Clinical studies of bioabsorbable poly-L-lactide sternal coaptation pins.

BACKGROUND: Median sternotomy has become the most commonly used incision in cardiac surgery. Since sternal dehiscence, however, is a major complication, we used bioabsorbable poly-L-lactide (P-L-LA) sternal coaptation pins for sternal closure to prevent it. METHODS: From February 1998 to October 1999, 99 patients (64 men, 35 women; mean age, 63+/-1.2 years) underwent median sternotomy for cardiac surgery using sternal coaptation pins. Nineteen patients had diabetes mellitus and seven had renal failure. In closure, two sternal pins were inserted into the bone marrow of the sternum, one into the manubrium, the other into the body, and the sternum was sutured with five stainless steel wires. RESULTS: Five patients died in the hospital. The causes of death were cardiac failure in two patients, respiratory problem in two and perforation of the stomach in one. The average length of hospitalization was 2 4.5+/-2.5 days. Sternal dehiscence occurred in one patient and mediastinitis in four. There was no bleeding from the bone marrow and no complication related to the use of the sternal pins. CONCLUSIONS: P-L-LA sternal pins were easy to insert and may be effective in preventing dehiscence of the sternum.     

Postoperative median sternotomy dehiscence

An analysis of the records of 2130 patients who consecutively underwent median sternotomy with or without cardiopulmonary bypass showed that sternal insufficiency necessitating refixation of the sternal plates developed in 12 patients (0.56%). This complication arose during the initial hospital stay in 11 patients, but in one patient the sternal instability appeared about a year after the operation. Re-exploration showed interruption of the stainless steel wires in six cases. In the other cases the wires had loosened, or knots had opened, or wires had cut through the sternal bone. All 12 patients had undergone open-heart surgery. The commonest risk factors for sternotomy dehiscence were excessive blood loss with heavy transfusion requirements, and postoperative wound infections. Other factors were respiratory complications and postoperative ventilatory support, low cardiac output syndrome, chronic obstructive pulmonary disease and obesity. Careful closure of the sternum, using figure-of-eight sutures if necessary, and avoidance of excessive application of bone wax are important for preventing this harmful complication.     

Polydioxanone sternal sutures for prevention of sternal dehiscence

BACKGROUND: Sternal dehiscence and wound instability are troublesome complications following median sternotomy. Classic sternal approximation with stainless steel wires may not be the ideal approach in patients predisposed to these complications. We tested the efficacy of polydioxanone (PDS) suture in sternal closure and in prevention of complications in comparison to steel wires in high-risk individuals. METHODS: Three hundred sixty-six patients undergoing elective cardiac surgery with full median sternotomy and having body surface area (BSA) less than 1.5 m(2) were randomly assigned to receive PDS (n = 181) or stainless steel (SS, n = 185) sternal approximation. The study was focused on aseptic sternal complications, namely bone dehiscence and superficial wound instability. RESULTS: Both bone dehiscence and superficial wound instability were less frequent in the PDS Group (4 and 3 cases in the SS Group, respectively, vs. no cases in the PDS Group). Cox proportional hazards regression model in the whole study population identified female sex, chronic renal insufficiency, diabetes, advanced age, lower sternal thickness, osteoporosis, corticosteroid therapy, and prolonged CPB or ventilation times as predisposing factors to any of the two studied sternal complications. DISCUSSION: Data suggest that PDS suture can protect against development of aseptic sternal complications following median sternotomy in high-risk patients with little body mass. The adoption of PDS in other subsets of patients, i.e., obese individuals, is to be questioned.     

A bioresorbable osteosynthesis device can induce an earlier sternal fusion after median sternotomy

OBJECTIVES We examined the impact of the bioresorbable osteosynthesis sternal pin (Super Fixsorb 30) on sternal healing after median sternotomy. METHODS Sixty-three patients who underwent aortic surgery through median sternotomy between January 2006 and March 2009 were analysed. Sternal pins were utilized in 36 patients in addition to the standard closure of the sternum with Ethibond sutures (Group A), and 27 patients received no pins with the standard Ethibond sternal closure (Group B). The occurrence of transverse sternal dehiscence, anterior-posterior displacement and complete fusion of the sternum were evaluated by a computed tomography scan. The cross-sectional cortical bone density area (CBDA) of the sternum was examined to evaluate the osteoconductivity of the sternal pin over a 12-month period. RESULTS There was no sternal displacement (0%) observed in Group A at discharge. Meanwhile, five displacements (18.5%) were observed in Group B (P?=?0.007). The complete sternal fusion rates at 12 months postoperatively were 100% in Group A, and 21.6% in Group B (P?相似文献   

Pericostal Sutures to Reinforce Sternal Closure After Cardiac Surgery

A bstract Background and Aim of the Study : An increasing number of elderly and medically complex patients are undergoing cardiac surgery and are at increased risk for sternal dehiscence. A technique of sternal closure reinforcement with pericostal wires is described, and results are reviewed. Methods : After placement of the standard peristernal wires, one or two sets of pericostal wires were placed around ribs in the mid-portion of the sternotomy to reinforce the closure. A retrospective study over a 6-year period was carried out to determine the incidence of sternal dehiscence and any associated complications. Pericostal wires were used in well over 50% of cases. Results : The incidence of sternal dehiscence was 4 out of 1048 operations (0.38%). No adverse effects of the pericostal wires were identified. Conclusions : Frequent use of pericostal wires is associated with a low incidence of sternal dehiscence.     

A modified parasternal wire technique for prevention and treatment of sternal dehiscence

Background

Sternal dehiscence with or without mediastinitis is a devastating complication of median sternotomy. Various techniques of sternotomy closure including ‘figure of eight’ wire sutures, nylon bands, and custom-made titanium-H plates have been described. We have devised and tested a new method of sternal closure to prevent sternal wound complications in patients at high risk of sternal dehiscence.

Methods

1336 patients underwent sternotomy for various cardiac operations from January 1996 to January 2002. Patients were divided into two groups. Group I consisted of 560 patients who did not have any high risk factors for sternal dehiscence and received a standard six wire closure. Group II comprised of patients at high risk of sternal dehiscence and were divided randomly into subgroup II A (n = 390), which included patients who had conventional sternal closure. While in subgroup II B (n = 386) patients had a modified parasternal wire closure according to the finalized protocol.

Results

Sternal instability was noticed in 1/560 and none had sternal dehiscence in group I, but 16/390 patients had sternal instability and 3/390 had sternal dehiscence in subgroup II A, whereas only one patient in high risk subgroup II B developed sternal dehiscence with mediastinitis and required a pectoral flap advancement for sternal closure.

Conclusions

Use of modified parasternal wire closure in patients with a high risk of sternal dehiscence is a safe, effective, technically easily reproducible, as well as economical, method of preventing and treating sternal dehiscence.     

New transverse plate fixation system for complicated sternal wound infection after median sternotomy

Wire fixation after median sternotomy is a safe procedure, but it is still associated with potential wound infection including bony dehiscence. In case of infection and dehiscence the sternum is re-fixated with steel wires. If this is insufficient, then flap reconstruction would be another option. We describe an alternative way for complicated sternal closure by using a rigid sternal fixation system that is feasible for cardiac surgeons. Three patients suffering from sternal instability and infection were operated on with the new titanium plates. The procedures were uneventful and short-term follow-up showed stable sternal conditions. In this report the technical concept has been described in detail in 1 patient. This new sternal fixation technique is safe and easy to handle and broadens the spectrum for closure of complicated sternal wound infections or dehiscence.     

Technique of closure of median sternotomy with trans-sternal figure-of-eight wires

A technique of closure of median sternotomy with trans-sternal figure-of-eight wires is described. This method has the advantages of very stable sternotomy and can be performed by the surgeon without need for surgical assistance. This technique has resulted in 0.4% incidence of dehiscence and no sternal infections.     

Resuture using Shirodkar tape for sternal dehiscence after extended thymectomy via median sternotomy

Sternal dehiscence is one complication after median sternotomy. We followed a patient with sternal dehiscence for 6 months after extended thymectomy via median sternotomy. His diagnosis was myasthenia gravis without thymoma and with complicating diabetes mellitus. Sixteen days after the operation chest radiography revealed that one of six sternal wires was cut, although sternal dehiscence was not apparent. Six months after the operation, chest radiography revealed that five of six wires were cut. The patient experienced sternal dehiscence, could not cough, and felt pain at the median wound site. We implemented a resuture technique of the sternum using Shirodkar tape for postoperative sternal dehiscence. After the second operation, sternal dehiscence was not apparent. He was able to cough and had no respiratory deficiency. One year after the second operation, chest computed tomography revealed no sternal dehiscence. Shirodkar tape is extremely useful and is low in price.     

Prospective evaluation of a new sternal closure method with thermoreactive clips.

OBJECTIVES: The role of the sternal closure techniques on the incidence of sternal dehiscence and wound infection are well defined among a high number of other variables involved. In the various series, the incidence of wound complication in cardiac surgery varies from 2 to 8%. The aim of our study is to evaluate the role of thermal-dependent shape-memory Nitillium clips in reducing the incidence of sternal dehiscence following sternotomy. METHODS: We perspectively randomized 1000 consecutive patients requiring cardiac surgery to evaluate the incidence of sternal wound complications (SWC), sternal dehiscence and/or other related complications. We compared Group I (500 patients), in which sternal closure was achieved with standard sternal wires, with Group II (500 patients), in which sternal approximation was carried out by means of thermoreactive Nitillium clips. The two randomized groups were comparable in terms of age, gender, Euroscore and risk factors for sternal/wound complications. RESULTS: In our study the overall incidence of SWC was 4.7%. The incidence of SWC was considerably higher in Group I (6.8%) when compared to Group II (2.6%) (P=0.003). Mechanical sternal dehiscence without infection occurred in 14 patients in Group I and in one patient in Group II (P=0.002). Despite sternotomy wound infection occurred similarly in both groups (15 patients in Group I vs. 12 patients in Group II), sternal revision was performed only in patients of Group I (Group I: 9/15 vs. Group II: 0/12; P=0.001). CONCLUSION: Thermal shape-memory Nitillium clips provided superior results in sternal osteosynthesis following midline sternotomy, due to a considerable reduction of sternal dehiscence and related complications. The clinical benefit of Nitillium clips was demonstrated even in patients with several risk factors for SWC.     

The application of poly (L-lactide) sternal coaptation pins for median sternotomy

Poly (L-lactide) sternal coaptation pin has been developed as an assistant material for the fixation of sternum. We used the novel material to a patient who underwent median sternotomy. A 21-year-old male was suspected to have invasive thymoma in the anterior mediastinum. The median sternotomy was indicated as an approach for the resection of tumor. Tumor was completely resected and there was no invasion to sternum. For the fixation of sternum, three poly (L-lactide) sternal coaptation pins were inserted in the bone marrow of sternum and five stainless steel wires were used as conventional procedure. Sternum was adapted without slippage and no complication from the material was observed in the post-surgical period. The application of poly (L-lactide) sternal coaptation pin is a good option for ensuring the fixation of sternum.     

Definitive closure of the infected median sternotomy wound: a treatment algorithm utilizing vacuum-assisted closure followed by rigid plate fixation

Mediastinitis and sternal wound dehiscence are devastating and life-threatening complications of median sternotomy incision. Ten consecutive patients between July 2001 and May 2005 were diagnosed with sternal wound infection and dehiscence following median sternotomy. Patients were managed by precise debridement and wound excision in the operating room and then dressed with vacuum-assisted closure device. Intravenous antibiotics were prescribed for wound and blood culture microbiological sensitivity. When wounds were bacteriologically controlled, patients returned to the operating room for definitive closure using rigid sternal plating. All patients were extubated postoperatively. No patients died. Average total hospital stay was 21 days. The pectoralis advancement flap was exclusively used for soft tissue reconstruction in 7 patients. There were 2 cases of chronic superficial sternal infection requiring plate removal; however, bony union of the sternum was achieved in all patients. This treatment algorithm provides a useful management strategy for patients with complicated median sternotomy.     

Sternotomy Closure with Parham Bands

The closure of a median sternotomy incision requires secure bony approximation to prevent postoperative pain, sternal click, and/or nonunion of bone. The standard technique of sternotomy closure involves the use of stainless steel wires for reapproximation of the sternum. These wires occasionally break or pull through bone, resulting in instability of either a portion of the sternum or the entire sternum. Presented here is our technique for sternotomy closure that provides secure closure with reduced postoperative morbidity.     

Interlocking figure-of-8 closure of the sternum

Sternal dehiscence and mediastinitis are two of the most severe complications of a median sternotomy. A technique of closure is described that appears to provide a more stable sternal approximation without any increase in overall complication rate. Using this technique in 978 consecutive patients, no cases of sternal dehiscence or mediastinitis have been seen.     

Enhancing sternal closure using Kryptonite bone adhesive: technical report

A novel approach to enhance the mechanical stability of primary sternal closure is described. An osteoconductive bone adhesive is used to augment conventional wire cerclage. More than 30 patients have undergone primary sternal closure using Kryptonite bone adhesive. All patients recovered well with no adverse side effects or adhesive-associated complications. Adhesive-enhanced sternal closure may accelerate functional recovery after sternotomy, improve early outcomes and prevent major sternal complications such as deep sternal wound infection and dehiscence. The technique is simple, safe, and expedient.     

A biomechanical study of median sternotomy closure techniques.

OBJECTIVE: Sternal dehiscence is a complication of median sternotomy incisions with high mortality and morbidity. Different techniques of sternal closure have been described. Rigid fixation of the sternum results in earlier union. We measured the rigidity of sternotomy fixation using a mechanical model in order to differentiate different techniques of sternal closure using their biomechanical characteristics. METHODS: We measured the force-displacement curves of six different fixation techniques using a metal sternal model using a computerized materials-testing machine. We tested straight wires (the most commonly used surgical technique), figure-of-8 wires, 'repair' technique (used when a wire breaks), Ethibond, Sterna-band and a 'multitwist' closure described for the first time. RESULTS: At 20 kg force, twisted wires used for sternotomy closures start to untwist. The most rigid closure was a multitwist closure that displaced only 0.37 mm at a force of 20 kg. Straight wires displaced 0.78 mm, figure-of-8 wires 1.20 mm, Sterna-band 1.37 mm, repair wires 5.08 mm, Ethibond 9.37 mm. The single factor Anova test for the rigidity of the different closures had P-values <0.0001. CONCLUSIONS: We applied a mathematical model to calculate chest wall forces during coughing, in order to determine the force placed upon a sternotomy closure. We conclude that severe coughing may cause wires to untwist. We discuss potential applications of different wire closures based on their characteristics.     

Sternal wound dehiscence after internal mammary artery harvesting. Logical management. Part 2

Wound breakdown is a serious complication of median sternotomy. This is generally met with a further attempt at surgical apposition using sutures of monofilament surgical steel, following wound debridement. This often fails. The aim of this article is to demonstrate one surgeon's experience in his revised management of sternal wound dehiscence, following internal mammary artery (IMA) harvest, over a 7-year period. Treatment consisted of sternal and soft tissue debridement, and closed irrigation. Wound closure was performed using multiple interrupted deep tension sutures (DTS) only. We believe this article demonstrates that the use of DTS is a safe and effective method of closure, for patients suffering from sternal wound dehiscence following IMA harvest.     

Ten-year experience with Mersilene-reinforced sternal wound closure

BACKGROUND: We were interested in reviewing our experience with Mersilene-reinforced sternal wound closure to evaluate its overall morbidity and its impact on patient management. METHODS: We reviewed our experience with 1,039 patients undergoing median sternotomy with Mersilene-reinforced sternal wound closure over the past 10 years. Major wound complications, which were categorized into two groups, required in-hospital management and operative intervention. Group 1 had a sternal dehiscence alone. Group II had a major sternal infection or mediastinitis. RESULTS: The incidence of wound morbidity was 2.4% (n = 25). There were 6 (0.58%) sternal dehiscences (Group I) and 19 (1.8%) sternal wound infections (Group II). Patients taken to the operating room for repair of their sternal dehiscence or sternal infection were noted to have two completely intact sternal halves. CONCLUSIONS: While wound related morbidity with Mersilene tape closure is equivalent to the historical results of conventional wire closure, dehiscence occurs in a more controlled fashion with less bony destruction. The reduction in tissue damage associated with sternal wound dehiscence and sternal infection after Mersilene-reinforced sternal wound closure makes treatment of these potentially devastating complications easier and more efficient.     

Improvement of sternal closure stability with reinforced steel wires

BACKGROUND: Sternal dehiscence occurs when steel wires pull through sternal bone. This study tests the hypothesis that closure stability can be improved by jacketing sternal wires with stainless steel coils, which distribute the force exerted on the bone over a larger area. METHODS: Midline sternotomies were performed in 6 human cadavers (4 male). Two sternal closure techniques were tested: (1) approximation with six interrupted wires, and (2) the same closure technique reinforced with 3.0-mm-diameter stainless steel coils that jacket wires at the lateral and posterior aspects of the sternum. Intrathoracic pressure was increased with an inflatable rubber bladder placed beneath the anterior chest wall, and sternal separation was measured by means of sonomicrometry crystals. In each trial, intrathoracic pressure was increased until 2.0 mm of motion was detected. Differences in displacement pressures between groups were examined at 0.25-mm intervals using the paired Student's t test. RESULTS: The use of coil-reinforced closures produced significant improvement in sternal stability at all eight displacement levels examined (p < 0.03). Mean pressure required to cause displacement increased 140% (15.5 to 37.3 mm Hg) at 0.25 mm of separation, 103% (34.3 to 69.8 mm Hg) at 1.0 mm of separation, and 122% (46.8 to 103.8 mm Hg) at 2.0 mm of separation. CONCLUSIONS: Reinforcement of sternal wires with stainless steel coils substantially improves stability of sternotomy closure in a human cadaver model.     

Faulty sternotomy and complications after median sternotomy

In 11 of 55 patients with complications of median sternotomy, a paramedian sternotomy has been detected by computed tomography or at reparative operation. The thin side of the sternum is easily broken by the closing wires, this being the cause of instability and probably dehiscence and consequent infection and osteomyelitis. Most of the 11 patients in this group had some other predisposing risk factors, such as obesity, prolonged aortic cross-clamp time, and prolonged respiratory assistance. We suggest that, if a paramedian sternotomy is diagnosed at the primary operation, special closure techniques should be undertaken. Each patient with early dehiscence of a median sternotomy should undergo a computed tomographic examination. If a paramedian sternotomy is proved, simple reclosure is inadvisable. Sternectomy and closure with muscle flaps are then indicated.