fractured sternum (70 ×), and obesity (31 ×) were the most frequently cited risk factors. The preferred osteosynthetic procedure for patients with an increased risk for sternal instability was the method of Robicsek (48 ×). Conclusion: There is no uniform osteosynthetic method for primary sternal closure and there is substantial variation in the perception of risk factors for sternal instability and possible surgical consequences among the surgical heart centers in Germany.
Key words
Sternal instability - mediastinitis - risk patient - Robicsek sternal closure
References
1
Losanoff J E, Collier A D, Wagner-Mann C C, Richmann B W, Huff H, Hsieh F, Diaz-Arias A, Jones J W.
Biomechanical comparison of median sternotomy closures.
Ann Thorac Surg.
2004;
77
203-209
2
Negri A, Manfredi J, Terrini A, Rodella G, Bisleri G, El Quarra S, Muneretto C.
Prospective evaluation of a new sternal closure method with thermoreactive clips.
Eur J Cardiothorac Surg.
2002;
22
571-575
3
Robicsek F, Fokin A, Cook J, Bhatia D.
Sternal instability after midline sternotomy.
Thorac Cardiov Surg.
2000;
48
1-8
4
McGregor W E, Payne M, Trumble D R, Farkas K M, Magovern J A.
Improvement of sternal closure stability with reinforced steel wires.
Ann Thorac Surg.
2003;
76
1631-1634
5
Pai S, Gunja N J, Dupak E L, McMahon N L, Roth T P, Lalikos J F, Dunn R M, Francalancia N, Pins G D, Billiar K L.
In vitro comparison of wire and plate fixation for midline sternotomies.
Ann Thorac Surg.
2005;
80
962-968
6
Losanoff J E, Jones J W, Richmann B W.
Primary closure of median sternotomy: techniques and principles.
Cardiovasc Surg.
2002;
2
102-110
7
Fowler V G, O'Brien S M, Muhlbaier L H, Corey G R, Ferguson T B, Peterson E D.
Clinical predictors of major infections after cardiac surgery.
Circul.
2005;
112
358-365
8
Casha A R, Yang L, Kay P H, Saleh M, Cooper G J.
A biomechanical study of median sternotomy closure technique.
Eur J Cardiothorac Surg.
1999;
15
365-369
9
Casha A R, Gauci M, Yang L, Saleh M, Kay P H, Cooper G J.
Fatigue testing median sternotomy closure.
Eur J Cardiothorac Surg.
2001;
19
249-253
10
Cohen C DJ, Griffin L V.
A Biomechanical comparison of three sternotomy closure techniques.
Ann Thorac Surg.
2002;
73
563-568
11
Bruhin R, Stock U A, Drücker J P, Azhari T, Wippermann J, Albes M A, Hintze D, Eckardt S, Könke C, Wahlers T.
Numerical simulation techniques to study the structural response of the human chest following median sternotomy.
Ann Thorac Surg.
2005;
80
623-630
12
Jutley R S, Watson M A, Shepherd D E, Hukins D W.
Finite element analyses of stress around a sternum screw used to prevent sternal dehiscence after heart surgery.
Proc Inst Mech Eng.
2002;
216
315-321
13
Sharma R, Puri D, Panigrahi B P, Virdi I S.
A modified parasternal wire technique for prevention and treatment of sternal dehiscence.
Ann Thorac Surg.
2004;
77
210-213
14
Molina J E, Lew R S, Hyland K.
Postoperative sternal dehiscence in obese patients: incidence and preventation.
Ann Thorac Surg.
2004;
78
912-917
15
Song D H, Lohmann R F, Renucci J D, Jeevanandam V, Raman J.
Primary sternal plating in high-risk patients prevents mediastinitis.
Eur J Cardiothorac Surg.
2004;
26
367-372
16
Riess F C, Awwad N, Hoffmann B, Bader R, Helmold H Y, Loewer C, Riess A G, Bleese N.
A steel band in addition to 8 wire cerclages reduces the risk of sternal dehiscence after median sternotomy.
Heart Surg Forum.
2004;
7
387-392
17
Bottio T, Rizzoli G, Vida V, Casarotta D, Gerosa G.
Double crisscross sternal wiring and chest wound infections: a prospective randomised study.
J Thorac Cardiovasc Surg.
2003;
126
1352-1356
18
Kiessling A H, 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
19
Khasati N, Sivaprakasam R, Dunning J.
Is the figure-of-eight superior to the simple wire technique for closure of the sternum?.
Interactive Cardiovasc Thorac Surg.
2004;
3
191-194
20
Peivani A A, Kasper-König W, Quinkenstein E, Loos A H, Dahm M.
Risk factors influencing the outcome after surgical treatment of complicated deep sternal wound complications.
J Cardiovasc Surg.
2001;
42
601-603
Dr. Christoph Schimmer
Klinik und Poliklinik für Herz-, und Thoraxchirurgie der Universität Würzburg
Oberdürrbacher Straße 6
97080 Würzburg
Germany
Phone: + 49 9 31 20 13 30 01
Fax: + 49 9 31 20 13 30 09
Email: schimmer_c@klinik.uni-wuerzburg.de