Total and superior sternal clefts in newborns: a simple technique for surgical correction

The authors discuss six cases of superior and total sternal clefts treated in their department in the last 34 years and discuss the problems of this congenital malformation. The inferior sternal clefts including Cantrell's pentalogy and the total ventral clefts were excluded because in these cases severe associated anomalies require another approach. In superior and total sternal clefts, cardiac, vascular anomalies in lungs and abdomen and craniofacial dysgenesias are rarely present. In these cases a primary repair during the first weeks of life should be performed. Furthermore, the authors describe their own surgical approach, consisting of the conversion of the partial cleft into a total one. Then the rims are trimmed, and a complete approximation of the two segments is possible.     

不横断胸骨双侧前胸切口双肺移植

目的探讨不横断胸骨双侧前胸切口序贯式双侧单肺移植的可行性及手术技术。方法2004年12月至2005年3月，为3例终末期肺病患者进行了不横断胸骨双侧前胸切口序贯式双侧单肺移植。供肺均以改良的棉子糠LPD液灌注保存；手术时间分别为9．5h、6．5h和8．5h；第1和第2个植入供肺的冷缺血时间分别为195／465、250／330和250／440min。结果受者术后脱离呼吸机的时间分别为6、11和10d；ICU病房停留时间分别为9、16和13d；康复出院时间分别为41、67和30d。没有1例发生影响伤口愈合的并发症。结论双侧前胸切口不横断胸骨开胸双肺移植，手术创伤小，且安全可靠，减少了胸骨愈合的并发症，术后恢复快，有助于患者术后肺功能的提高，值得在我国进一步推广应用。     

Current concepts in the management and reconstruction of the dehisced median sternotomy

This review will delineate the underlying conditions that predispose patients to deep mediastinal infection and sternal dehiscence, discuss the principles of thorough debridement and preparation of the wound, and assess the appropriate options available for successful reconstruction.     

Resection of Sternal Tumors and Reconstruction of the Thorax: A Review of 15 Patients

Purpose We report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh. Methods Fifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two. Results All patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months. Conclusions Wide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.     

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.     

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.     

冠心病搭桥术后胸骨裂开的防治(附5例报道)

目的 探讨冠心病搭桥术后胸骨裂开及其合并感染的诊断、治疗和预防。方法 未感染者及时再手术重新固定,合并感染者及时彻底清创、有效引流、牢固固定。结果 本组治愈率100％,伤口愈合时间平均10天(7～14天),1例除外。二次术后平均拔除引流管时间7.4天(2～20天)。结论 伤口局部的症状、体征、全身表现和X线胸片对诊断和治疗有重要意义。早发现、早诊断,及时重新固定,合并感染者及时彻底清创、有效引流、牢固固定是治疗成功的关键,可以有效缩短住院时间。重视胸骨裂开的预防,可减少其发生率。     

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.     

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.     

Selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass

Thirty-six (4.6%) patients required exploration for hemorrhage after 788 coronary artery bypass grafting procedures. Twenty-three (64%) patients with a specific site of bleeding that was surgically controlled or with improving coagulopathy were managed by immediate sternal closure. Continued hemorrhage or tamponade necessitated reexploration in 5 of these patients. All 5 patients were then treated by open sternotomy and delayed sternal closure. There were no deaths or sternal wound infections in this subgroup. Thirteen (36%) patients explored for hemorrhage were initially treated by open sternotomy and delayed sternal closure because of ongoing coagulopathy with refractory bleeding. Twelve patients recovered without further complication. One patient died 30 days after delayed sternal closure. There were no sternal wound infections. This experience supports a selective approach to sternal closure after exploration for hemorrhage following coronary artery bypass grafting. Immediate closure is recommended if a specific site of bleeding can be located and corrected. However, in the presence of refractory hemorrhage due to coagulopathy, delayed sternal closure should be considered to avoid the subsequent morbidity of continued bleeding, including cardiac tamponade, multiple reexplorations with sternal trauma, and retained mediastinal hematoma.     

延迟关胸在儿童心脏移植中的应用

目的探讨延迟关胸技术在儿童心脏移植中的应用价值。 方法回顾性分析华中科技大学同济医学院附属协和医院2018年1月1日至2021年8月31日73例儿童心脏移植受者临床资料,根据术后一期胸骨闭合情况分为延迟关胸组(10例)和非延迟关胸组(63例),分析延迟关胸对于受者心功能恢复、手术切口感染、肺部感染、术后30 d和住院期间死亡情况的影响。 结果延迟关胸组原发病以复杂先天性心脏病心力衰竭为主,非延迟关胸组以心肌病心力衰竭为主。延迟关胸组延迟关胸时间中位数4 d,采用一次或分次关胸技术均成功关胸。延迟关胸组平均年龄(6.4±5.3)岁,平均体质量(16.3±11.4)Kg,均小于非延迟关胸组[(9.7±4.7)岁和(29.5±15.6)Kg];供受者体质量比为(3.1±1.4),高于非延迟关胸组[(1.9±0.7)],差异均有统计学意义(t＝2.0、3.2和-4.5,P均<0.05)。延迟关胸组术前和术后使用VA-ECMO辅助、术后肾脏替代治疗的受者比例以及发生肺部感染和住院期间死亡的受者比例均高于非延迟关胸组,差异均有统计学意义(P均<0.05)。延迟关胸组受者术后2周右室面积变化分数为(37.0±5.8)%,低于非延迟关胸组[(43.1±7.8)%],差异有统计学意义(t＝2.4,P<0.05)。2组受者性别、术前血清总胆红素和肌酐、术后2周左室射血分数、手术切口感染及术后30 d内死亡发生率差异均无统计学意义(P均>0.05)。 结论延迟关胸是儿童心脏移植供受者体质量不匹配时一种安全且有效的治疗策略。     

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.     

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.     

Reinforced sternal closures for prevention of sternal dehiscence in high risk patients

BACKGROUND: Sternal dehiscence is still a frequent complication after cardiac surgery procedures, performed through midline sternotomy. Its cumulative incidence has been reported to be around 2.5%, but several risk factors for increased incidence have also been identified. In past years several techniques have been proposed to achieve reinforced sternal approximation, mainly considered for the treatment of sternal dehiscence, more than for its prevention. The objective of this paper is the evaluation of the results, in terms of prevention of sternal dehiscence in high-risk patients, using reinforced closure techniques compared to standard technique. METHODS: Our study population included 212 patients who underwent cardiac surgery procedure and presented at least one of the increased risk factor for sternal dehiscence. Fifty-six patients (26.4%) received a reinforced sternal closure technique (RC group), 156 patients (73.6%) received a conventional sternal closure (CC group). RESULTS: The cumulative incidence of sternal refixation, in this selected population, was 5.6% with a statistically significant difference in favour of the RC group. The results of this study clearly show that the appropriate utilisation and selection of one of the several techniques of reinforced sternal closures can be effective in the reduction of sternal dehiscence in high risk patients. CONCLUSIONS: A reinforced technique should therefore be utilised in all patients undergoing cardiac surgery, presenting one or more risk factors for increased incidence of sternal dehiscence.     

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   

Early postoperative sternal approximation after ITA harvesting: computed tomographic evaluation

Between November 1989 and February 1990, 66 randomized sternotomized patients underwent aortocoronary bypass and were subjected to a sternal scanner in the early postoperative period. Each examination included a manubrial and a sternal body print. At each level, we studied the occurrence of spacing or misalignment of the sternal layers. The 66 patients were subdivided into four groups according to the type of conduit harvested (single left internal thoracic artery or saphenous vein) and the type of material used for the sternal closure (steel wires or nylon yarns). In all cases, adequate early sternal approximation, which is represented by a good alignment as well as by an excellent contact of the sternal layers, was infrequently demonstrated. Moreover, the two abnormalities most often observed were manubrial spacing and sternal body misalignment. The sternal closure technique and internal thoracic artery harvesting had no significant effect on the sternal approximation. To minimize manubrial spacing and sternal body misalignment, we propose that the surgeon should apply three threads through the manubrium, withdraw the shoulder roll beforehand, elevate both of the patient's shoulders, and maintain the two xyphoid layers in the same plane and in fairly close contact during the tightening of the wires.     

Delayed sternal closure after cardiac surgery

Fifty-seven patients undergoing various cardiac operations were managed with delayed sternal closure because of ongoing mediastinal hemorrhage or extreme cardiac dilatation. This strategy facilitated rapid access to the mediastinum for evacuation of clot when the risk of tamponade from hemorrhage was deemed great. When sternal closure over a dilated and edematous heart caused hemodynamically significant cardiac compression, wound closure without sternal reapproximation facilitated hemodynamic stability. Postoperative correction of hemodynamic and hemostatic functions allowed delayed sternal closure to be done a mean of 2.8 days later. Thirty-eight patients survived to leave the hospital. Recognized complications of delayed sternal closure included superficial wound infection (3 patients), sternal osteomyelitis (1 patient), and fatal mediastinal infection (1 patient). Delayed sternal closure may be beneficial in selected patients. Morbidity and mortality related to this technique have proved acceptable in this high-risk group.     

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.     

Primary sternal osteomyelitis in infants: a report of two cases

Primary sternal osteomyelitis in infants, older children, and adults is rare. Secondary sternal osteomyelitis, however, is more common because of the increased frequency of cardiothoracic surgery and intravenous drug abuse. Primary sternal osteomyelitis is reviewed, two infants with further cases of primary sternal osteomyelitis are presented, and diagnosis and management are discussed.     

Bridging the cleft over the throbbing heart

Primary repair of sternal cleft deformities are best achieved in the neonatal period. Conversion of a partial defect to a complete sternal cleft with sternal bar mobilization is able to achieve sternal approximation in most cases. We describe a new technique of fracturing the clavicles in unyielding cases as was our experience in a 6-week-old infant.