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Reinforced Sternal Closure: the Bilateral Straight Longitudinal Wire Technique

Department of Cardiac Surgery, Al Hada Armed Forces Hospital, Taif, Saudi Arabia

For reprint information contact: Khalid Al Ebrahim, FRCSC Tel: 966 2 754 1610 Fax: 966 2 754 1238 email: khaled_alebrahim{at}yahoo.com Department of Cardiac Surgery, Al Hada Armed Forces Hospital, P.O. Box 1347, Taif, Saudi Arabia.

	ABSTRACT

TOP ABSTRACT INTRODUCTION TECHNIQUE DISCUSSION REFERENCES

 
Sternal dehiscence and mediastinitis are among the most severe complications of median sternotomy. A simplified technique of reinforced closure is described. A straight wire is inserted longitudinally on each side of the sternum, placed within the transverse wires when the latter are approximated. Using this technique in 112 patients with a precarious sternum, no cases of sternal dehiscence or mediastinitis have been seen.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION TECHNIQUE DISCUSSION REFERENCES

 
Sternal complications are among the most preventable problems in cardiac surgery. They include sternal instability, non-union, dehiscence, abscess, and osteomyelitis, which occur in 1% to 2% of cases.^1–3 Predisposing factors of sternal complications include old age, diabetes, steroid treatment, postmenopause, obesity, osteoporosis, reoperation, and the use of the bilateral internal mammary arteries. A secure, stable sternal closure is the most important factor in avoiding these complications.

	TECHNIQUE

TOP ABSTRACT INTRODUCTION TECHNIQUE DISCUSSION REFERENCES

 
This technique is used in all cases where the sternum is felt to be precarious, osteoporotic, fragile, or has multiple fractures. A wire is inserted longitudinally above the xiphoid outside-in and pulled underneath the sternum to exit inside-out on the manubrium. It is twisted snuggly around the middle of the sternum. Another similar wire is entered through the other side of the sternum. Following that, standard transverse wires are placed and approximated (Figure 1). Thus, the longitudinal wires act as a vertical support to the sternum, stabilizing any fractures and preventing the transverse wires from tearing through the sternal edge. The radiographic appearance of the wire structure is shown in Figure 2.

View larger version (39K): [in this window] [in a new window]   Figure 1. Reinforced closure of the sternum using the straight longitudinal wire technique.

View larger version (175K): [in this window] [in a new window]   Figure 2. Chest radiographs in (A) posteroanterior and (B) lateral views showing the wire structure.

	DISCUSSION

TOP ABSTRACT INTRODUCTION TECHNIQUE DISCUSSION REFERENCES

 
Different techniques of sternal reinforcement have been described. These include the original and the modified Robicsek closure using 2 longitudinal weaving wires on each side of the sternum, the interlocking figure-of-8 closure, and the use of metal plates and steel bands.^4–7 We described previously the use of a longitudinal weaving wire on each side of the sternum placed within the transverse wires.⁸

We have found all the previous procedures we have used time consuming, complicated, and cause more bleeding and a higher incidence of injury to the internal mammary artery. The bilateral straight wire technique is quick, practical, simple, and has proved to be reliable in reducing or avoiding the risk of sternal instability and infection. It is currently our preferred closure technique on all patients at high risk of sternal dehiscence or mediastinitis.

	REFERENCES

TOP ABSTRACT INTRODUCTION TECHNIQUE DISCUSSION REFERENCES

 

1. Breyer RH, Mills SA, Hudspeth AS, Johnston FR, Cordell AR. A prospective study of sternal wound complications. Ann Thorac Surg 1984;37:412–6.[Abstract]

2. Grossi EA, Culliford AT, Krieger KH, Kloth D, Press R, Baumann FG, et al. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214–23.[Abstract]

3. Ottino G, De Paulis R, Pansini S, Rocca G, Tallone MV, Comoglio C, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg 1987;44:173–9.[Abstract]

4. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267–8.[Abstract]

5. Tavilla G, van Son JA, Verhagen AF, Lacquet LK. Modified Robicsek technique for complicated sternal closure. Ann Thorac Surg 1991;52:1179–80.[Abstract]

6. Di Marco RF Jr, Lee MW, Bekoe S, Grant KJ, Woelfel GF, Pellegrini RV. Interlocking figure-of-8 closure of the sternum. Ann Thorac Surg 1989;47:927–9.[Abstract]

7. Soroff HS, Hartman AR, Pak E, Sasvary DH, Pollak SB. Improved sternal closure using steel bands: early experience with three-year follow-up. Ann Thorac Surg 1996;61: 1172–6.[Abstract/Free Full Text]

8. Al-Ebrahim K, Shafei H. A new technique for reinforced sternal closure. Asian Cardiovasc Thorac Ann 1996;4: 117–8.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Al Ebrahim, K. Search for Related Content PubMed PubMed Citation Articles by Al Ebrahim, K. Related Collections Chest wall