Asian Cardiovasc Thorac Ann 2007;15:59-63
© 2007 Asia Publishing EXchange Ltd
Sternal Bands for Closure of Midline Sternotomy Leads to Better Wound Healing
Susmit Bhattacharya, MCh,
Indrajit Sau, MBBS,
Man Mohan, MCh,
Kunal Hazari, MCh,
Rajarshi Basu, MCh,
Ajay Kaul, MCh
Department of Cardiac Surgery, BM Birla Heart Research Centre, Kolkata, India
For reprint information contact: Susmit Bhattacharya, MCh, Tel: 91 33 2456 7890, Fax: 91 33 2456 7000, Email: susmeetbh{at}yahoo.com, Department of Cardiac Surgery, BM Birla Heart Research Centre, 1/1 National Library Avenue, Kolkata 700027, India.
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ABSTRACT
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Midline sternotomy is the most common incision for cardiac surgery, but problems of wound healing and sternal instability are still matters of concern. The use of stainless steel wires only was compared with the use of wires plus sternal bands for closure of midline sternotomy wounds in a 2-year period. Of 370 patients in whom only stainless steel wires were used, 14 (3.78%) required re-operation for dehiscence. Only 3 (0.76%) of 395 patients in whom sternal bands were also used, required re-operation for dehiscence. The difference was highly significant. It was concluded that use of sternal bands leads to a more stable union.
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INTRODUCTION
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Keyhole surgery is gaining in popularity, but a median sternotomy is still the most popular incision for cardiac surgery because of its familiarity and versatility. The complications of median sternotomy are well known. They range from incision pain and sternal instability to nonunion and dehiscence. Sternal instability leads to decreased inspiratory effort, atelectasis and pneumonia, as well as loss of wound integrity, which promotes bacterial infection. The standard method of closure of median sternotomy wounds is with stainless steel wires. McGregor and colleagues1 illustrated the postoperative physiological forces that lead to stainless steel wires sawing through the sternum, resulting in sternal instability. To reduce the incidence of complications, improved closure techniques have been sought. Figure-of-eight steel wires, the prophylactic Robicsek closure, nylon bands, and Mersilene ribbons have been tried with varying degrees of success.2–5 Flat steel bands have been used with good results.6–9 We started using sternal bands from October 2003 in the belief that this closure device would reduce the incidence of migration through the bone, thus ensuring a more stable closure. To assess the usefulness of sternal bands, we compared the incidence of wound dehiscence in patients who underwent coronary artery bypass grafting (CABG) with and without the use of such bands.
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PATIENTS AND METHODS
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In the 370 patients (group A) who underwent CABG from October 1, 2002 to September 30, 2003, the sternum was closed with sternal wires only. From October 1, 2003 to September 30, 2004, 395 patients (group B) underwent CABG and their sternotomy wounds were closed with 1 or 2 sternal bands in addition to steel wires. The hospital charts of these 765 patients were reviewed. Each group included a comparable number of patients at risk of sternal dehiscence on the basis of age, sex, diabetes, chronic obstructive pulmonary disease (COPD), body mass index, ejection fraction, infection, use of bilateral internal mammary arteries (IMAs), and re-exploration. Patients with associated procedures were also included in the study. The baseline demographics and operative variables known to affect wound healing are listed in Table 1
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All patients received cefuroxime sodium as the preoperative prophylactic antibiotic. The operative field was painted with Microshield (Johnson & Johnson, India) solution and the skin was covered with Ioban 2 (3M Health Care, St Paul, MN, USA). Skin and subcutaneous tissue were cut with a scalpel, using electrocautery only for coagulation of bleeding points. Bone wax (Ethicon, India) was used when necessary. All patients in the first year of the study had their sternum closed with stainless steel wires as single loops. Three loops were used in the manubrium and 4 were used parasternally and tightened so that no instability was detected. Figure-of-eight loops of steel wire were never used. A prophylactic Robicsek closure was carried out if the sternum was found to be soft or broken. In the second year of the study, all patients had their sternum closed with at least one sternal band. Sternal bands of CrNi alloy (Johnson & Johnson, Beerse, Belgium) were tightened with a tensioning device supplied by the manufacturer (Figure 1). The 4th wire was replaced with a band. A single band was used through the 2nd intercostal space parasternally and tightened with the tensioning device. When the sternum was soft and osteoporotic, another band was put in through the 3rd intercostal space, below the first one; thus, the 4th and 5th wires were replaced with bands. The manubrium was closed with 3 loops of stainless steel wire, and the rest of the sternum was closed with 2 or 3 additional stainless steel wires, depending on the number of bands used. A prophylactic Robicsek closure was carried out if the sternum was found to be soft or broken. The presternal space was obliterated with 2 layers of delayed absorbable sutures, leaving a subcutaneous suction drain if the patient was obese. Patients were extubated when hemodynamically stable, usually after 6–8 hr. Pleural drains were taken out when drainage was < 100 mL in 24 hr, and the subcutaneous drain was removed after 6 to 7 days.
Deep wound infection was defined as one or more of the following findings: isolation of an organism from culture of the mediastinal tissue or fluid, visual evidence of mediastinitis, chest instability, or fever associated with purulent drainage.10 Superficial sternal infection was defined as purulent discharge not involving mediastinal tissues.10 Only deep wound infection requiring surgical intervention was considered in this study because re-operation increases the psychological effects, hospital stay, and financial burden on the patient, and may be fatal if inadequately managed. Postoperative pain could not be evaluated as this was a retrospective study. Superficial infections were treated with antibiotics and local dressing. If re-suturing was required, only soft tissues were closed in multiple layers reinforced with horizontal mattress tension-relieving sutures, keeping a subcutaneous suction drain in all patients. When sternal mobility was significant and the wires had to be cut and reapplied, this was usually performed after a Robicsek closure. When the sternum had broken into pieces and direct rewiring was not possible, the abdomen was opened through a small incision in continuity with the main incision. The omentum was mobilized and pulled up to the suprasternal notch. The sternum was extensively débrided. Only the skin, subcutaneous tissue, and muscle were closed with deep mattress sutures in a single layer, keeping 2 tube drains in the subcutaneous space.
The results are reported as mean ± standard deviation or as percentages, where appropriate. Univariate analysis was performed using Fisher’s exact test for categorical variables and the two-tailed Student t test for continuous variables. A value of p < 0.05 was considered significant.
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RESULTS
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Of the 370 patients in group A, 14 (3.78%) needed some form of re-operation for wound dehiscence, whereas only 3 (0.76%) of the 395 patients in group B had a re-operation for wound dehiscence ( p = 0.0056). All patients did well after re-operation for wound dehiscence. Those with a deep sternal infection had a mean hospital stay of 25 ± 3 days vs 10 ± 1 days for the other patients. Those with a superficial infection were routinely discharged and followed up in our outpatient department.
Of the risk factors for wound healing, only the use of bilateral IMAs is at the surgeon’s discretion. Over the last couple of years, the trend has been towards more frequent use of bilateral IMAs, except for patients with very diffuse coronary disease requiring long arteriotomies and in the setting of recent myocardial infarction (within 2 weeks) and severe unstable angina. All IMAs harvested were pedicled and not skeletonized. Risk factors such as obesity, COPD, diabetes, and female sex were not considered contraindications to the use of bilateral IMAs. Very few patients come for redo CABG in our institute; there were 2 patients in each group who underwent redo CABG, none of whom developed a wound complication. Univariate analysis of the other potential risk factors for development of wound complications was performed using the variables listed in Table 1
. There were more risk factors for poor wound healing in group B, including a significantly greater proportion of females and patients with diabetes, substantially more bilateral IMA grafts, higher incidences of re-exploration for bleeding and COPD, as well as a slightly higher body mass index compared to group A. There were more elderly patients (age > 74 years) and more with a low ejection fraction (< 35%) in group A compared to group B. It would be expected, therefore, that there might be more patients in group B with delayed wound healing and more cases of re-operation for wound dehiscence.
The risk profile of all the patients who underwent re-suturing was studied. Although not statistically significant; sex, age, diabetes, body mass index, COPD, bilateral IMAs, re-exploration, and infection may have contributed to wound complications in group A, but these factors barely contributed to wound problems in group B (Table 2). Of the 17 patients who required re-suturing, 7 (41%) had wound swabs positive for bacterial growth and 10 (59%) were culture-negative. It should be noted that culturing for mycoplasma or fungi was not performed and some of the culture-negative infections may have been caused by these organisms. In addition, wound swabs in contact with skin may result in false-positive cultures. Hence, wound complications can be attributed to infection in only a small percentage of patients. There were 15 (4%) patients in group A and 10 (3%) in group B who developed superficial wound infection ( p = 0.0329); one from each group grew Klebsiella. They were given broad-spectrum antibiotics and local dressings, and all became culture-negative.
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DISCUSSION
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Sternal wound dehiscence is a well-described complication after CABG.11 In this study, the effect of a change in closure technique on wound healing was evaluated retrospectively. Sternal bands were used for closure of the sternum in all patients undergoing CABG in the second year of the study. This group was compared with all patients undergoing CABG in the year prior to the availability of sternal bands. Therefore, there exists no bias in selection of patients in either group. Our incidence of wound complications in group A was 3.78%, which is slightly higher than that reported for isolated CABG.11–13 However, when sternal bands were used, 0.76% of patients required re-operation for wound dehiscence, which conforms to that quoted in the literature.12,13
Of the 14 patients requiring re-operation for wound dehiscence in group A, 13 were male, whereas 2 of the 3 patients who underwent re-operation in group B were female. Male sex has been cited as a risk factor for sternal wound dehiscence in other studies.14–16 The reason may be the increased tension on sternal incisions due to coughing and sneezing, which leads to the steel wires sawing through the sternum, resulting in instability and associated problems. When the tension is spread over a larger area with the use of bands, sternal union becomes more stable. The fact that 2 of 3 patients with wound dehiscence in group B were female and diabetic without any infection suggests that an osteoporotic and soft sternum may be important in sternal instability, because even the bands cut through in such patients.
Of the 795 patients, only 7 (0.9%) had cultures positive for bacterial growth, which is less than previously reported.12,13 If operating room sterility is within acceptable limits and proper prophylactic antibiotics are used, we believe that infection is not the primary cause of wound complications. When the wires start migrating through the sternum, there is mobility and instability of the sternum and the pericardial fluid oozes out. When pericardial fluid comes in contact with the external surface, it tends to become infected.
The use of sternal bands seems to have eliminated or reduced the influence of risk factors for wound healing (Table 2). The use of pedicled bilateral IMAs has been reported to have a sternal dehiscence rate of up to 14%.17 When sternal bands were used, the use of bilateral IMAs did not contribute to wound complications. Good results from sternal closure using bands were reported by Kalush and Bonchek6 in 1976. Badellino and colleagues7 used Parham bands with good results. Cheng and colleagues8 stated that by spreading the load over a larger surface, the tendency of the bands to cut through would be reduced. Also, at equivalent loads, a band is less likely to break or cut through the sternum. However, they concluded that steel wires were better for sternal closure. This is probably because the bands they used did not have proper fastening or tying mechanisms. Soroff and colleagues9 used their own sternal bands with good results in a study of 48 patients. We used the sternal bands manufactured by Ethicon and their tensioning device, as advised, with good results. Whereas Soroff and colleagues9 used 4 to 6 bands for closure, we used 1 or 2 bands in all patients and found that to be adequate.
It was concluded that the use of bands greatly reduced inaccurate and insecure sternal closure, and thus reduced the incidence of important sternal infection and also sterile sternal dehiscence, leading to a more rigid fixation and better wound healing.
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ACKNOWLEDGMENTS
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The authors gratefully acknowledge the help of Dr. Bani Chanda, MBBS, Medical Research Coordinator, for the statistical backup and compilation of this manuscript.
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REFERENCES
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- 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]
- Goodman G, Palatianos GM, Bolooki H. Technique of closure of median sternotomy with trans-sternal figure-of-eight wires. J Cardiovasc Surg (Torino) 1986;27:512–3.[Medline]
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- LeVeen HL, Piccone VA. Nylon-band chest closure. Arch Surg 1968;96:36–9.[Abstract/Free Full Text]
- Johnston RH Jr, Garcia-Rinaldi R, Vaughan GD 3rd, Bricker D. Mersilene ribbon closure of the median sternotomy: an improvement over wire closure. Ann Thorac Surg 1985;39:88–9.[Abstract]
- Kalush SL, Bonchek LI. Peristernal closure of median sternotomy using stainless steel bands. Ann Thorac Surg 1976;21:172–3.[Abstract]
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ABSTRACT
INTRODUCTION
