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Bilateral Longitudinal Reinforcement of Median Sternotomy Closure

Department of Surgery, University of Missouri, Columbia, MO 65212, USA

We read with interest the recent article by Al Ebrahim on bilateral longitudinal reinforcement of median sternotomy closure.¹ The author used two longitudinal transsternal wire loops; the two halves of the sternum were then tightly opposed by means of multiple single suture wires tightened against the longitudinal wires. This technique was used successfully in 112 patients with precarious sterna; there was no incidence of dehiscence or sternal infection following the procedure.

Al Ebrahim writes that his technique is new, but Chlosta and Elefteriades described the addition of longitudinal wires to the repair of midline sternotomy in 1995.² The longitudinal wires entered above the xiphoid outside-in on the sternum, extended beneath it, and exited inside-out on the manubrium. The vertical wire lay within the transverse wires, which firmly approximated the sternal halves; the longitudinal support wires acted as impenetrable pledgets, thus preventing the transverse wires from tearing through the sternal substance.² The effectiveness of this technique was confirmed by subsequent investigators.³

The Al Ebrahim paper could have been substantially strengthened by discussing other published methods of using lateral sternal support to achieve a durable sternal union. Longitudinal wire passed in and out through the interspaces bilaterally along the length of the sternum, sternal wiring over longitudinally drilled Kirschner wires, small-fragment bone plates placed in a paramedian alignment, longitudinally oriented stainless steel struts, and paramedian staples corresponding to the exit sites of transverse wires through the sternal bone were all reviewed by a recently published article.³ These methods are based on common principles: improved distribution of distraction forces and decreased risk of wires cutting through the bone.³ None of the studies, including Dr. Al Ebrachim’s, was preceded by biomechanical testing with control groups.

Al Ebrachim believes his technique improves sternal stability, but he provides no comparative data showing the biomechanical superiority of transsternal longitudinal wires to the established parasternal weave developed by Robicsek for use in precarious sterna.³ Steel wires placed parasternally use the lateral cortex to significant advantage; it has been shown that the incidence of parasternal wires’ cutting through bone is one-fifth that seen with conventional wires.⁴ Sternal traction and resulting sternal movement typically occur laterally when exposed to simulated Valsalva force.⁵ These findings suggest that parasternal wires using lateral cortical support offer considerably better biomechanical stability than the longitudinal transsternal wires used in the Al Ebrachim study.¹

The methods described by Chlosta and Elefteriades,² Al Ebrachim,¹ and others^3–5 broaden the surgeon’s armamentarium in confronting difficult midline sternotomy wounds. This clinical experience can be further strengthened by biomechanical laboratory studies and valid comparative statistical outcome measures.

REFERENCES

1. Al Ebrahim K. Reinforced sternal closure: the bilateral straight longitudinal wire technique. Asian Cardiovasc Thorac Ann 2003;11:90–1.[Abstract/Free Full Text]

2. Chlosta WF, Elefteriades JA. Simplified method of reinforced sternal closure. Ann Thorac Surg 1995;60:1428–9.[Abstract/Free Full Text]

3. Losanoff JE, Jones JW, Richman BW. Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg 2002;10:102–10.[Medline]

4. Casha AR, Gauci M, Yang L, Saleh M, Kay PH, Cooper GJ. Fatigue testing median sternotomy closures. Eur J Cardiothorac Surg 2001;19:249–53.[Abstract/Free Full Text]

5. McGregor WE, Trumble DR, Magovern JA. Mechanical analysis of midline sternotomy wound closure. J Thorac Cardiovasc Surg 1999;117:1144–50.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Author home page(s): James W Jones Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Losanoff, J. E Articles by Jones, J. W Search for Related Content PubMed PubMed Citation Articles by Losanoff, J. E Articles by Jones, J. W Related Collections Chest wall