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.     

Poly-lactic-acid (PLA) sternal pins for the closure of median sternotomy--report of a case]

Poly-lactic-acid (PLA) sternal pins were used for the closure of median sternotomy in a case of bilateral pneumothorax. After placement 7 sutures of polyester and 2 wires, PLA sternal pins were inserted into the bone marrow of the sternum. The wires were then twisted and tightened, and all sutures were tightened, and the wires were removed. No significant postoperative complications, i.e., osteomyelitis and mediastinitis, sternal dehiscence, or bone marrow dysfunction, were observed. In addition, the PLA sternal pins were absorbed. In the closure of median sternotomy, PLA sternal pins provide stable sternal adhesion, which is essential to the prevention of sternal dehiscence and other complications. Moreover, with the use of PLA sternal pins, the retention of steel wires in the body is unnecessary.     

Thoracic traction for median sternotomy dehiscence

Standard management of median sternotomy dehiscence sometimes fails to achieve lasting reduction and fixation of the sternal halves. An effective method of external thoracic traction that augments internal fixation of the sternal fracture is presented.     

Superficial and deep sternal wound complications: incidence, risk factors and mortality

Objectives: Sternal wound complications often have a late onset and are detected after patients are discharged from the hospital. In an effort to catch all sternal wound complications, different postdischarge surveillance methods have to be used. Together with this long-term follow-up an analysis of risk factors may help to identify patients at risk and can lead to more effective preventive and control measures. Methods: This retrospective study of 3008 adult patients who underwent consecutive cardiac surgery from January 1996 through September 1999 at Linköping University Hospital, Sweden, evaluated 42 potential risk factors by univariate analysis followed by backward stepwise multivariate logistic regression analysis. Results: Two-thirds of the 291 (9.7%) sternal wound complications that occurred were identified after discharge. Of the 291 patients, 47 (1.6%) had deep sternal infections, 50 (1.7%) had postoperative mediastinitis, and 194 (6.4%) had superficial sternal wound complications. Twenty-three variables were selected by univariate analysis (P<0.15) and included in a multivariate analysis where eight variables emerged as significant (P<0.05). Preoperative risk factors for deep sternal infections/mediastinitis were obesity, insulin-dependent diabetes, smoking, peripheral vascular disease, and high New York Heart Association score. An intraoperative risk factor was bilateral use of internal mammary arteries, and a postoperative risk factor was prolonged ventilator support. Risk factors for superficial sternal wound complications were obesity, and an age of <75 years. The 30 day mortality was 2.7% for patients without sternal wound complications and 2/291 (0.7%) for all patients with sternal wound complications, 0.5% for superficial sternal wound complications, and 1.0% for deep sternal infections/mediastinitis. The 1 year mortality rate was 4.8% for patients without sternal wound complications and 11/291 (3.8%) for patients with sternal wound complications, 2.1% for superficial sternal wound complications, and 7.2% for deep sternal infections/mediastinitis. Conclusions: The risk factors found in this study have been detected and reported in previous studies. The predictive ability was stronger though for deep sternal infections/mediastinitis (those needing surgical revisions) than for superficial sternal wound complications. Earlier recognition of sternal wound complications and aggressive treatment have probably contributed to the relatively low mortality rate seen in this study.     

Mersilene ribbon closure of the median sternotomy: an improvement over wire closure

With the increased utilization of median sternotomy in thoracic surgery, some difficulties have arisen with closure of the sternum. This article presents a simple, easy-to-perform method of sternal closure utilizing reinforcement of the sternal halves with a material that is less likely to cut through the sternum and that is readily available.     

A simple sternal turnover procedure using a vascular pedicle for a funnel chest

We have improved the sternal turnover surgical procedure by using a vascular pedicle for a funnel chest. Rather than performing a simple sternal turnover, we thought it better to use the sternum with the vascular pedicle attached, anticipating that this would lead to fewer postoperative complications and a more desirable result. The following method for performing the operation was devised: (1) cutting the deformed sternum at the second intercostal position; (2) cutting the second costal cartilages to allow a repositioning of the vascular pedicle onto the presternal surface; (3) turning the sternum over, placing one end on the other, and attaching one end to the other; and (4) making a groove in the turned-over sternum to prevent the decussated vascular pedicle from becoming constricted. By using this method, it is easily possible to keep the bilateral internal thoracic vessels intact. We used this surgical technique on a 17-year-old boy and obtained very favorable results.     

A prospective randomized study of sternal closure: comparison of Mersilene tape versus standard wire closure.

BACKGROUND: To compare in a prospective randomized study Mersilene tape and standard metal wire for complications and pain upon sternal wound closure. METHODS: Sixty-four patients scheduled for cardiac surgery were prospectively randomized to undergo sternal closure using either Mersilene tape (n=30) or standard metal wire (n=34). The intensity of postoperative pain from the chest wound was assessed using a visual analogue scale (VAS) on the second and seventh postoperative days and one month after surgery. The examinations with chest X-ray and computed tomography (CT) one month after surgery were performed to evaluate the chest wound and sternum. Follow-up data on sternal and wound healing was assessed for up to one year. RESULTS: No deaths, sternal dehiscence or infection occurred in either group. No wound complications were observed in either group during the year following surgery. A review of data revealed that there was no difference in the intensity of postoperative pain according to the VAS between the two groups. Chest CT demonstrated that no patients in either group had cuts in the sternum. CONCLUSION: This prospective randomized study showed Mersilene tape sternal closure not to be more closely associated with increased complications or patient discomfort due to sternal wound than the standard wire closure.     

Composite plate and wire fixation for complicated sternal closure

Many techniques have been described to achieve closure of complicated median sternotomy wounds. The standard method of closure uses stainless steel wiring of the sternal halves; however, in complicated sternal closures, sternal cut-through and wire failure can occur. Recent literature advocates the use of fixation plates that achieve bony union, with plating across the median sternal osteotomy site as a singular method. We describe a technique of composite closure using titanium fixation plates to buttress the sternum in combination with circumferential stainless steel wires. This composite technique has been used in 6 patients with complicated sternal closures. Successful wound closure without complication was achieved in all cases. The technique and the clinical series with an illustrative example are presented. The use of plate and wire fixation represents an alternate method to conventional techniques to achieve sternal closure, stability, and uncomplicated wound healing in these difficult-to-manage cases.     

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.     

THE “MEAT HOOK” OR “DOG CHAIN” RETRACTORS: A SIMPLE METHOD OF COSTAL MARGIN AND STERNAL ELEVATION RETRACTION

A brief history of sternal elevation retractors is given, and the authors detail their own method of sternal elevation and costal margin retraction, showing it to be an inexpensive, and a much simpler, more effective, and more efficient system than any other in use at this time.     

The number of wires for sternal closure has a significant influence on sternal complications in high-risk patients

OBJECTIVES Sternal dehiscence and mediastinitis are rare but serious complications following cardiac surgery. The aim of this study was to investigate the influence of the number of sternal wires used for chest closure on sternal complications. METHODS From May 2003 to April 2007, 4714 adult patients received cardiac surgery in our institute. X-ray images of all patients were reviewed and the used wires were counted. Patients who received another material or longitudinal wiring technique according to Robicsek for chest closure were excluded from this analysis; thus 4466 patients were included into the final analysis. Figure-of-eight wiring was counted as two wires. RESULTS Sternal complications occurred in 2.4%, and hospital mortality with or without sternal complications were 2.8 and 2.7%, respectively (P?=?0.60). Mean numbers of sternal wires were 7.8 in both patient groups with or without sternal complications (P?=?0.79). Multivariate analysis revealed diabetes mellitus [odds ratio (OR) 1.54, 95% CI 1.01-2.34, P?=?0.04], chronic obstructive pulmonary disease (OR 1.85, 95% CI 1.12-2.79, P?=?0.01) and renal insufficiency (OR 1.70, 95% CI 1.11-2.59, P?=?0.001) as significant risk factors for sternal complications. In high-risk patients, the use of less than eight wires was significantly associated with postoperative sternal complications. CONCLUSIONS Particularly in high-risk patients, careful haemostasis should be done and eight or more wires should be used to avoid sternal complications.     

Cutaneous closure after cardiac operations: a controlled, randomized, prospective comparison of intradermal versus staple closures.

OBJECTIVE: To determine the difference in wound complication and infection rates between suture and staple closure techniques applied to clean incisions in coronary bypass patients. BACKGROUND: The true incidence of postoperative wound complications, and their correlation with closure techniques, has been obscured by study designs incorporating small numbers, retrospective short follow-up, uncontrolled host factors, and narrowly defined complications. METHODS: Sternal and leg wounds were studied prospectively, each patient serving as his or her own control. Two hundred forty-two patients with sternal and saphenous vein harvest wounds had half of each wound closed with staples and the other half with intradermal sutures (484 sternal and 516 leg segments). Wound complications were defined as drainage, erythema, separation, necrosis, seroma, or infection. Infections were identified in the subset having purulent drainage, antibiotic therapy, or debridement. Wounds were examined at discharge, at 1 week after discharge, and at 3 to 4 weeks after operation. Patient preferences for closure type were assessed 3 to 4 weeks after operation. RESULTS: Neither leg nor sternal wounds had a statistically significant difference in infection rate according to closure method (leg sutured = 9.3% vs. leg stapled = 8.9%; p = 0.99, and sternal sutured = 0.4% vs. sternal stapled = 2.5%; p = 0.128). There was, however, a greater complication rate in stapled segments (leg stapled = 46.9% vs. leg sutured = 32.6%; p = 0.001, and sternal stapled = 14.9% vs. sternal sutured = 3.7%; p = 0.00005). Sutures were favored over staples among patients who expressed a preference (sternal = 75.6%, leg = 74.6%). CONCLUSIONS: With the host factors controlled by pairing staples and sutures in each patient, we demonstrated a similar incidence of infection but a significantly lower incidence of total wound complications with intradermal suture closure than with staple closure.     

Reconstruction of anterior chest wall: a clinical analysis

Objective

To investigate the methods and clinical efficacy of reconstruction of chest defects with titanium sternal fixation system after the surgical resection of sternal tumors.

Methods

A total of 6 patients with sternal tumor who were diagnosed and underwent resection and repair of the chest wall defects by titanium plates system, from 2017.3 to 2017.11 in our hospital were reviewed. Their pathological types, surgical reconstruction methods, follow-up results were analyzed.

Results

Six cases of sternal tumor were completely resected and the sternums were reconstructed with titanium sternal fixation system. There was no operative death, postoperative chest wall deformity, abnormal breathing or complications of respiratory circulation. After 3 to 10?months of follow-up, there was no loose screw or plate exposure. Not only the thoracic appearances were good, but patients’ satisfaction was high.

Conclusions

Surgical resection is the best treatment for sternal tumors, no matter it is benign or malignant. Titanium sternal fixation system combine with other soft materials can reconstruct the chest wall well after resection, and this technique is efficient as well as easy to learn.

     

Sternal wound complications-incidence, microbiology and risk factors

Objective: Sternal wound complications, i.e. instability and/or infection (mediastinitis), are important causes of morbidity in patients undergoing cardiac surgery via median sternotomy. Coagulase negative staphylococci, a normal inhabitant of the skin, have evolved as a cause of sternal wound infections. Since these opportunistic pathogens often are multiresistant, they can cause therapeutic problems. Methods: From 1980 through 1995 open heart surgery, was performed on 13,285 adult patients. Reoperation necessitated by sternal wound complications occurerd in 203 patients (1.5%). The incidence was 1.7% (168/9987) after coronary artery bypass grafting (CABG group) and 0.7% (35/3413) after heart valve surgery with or without concomitant CABG (HVR group). Results: Factors independently related to sternal complications in the CABG group (variable odds ratio [95% C.I.]): year of surgery, 1.9 [1.3–2.8] in 1990–1992, 2.0 [1.4–2.9] in 1993–1995; female sex, 0.4 [0.2–0.6]; diabetic disease, 1.8 [1.2–2.5]; bilateral ITA procedure, 3.3 [1.1–7.7]; and postoperative dialysis, 3.1 [1.4–6.9]. In the HVR group they were: use of ITA graft, 3.7 [1.7–7.7]; early re-exploration because of bleeding 3.0 [1.1–8.2]; and postoperative dialysis 3.1, [1.4–9.3]. Multivariate models were used to compute the risk for sternal complications in each patient. However, the prognostic models based on these risk scores provided low sensitivity and low predictive value. Patients with sternal wound complications showed no increased early mortality but worse long-term survival even after adjustment for other factors (relative hazard in CABG group 1.9 [1.2–2.8]; in HVR group 2.1 [1.1–4.3]. Conclusions: The use of ITA grafts seems to be one of the most important factors related to sternal wound complications. However, patients at truly increased risk for this complication could not be identified on the basis of the risk factors considered in this study.     

Early reexploration for excessive postoperative bleeding lowers wound complication rates in open heart surgery

Clinical reviews of sternal wound infections following open heart surgery indicate many predisposing factors including diabetes, low cardiac output, use of bilateral internal mammary grafts, and reoperation for excessive postoperative bleeding. This study was undertaken to determine the role of mediastinal re-exploration in the development of sternal wound complications. From a series of 2,271 patients undergoing median sternotomy for open-heart surgery between 1979 and 1984, 71 (3.1%) were re-explored for excessive bleeding. Nine of these patients died in the early postoperative period of noninfectious complications. The remaining patients were divided into two groups. Group 1 (54 patients) were re-explored without subsequent problems. Group 2 (8 patients) developed sternal and costochondral wound complications. Comparison of age, intercurrent and pre-existing disease, total bypass time, crossclamp time, and postoperative hemodynamic status showed no statistical difference. All patients bled an average rate of 247 ml/hr. However, the average time before re-exploration was 7.6 hours in group 1 compared to 13.8 hours in group 2 (P less than 0.001). Sternal wound complications may be minimized by a policy of early re-exploration for excessive postoperative bleeding (greater than 200 ml/hr for 4 hours).     

New method for sternal closure after vacuum-assisted therapy in deep sternal infections after cardiac surgery

The treatment of nonhealing and infected sternotomies after cardiac surgery is a challenging task with increased rates of mortality and morbidity, as well as high costs. A local vacuum therapy (ie, the vacuum-assisted closure system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing that stimulates granulation tissue formation. Aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. After some weeks of vacuum-assisted closure therapy, a complete preparation of the substernal structures is necessary. In this context, laceration of the right ventricle is a rare but life-threatening complication. We describe a new technique for sternal closure after vacuum-assisted wound treatment using Nitinol clips (Praesidia, Bologna, Italy), which can prevent these severe complications. Without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. This new method represents an easy, low-cost and complication-free procedure.     

应用超声刀经胸骨切迹下低位切口行甲状腺手术的研究

目的探讨应用超声刀经胸骨切迹下方低位切口行甲状腺手术的可行性和美容效果。方法使用经胸骨切迹下方低位切口应用超声刀行甲状腺切除术20例为研究组．传统经颈部切口甲状腺手术20例为对照组,均由同一手术组医生施术。分别比较2组的切口长度、切除甲状腺时间、术中出血量、术后引流量及手术并发症。结果在相同术式中,研究组的切口长度、手术时间、术中出血量和术后引流量均少于对照组（P〈0．001）;2组的总体手术并发症差异无统计学意义（P〉0．05）;研究组所有患者术后均恢复良好,未发现声音嘶哑、饮水呛咳和术后低血钙性抽搐或胸骨前瘢痕组织增生和肿瘤复发,无明显皮瓣粘连、水肿及颈部紧缩感。结论应用超声刀经胸骨切迹下方低位切口安全可行。它可以满足甲状腺手术所需要的切口暴露．不影响手术的效果,手术并发症少,同时更能满足患者美容的要求。     

Experience of sternal secondary closure by means of a titanium fixation system after transverse thoracosternotomy

Sternal dehiscence is a common complication after transverse thoracosternotomy in patients undergoing bilateral sequential lung transplantation (BSLT). These patients can be treated with conservative therapy, but severe dehiscence requires surgical reapproximation and secondary closure of the sternum. Seventy-one cases of patients who underwent BSLT between January 2007 and May 2009 were reviewed retrospectively. Out of 71 patients, the sternum was intact in two cases due to the use of bilateral anterolateral thoracotomy, and a clamshell incision had been utilized in 69 patients. Four patients (6.8%) presented with persistent chest pain with severe sternal dehiscence diagnosed by chest X-ray and/or chest computed tomography, and underwent sternal reapproximation using the Synthes Titanium Sternal Fixation System for longitudinal sternal plating. All four patients had successful sternal realignment and resolution of their preoperative clinical symptoms. No perioperative or postoperative complications were observed. The Synthes Titanium Sternal Fixation System is an appropriate and effective method for internal fixation of the sternum when used for symptomatic severe sternal dehiscence after sequential BSLT via transverse thoracosternotomy.     

Norwood Operation: Immediate vs Delayed Sternal Closure

BackgroundThe Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications.MethodsThis retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure).ResultsThe incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%).ConclusionsFor important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.     

Revision of midline sternotomies after cardiac surgery in 1988: retrospective study

Twenty-three of 514 (4.6%) patients who underwent cardiac surgery in 1988 with cardiopulmonary bypass were later reoperated for sternal complications. Several risk factors, including pre-, intra and postoperative variables, have been investigated. A significant correlation was found with the presence of diabetes mellitus, the type of operation (bilateral internal mammary artery grafting), early reoperations, haemodynamic alterations, pulmonary infections and incidence of serious non infectious complications. The different sternal complications are analyzed from a clinical and therapeutic point of view.