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ORIGINAL ARTICLE |
GB Pant Hospital, Maulana Azad Medical College, New Delhi, India
Sumith Narang, MCh, Tel: +91 129 4086920, Fax: +91 11 26672594; Email: sumit_narang{at}yahoo.com, House No. 127, Sector 7 A, Faridabad, Haryana 121006, India.
ABSTRACT
Dehiscence of the sternum is a serious and potentially devastating complication. The purpose of this prospective study was to determine whether a prophylactic sternal weave would decreased the incidence of noninfective sternal dehiscence, compared to routine sternal closure, in a high-risk group. Between 2000 and 2007, 200 patients undergoing median sternotomy for cardiac surgery, with one or more risk factors including New York Heart Association functional class III/IV, chronic obstructive pulmonary disease, osteoporosis, obesity, and off-midline sternotomy, were randomly assigned to group A (sternal weave closure, 100 patients) or group B (routine sternal wire closure, 100 patients). No patient in either group with a single risk factor had sternal dehiscence. The incidence of noninfective sternal dehiscence was significantly less in group A than group B in patients with 2 or more risk factors (2.5% vs. 12.5%). Routine sternal closure is sufficient in patients with a single risk factor, whereas a prophylactic sternal weave should be carried out in all patients with 2 or more risk factors, to decrease postoperative morbidity.
Key Words: Sternum • Thoracic Surgical Procedures • Wound Healing
INTRODUCTION
Dehiscence of the sternum is a serious and potentially devastating complication that can cause pulmonary dysfunction, chest wall discomfort, and superficial and mediastinal infection.1,2 Sternal motion and instability may occur in first few days or weeks after median sternotomy. This may resolve or it may lead to dehiscence because of fracture of the sternal bone or sternal wires.3 Sternal dehiscence occurs in 0.2%–5% of patients as a result of primary nonunion, poor wound healing, or premature overexertion.3–8 Certain patients are at greater risk of sternal wound complications, and preoperative and operative risk factors have been established. Preoperative risk factors include obesity, chronic obstructive pulmonary disease, New York Heart association functional class III/IV, osteoporosis, immunosuppression, and previous sternotomy.1,3,9,10 Operative risk factors include bilateral internal mammary artery harvesting, excessive volumes of blood transfused, and off-midline sternotomy.2,9–11 Many studies have described the use of reinforced sternal closure techniques to decrease the incidence of dehiscence.3,8,9,12,13 Although these techniques potentially reduce the incidence of sternal dehiscence, they are more invasive and technically cumbersome, and carry an increased risk of bleeding, making them less attractive options for routine sternotomy closure. The purpose of this study was to determine whether a prophylactic sternal weave would decrease the incidence of non-infective sternal dehiscence in high-risk patients.
PATIENTS AND METHODS
This prospective study was performed between 2004 and 2007. The study protocol was approved by the institutional review board, and informed consent was obtained from each patient. The study enrolled 200 patients with one or more risk factors undergoing elective cardiac surgery via median sternotomy. They were randomly assigned to group A (sternal weave closure, n = 100) or group B (routine sternal wire closure, n = 100). All patients presenting to treating unit A were assigned to group A; all patients presenting to treating unit B were assigned to group B. Obesity was defined as body mass index >35 kg m–2, chronic obstructive pulmonary disease was defined as forced expiratory volume in the 1st sec <80% of the predictive value. An off-midline sternotomy was more than 2/3 of the sternum on one side of the incision line. Osteoporosis criteria were subjective, depending on the bone condition at the time of surgery. All patients were medically optimized for cardiac and other comorbidities before surgery.
Cefazolin and amikacin were given for antibiotic prophylaxis just before induction of anesthesia, and continued for 2–3 days postoperatively in all patients. A partial sternal weave was performed on the thinner side in patients with an off-midline sternotomy in group A. In group B, 2 single wire loops were placed in the manubrium, and 3 figure-of-8 loops of regular nos. 5 and 6 (0.5- and 0.6-mm diameter) sternal wires were placed parasternally (Figure 1
). The Robicsek weave technique is a simple procedure in which 2 trans-manubrial and 4 parasternal single wire loops are placed around bilateral continuous vertical pericostal weave, using nos. 5 and 6 sternal wires (Figure 2).3 This takes 5–10 min longer than routine sternal wire closure. Conservative management was applied in those with intact skin and soft tissue, with no discharge or dehisced sternum. Surgery was undertaken in those with partial or complete skin and soft tissue dehiscence, discharge, or sternal dehiscence, according to a predetermined protocol. Diagnosis of sternal dehiscence was made on the bases of clinical criteria and chest radiography (anteroposterior and lateral views) in unexplored patients. In those with partial or complete skin and soft tissue dehiscence, discharge, and sternal dehiscence, diagnosis was made on clinical and microbiological bases. Computed tomography was not available. Investigators making the diagnosis of sternal dehiscence were blinded to the type of sternal closure. Mean follow-up of patients in both groups was 20 ± 6 months.
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RESULTS
The demographic profiles and risk factors were comparable in both groups (Table 1). No significant difference was found in the type of cardiac surgery each group (Table 2). None of the valve patients had active infective endocarditis. Bilateral internal mammary arteries were not used in any patient having coronary artery bypass. In group A, 52/66 coronary bypass operations were off-pump and 14 were on-pump. In group B, 53/65 coronary bypass operations were off-pump and 12 were on-pump. Complications in each group are shown in Table 3. One death in group A was due to low cardiac output, the other was due to infective mediastinitis. Two patients in group B died of low cardiac output. One of the patients with mediastinitis in group A had Staphylococcus aureus infection, the other had Staphylococcus epidermidis (coagulase-negative) on culture, as had the patient in group B. Two patients in group A and 5 in group B with sternal dehiscence were managed conservatively. These 7 patients presented with sternal instability and deep-seated pain with a feeling of bony crepitus on jerky movements. They were given extended chest binder support and advised to avoid activities that put strain on the sternum until adequate sternal stability was achieved. Pain and bony crepitus in 5 of these patients decreased with time ranging from 9 months to 3 years; the other 2 patients, with 9 months and 11 months of follow-up, have decreased mobility and are still on restricted activity. Five patients with sternal instability and discharge underwent reoperation, and various muscle flap closure techniques were used for sternal closure. One died postoperatively of multiorgan failure and 1 developed major respiratory complications requiring prolonged intensive care unit and hospital stay. None of the patients in either group with a single risk factor developed sternal dehiscence; 7% in group B with 2 risk factors had sternal dehiscence; 9% in group A and 25% in group B with 3 risk factors had sternal dehiscence (Table 3). No patient in this study had more than 3 risk factors.
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This study found a significantly lower incidence of noninfective sternal dehiscence in patients with a prophylactic sternal weave and 1 or more risk factors, compared to those who had routine sternal closure. Although many studies have described the use of a sternal weave in patients with sternal dehiscence, with good results, no prospective randomized study has investigated the prophylactic use of this technique in high-risk patients.2,3 Reinforced closure techniques designed to decrease the incidence of sternal dehiscence have been assessed.8,9,12,13 However, they were found to increase the risk of bleeding and are considered to be technically more cumbersome, making them less attractive options for routine closure. The sternal weave used in this study is a simple procedure in which peristernal single wire loops are placed around a continuous vertical pericostal weave.3 This requires only a few minutes more than routine sternal wire closure, and does not add significantly to postoperative bleeding complications.
We found no sternal dehiscence in patients with a single risk factor. In patients with 2 or more risk factors, the rate of dehiscence was 12.5% after routine wire closure and 2.5% after sternal weave closure. Hence we concluded that routine sternal closure is sufficient in all patients with single risk factor, whereas a prophylactic sternal weave should be performed in all high-risk patients (with 2 or more risk factors) undergoing median sternotomy for cardiac surgery, as it decreases the incidence of noninfective sternal dehiscence significantly, thereby decreasing the long-term morbidity. This study has also shown that conservative management of patients with sternal dehiscence and intact skin and soft tissue leads to good long-term results, and avoids reoperation which is associated with significant morbidity and mortality in this high-risk group.
ACKNOWLEDGMENTS
We acknowledge the assistance of Dr Ruchika Narang, MBBS, PhD, in analyzing data and in compilation of this manuscript.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:167-170
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103306
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