Interlocking figure-of-8 closure of the sternum

Evaluation of sternum closure methods by means of a nonlinear finite element analysis

The main purpose of this study is to develop a validated three-dimensional finite element model of sternum closure techniques. For this aim, the finite element method analysis results of three closure methods were compared with experimental test results. Also, three more closure techniques are simulated numerically to study the effect of the number of wires used in the manubrium and xiphoid regions. A three-dimensional model of polyurethane sternum foam was created based on computed tomography images. Six different closure techniques using steel wire, steel bands and ZipFix bands were modeled on the sternum and transferred into a three-dimensional finite element model. The sternum was modeled as an isotropic bilinear-elasto-plastic material, and nonlinear contact conditions were applied. The models were analyzed under lateral distraction loading, and load-displacement curves were obtained from displacements at the incision line. Allowable loads and stiffness values of the methods were evaluated from these curves. The results showed the importance of the including material as well as geometric nonlinearities in the simulations to obtain realistic results from the numerical analyses. Also, the analyses showed that closures that include steel or ZipFix bands are superior to conventional wiring, and addition of a single wire at the manubrium and xiphoid regions significantly improved the efficiency of the closure techniques.

Sternal wound closure in the current era: the need of a tailored approach

OBJECTIVE

Median sternotomy remains the most common access to perform cardiac surgery procedures. However, the experience of the operating surgeon remains a crucial factor during sternal closure to avoid potential complications related to poor sternal healing, such as mediastinitis. Considering the lack of major randomized controlled trials and the heterogeneity of the current literature, this narrative review aims to summarize the different techniques and approaches to sternal closure with the aim to investigate their reflections into clinical outcomes and to inform the choice on the most effective closure method after median sternotomy.

METHODS

A literature search through PubMed, Embase, EBSCO, Cochrane database of systematic reviews, and Web of Science from its inception up to April 2019 using the following search keywords in various combinations: sternal, sternotomy, mediastinitis, deep sternal wound infection, cardiac surgery, closure.

RESULTS

Single wire fixation methods, at present, seems the most useful method to perform sternal closure in routine patients, although patients with a fragile sternum might benefit more from a figure-of-eight technique. In high-risk patients (e.g. chronic pulmonary disease, obesity, bilateral internal mammary artery harvesting, diabetes, off-midline sternotomy), rigid plate fixation is currently the most effective method, if available; alternatively, weave techniques could be used.

CONCLUSION

The choice among the sternal closure techniques should be mainly inspired and tailored on the patient's characteristics, and correct judgement and experience play a pivotal role. A decisional algorithm has been proposed as an attempt to overcome the absence of specific guidelines and to guide the operative approach. This operative approach might be used also in non-cardiac procedure in which median sternotomy is required, such as in case of thoracic surgery.

New Technique for Reinforced Sternal Closure

A new technique for reinforced sternal closure is described. The method consists of placing longitudinal in-and-out wires, on each side of the sternum. The 2 longitudinal wires, which lie within the standard transverse wires, are joined and tightened at the upper and lower parts of the sternum after approximation of the transverse wires. This technique was found to be quick, simple and extremely effective.

Prospective, randomized, single blinded pilot study of a new FlatWire based sternal closure system

Background

Unstable steel wire cerclage following open heart surgery may result in increased pain, sternal cut-through, non-union, or dehiscence. These complications lead to longer hospital stays, increased cost, higher morbidity, and patient dissatisfaction. The Figure 8 FlatWire Sternal Closure System is a new construct which is a simple, intuitive, and inexpensive alternative for primary sternal repair following open heart surgery. Prior bench-top testing of FlatWire has demonstrated superior strength and stiffness compared to traditional steel wire. We present our initial experience in a prospective, randomized, single blinded pilot study utilizing this FDA approved system.

Methods

Sixty-three patients undergoing elective complete sternotomies at a single institution were randomly assigned to receive either the Figure 8 FlatWire or standard steel wire cerclage. All surgeries were performed by a single board certified cardiothoracic surgeon. Data collected included: Age, BMI, pump time, off pump to surgical stop time, length of hospital stay after surgery, cost from time of surgery to discharge, and pain on a visual analog pain scale on the day of discharge, day 30, and day 60.

Results

The groups were well matched. Patients receiving the Figure 8 FlatWire (33) had a reduction in length of stay compared to patients receiving steel wire circlage (30), but it was not statistically significant (6.8 vs. 7.8 days respectively, p < 0.093). Additionally those with the FlatWire reported significantly decreased pain at day of discharge (3.07 vs. 4.92 points on pain scale, p < 0.0066), with similar pain scores at 30 and 60 days. Off pump to surgery stop time was increased by 15.9 minutes in patients receiving the FlatWire vs. steel wires (55.7 vs. 71.6 minutes, p = 0.00025). Mean cost from surgery until discharge was $87,820.98 in the FlatWire group vs. $91,930.29 in the steel wire group (p < 0.3082).

Conclusion

Early clinical results suggest that Figure 8 FlatWire provides excellent stability, which resulted in significantly diminished postoperative pain at discharge. Although not significant there was a trend toward decreased length of stay, and reduced cost. Further clinical research is warranted to expand upon these initial trends and validate long term outcomes.

Comparison of straight median sternotomy and interlocking sternotomy with respect to biomechanical stability

AIM: To increase the stability of sternotomy and so decrease the complications because of instability.

METHODS: Tests were performed on 20 fresh sheep sterna which were isolated from the sterno-costal joints of the ribs. Median straight and interlocking sternotomies were performed on 10 sterna each, set as groups 1 and 2, respectively. Both sternotomies were performed with an oscillating saw and closed at three points with a No. 5 straight stainless-steel wiring. Fatigue testing was performed in cranio-caudal, anterio-posterior (AP) and lateral directions by a computerized materials-testing machine cycling between loads of 0 to 400 N per 5 s (0.2 Hz). The amount of displacement in AP, lateral and cranio-caudal directions were measured and also the opposing bone surface at the osteotomy areas were calculated at the two halves of sternum.

RESULTS: The mean displacement in cranio-caudal direction was 9.66 ± 3.34 mm for median sternotomy and was 1.26 ± 0.97 mm for interlocking sternotomy, P < 0.001. The mean displacement in AP direction was 9.12 ± 2.74 mm for median sternotomy and was 1.20 ± 0.55 mm for interlocking sternotomy, P < 0.001. The mean displacement in lateral direction was 8.95 ± 3.86 mm for median sternotomy and was 7.24 ± 2.43 mm for interlocking sternotomy, P > 0.001. The mean surface area was 10.40 ± 0.49 cm² for median sternotomy and was 16.8 ± 0.78 cm² for interlocking sternotomy, P < 0.001. The displacement in AP and cranio-caudal directions is less in group 2 and it is statistically significant. Displacement in lateral direction in group 2 is less but it is statistically not significant. Surface area in group 2 is significantly wider than group 1.

CONCLUSION: Our test results demonstrated improved primary stability and wider opposing bone surfaces in interlocking sternotomy compared to median sternotomy. This method may provide better healing and less complication rates in clinical setting, further studies are necessary for its clinical implications.

A review of sternal closure techniques

Sternotomy and sternal closure occur prior to and post cardiac surgery, respectively. Although post-operative complications associated with poor sternal fixation can result in morbidity, mortality, and considerable resource utilization, sternotomy is preferred over other methods such as lateral thoracotomy. Rigid sternal fixation is associated with stability and reduced incidence of post-operative complications. This is a comprehensive review of the literature evaluating in vivo, in vitro, and clinical responses to applying commercial and experimental surgical tools for sternal fixation after median sternotomy. Wiring, interlocking, plate-screw, and cementation techniques have been examined for closure, but none have experienced widespread adoption. Although all techniques have their advantages, serious post-operative complications were associated with the use of wiring and/or plating techniques in high-risk patients. A fraction of studies have analyzed the use of sternal interlocking systems and only a single study analyzed the effect of using kryptonite cement with wires. Plating and interlocking techniques are superior to wiring in terms of stability and reduced rate of post-operative complications; however, further clinical studies and long-term follow-up are required. The ideal sternal closure should ensure stability, reduced rate of post-operative complications, and a short hospitalization period, alongside cost-effectiveness.

Septic rupture of the ascending aorta after aortocoronary bypass surgery

We describe an exceptional case of non-fatal septic rupture of the ascending aorta in a patient with sternal dehiscence, deep sternal wound infection (DSWI) and pleural empyema after aortocoronary bypass surgery. Routine follow-up computed tomography (CT) detected a mediastinal pseudoaneurysm originating from the ascending aorta. Thereby, massive and irregular sternal bone defects and contrast-enhancing mediastinal soft tissue suggest osteomyelitis and highly-active and aggressive DSWI as initial triggers. Urgent thoracotomy 1 day later included ascending aorta reconstruction, total sternum resection and broad wound debridement. Follow-up CT 1 year later showed a regular postoperative result in a fully recovered patient.

Sternal closure reinforced with rib heads: a novel technique for prevention and treatment of sternal dehiscence

BACKGROUND

When a sternotomy cannot be performed at the midline and/or there is infection at the operation site, sternotomy revision can cause problems that increase the mortality and morbidity of the patients. There is no agreement on the best treatment method. In this paper we present a modified wiring technique.

METHODS

This technique consisted of wrapping wires twice around each rib head and placing standard circumferential wire sutures, thus providing full stability by decreasing the load on the sternum using only steel wires. The study group included 23 patients with sternal dehiscence because of inappropriate sternotomy (n = 10) and/or mediastinitis (n = 13). Two mediastinal tubes were placed for irrigation in 13 patients with mediastinitis and/or wound infection, and mobilization and interposition of omentum as an axial graft was performed in 2 patients. Irrigation and antibiotherapy were continued for 4 to 6 weeks.

RESULTS

Complete wound healing was obtained in all patients. Twenty-two patients treated with this technique survived. One patient died on postoperative 42nd day because of renal insufficiency and multi-organ failure.

CONCLUSION

Early and aggressive debridement of infected and necrotic tissue, irrigation, and antibiotics are necessary for successful treatment, but we believe that the most important factor is full stabilization of the sternal tissue with minimal use of foreign stabilization material. Despite the limited number of cases, we suggest that our stabilization technique seems to be successful in achieving full stabilization even in infected and fragile sternal bony tissue in patients with sternal dehiscence and/or inappropriate sternotomy.

An Alternative Reinforced Closure Technique with External Kirschner Wires in Sternal Dehiscence

OBJECTIVE

We present an alternative closure technique that is effective in length stabilization of the dehisced sternum, technically easy, and less time consuming.

METHODS

Between June 2000 and June 2003, 850 patients underwent open heart surgery in the participating clinics. In all of the patients, the sternotomies were primarily closed with No. 5 steel wires in a figure 8 manner or with single sutures. Eleven patients with sterile sternal dehiscence underwent operations with Kirschner wires.

RESULTS

During the postoperative period, no complications related to the implants were observed in any of the patients in the early and late follow-ups.

CONCLUSION

With this technique, the fragile sternum is easily and effectively stabilized by reinforcing with suprasternal Kirschner wires without applying complicated manipulations.

Corpus Sterni Reinforcement Improves the Stability of Primary Sternal Closure in High-Risk Patients

PURPOSE

To compare standard sternal closure techniques with reinforcement longitudinal wire placement in the corpus sterni in high-risk patients undergoing open-heart surgery via median sternotomy.

METHODS

The subjects of this study were 71 high-risk patients, 32 (45%) of whom underwent sternal closure by conventional methods (group 1) and 39 (55%) of whom underwent sternal closure with corpus sterni reinforcement. The patients were followed up for a mean period of 90 days.

RESULTS

In group 2, none of the patients had sternal dehiscence and no revision was required, but in group 1, five (15.5%) patients had sternal dehiscence. This difference was significant between the groups (P = 0.024), but there were no significant differences in mediastinitis and mortality (P > 0.05).

CONCLUSIONS

Our findings suggest that primary sternal closure with longitudinal wire reinforcement on both sides of the corpus sterni will decrease the risk of infection and improve wound-healing in parallel with a decrease in sternal dehiscence.

Polydioxanone Sternal Sutures for Prevention of Sternal Dehiscence

BACKGROUND

Sternal dehiscence and wound instability are troublesome complications following median sternotomy. Classic sternal approximation with stainless steel wires may not be the ideal approach in patients predisposed to these complications. We tested the efficacy of polydioxanone (PDS) suture in sternal closure and in prevention of complications in comparison to steel wires in high-risk individuals.

METHODS

Three hundred sixty-six patients undergoing elective cardiac surgery with full median sternotomy and having body surface area (BSA) less than 1.5 m(2) were randomly assigned to receive PDS (n = 181) or stainless steel (SS, n = 185) sternal approximation. The study was focused on aseptic sternal complications, namely bone dehiscence and superficial wound instability.

RESULTS

Both bone dehiscence and superficial wound instability were less frequent in the PDS Group (4 and 3 cases in the SS Group, respectively, vs. no cases in the PDS Group). Cox proportional hazards regression model in the whole study population identified female sex, chronic renal insufficiency, diabetes, advanced age, lower sternal thickness, osteoporosis, corticosteroid therapy, and prolonged CPB or ventilation times as predisposing factors to any of the two studied sternal complications.

DISCUSSION

Data suggest that PDS suture can protect against development of aseptic sternal complications following median sternotomy in high-risk patients with little body mass. The adoption of PDS in other subsets of patients, i.e., obese individuals, is to be questioned.

Median Sternotomy Closure in Dogs: A Mechanical Comparison of Technique Stability

OBJECTIVE

To evaluate the mechanical properties of canine median sternotomy closure using double-loop cerclage compared with other commonly used cerclage sternotomy closure patterns.

STUDY DESIGN

Experimental study.

SAMPLE POPULATION

Forty canine cadaveric sternal segments.

METHODS

Median sternotomy-wire constructs were loaded to failure in a materials testing machine. Each construct was radiographed before and after testing. Specific wire configurations tested were: 2 single twist cerclage centered on the sternebrae, single twist figure of 8 pattern centered on the sternal synchondrosis, double twist figure of 8 pattern centered on the sternal synchondrosis, 2 double-loop cerclage centered on the sternebrae, and 1 double-loop cerclage centered on the sternal synchondrosis. Wire configurations were compared by craniocaudal translation of sternabrae on pre-test radiographs, and displacement during loading, and mode of failure, based on analysis of test video, and post-test radiographs.

RESULTS

Double-loop cerclage did not provide superior mechanical stabilization of median sternotomy. Both figure of 8 patterns had the least displacement at higher loads. Two single twists that were centered on sternebrae were least able to prevent displacement at higher loads, caused the most craniocaudal translation before testing, and fractured more often at loads < or = 200 N compared with other configurations.

CONCLUSION

Sternal wiring techniques stabilizing sternal synchondroses had the least displacement. Overall, figure of 8 cerclage appeared most suitable because they minimized displacement at high loads and facilitated accurate reduction during tensioning.

CLINICAL RELEVANCE

In closing canine sternotomy, figure of 8 cerclage may be most suitable. Double-loop cerclage centered on the sternal synchondrosis should be avoided because of wire failure at high loads.

Advanced Sternal Closure to Prevent Dehiscence in Obese Patients

Sternal dehiscence is a frequent complication after cardiac surgical procedures. The objective was to evaluate a novel method for advanced sternal closure compared with standard techniques for preventing sternal dehiscence. Our investigation comprised 100 patients with a body mass index above 32. Patients were randomly assigned to receive either advanced sternal closure with three stainless steel double wires or standard techniques with stainless steel single wires. The incidence of sternal refixation was 6 of 50 patients in the standard techniques group and 1 of 50 in the advanced sternal closure group during a follow-up period of 6 months.

Numerical Simulation Techniques to Study the Structural Response of the Human Chest Following Median Sternotomy

BACKGROUND

The optimal closure technique of median sternotomy remains controversial. The objective of this study was to analyze the structural response of the separated sternum using computer-based numerical discretization techniques, such as finite element methods.

METHODS

Thoracic computer tomographic scans (2.5-mm slices) were segmented, analyzed by image processing techniques, and transferred into a three-dimensional finite element model. In a first approach a linear elastic material model was used; neglecting nonlinear and damage effects of the bones. The influence of muscles and tendons was disregarded. Nonlinear contact conditions were applied between the two sternal parts and between fixation wires and sternum. The structural response of this model was investigated under normal breathing and asymmetric leaning on one side of the chest. Displacement and stress response of the segmented sternum were compared regarding two different closure techniques (single loop, figure-of-eight).

RESULTS

The obtained results revealed that for the normal breathing load case the single loop technique is capable of clamping the sternum sufficiently, assuming that the wires are prestressed. For asymmetric loading conditions, such as leaning on one side of the chest, the figure-of-eight loop can substantially reduce the relative longitudinal displacement between the two parts compared with the single loop.

CONCLUSIONS

The application of numerical simulation techniques using complex computer models enabled the determination of structural behavior of the chest regarding the influence of different closure techniques. They allowed easy and fast modifications and therefore, in contrast to a real physical model, in-depth parameter studies.

Interlocking sternotomy: initial experience

An interlocking sternotomy using a lazy-S-shaped incision was performed in 91 patients undergoing cardiac surgical procedures (group A). The results were compared with those of 77 patients (group B) who underwent a standard sternotomy by the same surgical team. In group A, the incidence of sternal instability was 2.27% (2/88) versus 8.21% (6/73). No dehiscence or mediastinitis was noted in group A, whereas 6.85% (5/73) in group B had this complication. Analysis of diabetics revealed no sternal complication in group A compared to 50% (3/6) in group B. The interlocking sternotomy significantly reduced the incidence of sternal instability and helped to prevent sternal dehiscence and mediastinitis. Use of this safe, simple, and reproducible technique is strongly recommended, especially in diabetics.

A modified parasternal wire technique for prevention and treatment of sternal dehiscence

BACKGROUND

Sternal dehiscence with or without mediastinitis is a devastating complication of median sternotomy. Various techniques of sternotomy closure including 'figure of eight' wire sutures, nylon bands, and custom-made titanium-H plates have been described. We have devised and tested a new method of sternal closure to prevent sternal wound complications in patients at high risk of sternal dehiscence.

METHODS

1336 patients underwent sternotomy for various cardiac operations from January 1996 to January 2002. Patients were divided into two groups. Group I consisted of 560 patients who did not have any high risk factors for sternal dehiscence and received a standard six wire closure. Group II comprised of patients at high risk of sternal dehiscence and were divided randomly into subgroup II A (n = 390), which included patients who had conventional sternal closure. While in subgroup II B (n = 386) patients had a modified parasternal wire closure according to the finalized protocol.

RESULTS

Sternal instability was noticed in 1/560 and none had sternal dehiscence in group I, but 16/390 patients had sternal instability and 3/390 had sternal dehiscence in subgroup II A, whereas only one patient in high risk subgroup II B developed sternal dehiscence with mediastinitis and required a pectoral flap advancement for sternal closure.

CONCLUSIONS

Use of modified parasternal wire closure in patients with a high risk of sternal dehiscence is a safe, effective, technically easily reproducible, as well as economical, method of preventing and treating sternal dehiscence.

Reinforced sternal closure: the bilateral straight longitudinal wire technique

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.

Closure of median sternotomy in dogs: suture versus wire

Twenty normal, large-breed dogs underwent median sternotomy. Median sternotomies were closed with 20-gauge orthopedic wire in 10 dogs and no. 2 polybutester in 10 dogs. Closure with suture was faster than with wire (6.7 +/- 1.8 minutes versus 9.1 +/- 1.9 minutes, respectively). Significant differences were not observed in degree of postoperative pain or wound complication rates. Sternotomies closed with wire showed a trend to be more stable and had significantly less displacement on radiographic evaluation at 28 days. All sterna closed with wire examined histopathologically showed evidence of chondral or osteochondral bridging, while sterna closed with suture only showed fibrous union.

Fatigue testing median sternotomy closures

OBJECTIVE

Sternal dehiscence is commonly due to wire cutting through bone. With a biological model, we measured the rate of cutting through bone, of standard steel wire closure, peristernal steel wire, figure-of-eight closure, polyester and sternal bands sternotomy closure techniques.

METHODS

Polyester, figure-of-eight, peristernal and sternal band closures were tested against standard closure eight times using adjacent paired samples, to eliminate biological variables. Fatigue testing was performed by a computerized materials-testing machine, cycling between loads of 1 and 10 kg. The displacements at maximum and minimum loads were measured during each cycle. Cutting through, manifested by the displacement at the maximum load between the 1st and 150th cycles was measured. The percentage cut-through of each closure method versus standard closure was calculated.

RESULTS

The differences in the displacement between each of the polyester (1.01 mm), figure-of-eight (0.52 mm), peristernal (0.72 mm) and sternal band (0.66 mm) groups versus standard closure (0.22, 0.22, 2.1, 3.2 mm) in the paired samples were statistically significant (Student's paired t-test; P<0.01). There were statistically significant differences in the percentage cut-through of polyester, figure-of-eight, peristernal and sternal bands (ANOVA, P<0.001), versus standard closure.

CONCLUSIONS

In our sheep sternum model, we have quantified the differing rate of cutting through bone of five types of median sternotomy closure techniques. We have controlled for bone variables by testing each closure versus standard closure using paired adjacent bone samples. Peristernal and sternal band closure techniques are significantly superior to standard closure. The use of polyester and figure-of-eight closures requires caution.

Routine sternal closure using interlocking multitwisted wires

We describe a method of sternal closure that enhances sternal stabilization and minimizes bleeding from sternal fractures caused by retraction. With the technique of interlocking multitwisted wires the initial placement of the wire sutures is the same as in traditional sternal closure, however the twisting technique is improved, with multiple twisting including four twisted strands. Our method of closure is effective, simple and quick to perform and has several advantages over conventional or figure-of-eight closure. This closure is also biomechanically more rigid than conventional or figure-of-eight closure. We therefore recommend routine sternal closure using interlocking multitwisted wires.

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.

Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps

BACKGROUND

The treatment of sternal wound complications is controversial. It is our practice to combine early aggressive debridement, a modified Robicsek sternal closure, and bilateral pectoralis major advancement flaps with or without closed irrigation in a single procedure. We reviewed our experience to determine the efficacy of this approach.

METHODS

Grade II to IV mediastinitis (dehiscence and infection) developed in 47 patients 3 to 14 days after routine open heart operations between 1990 and 1995. Culture-positive infection was identified in 60% (n = 28); 62% (n = 29) had septicemia. Thirty patients underwent incision, drainage, and surgical assessment of the wound. Once systemic signs of infection were under control (no pyrexia, normal white blood cell count), formal single-stage debridement of all infected soft tissues and bones was performed. Sternal stability was achieved using a modified Robicsek closure and bilateral pectoralis major advancement flaps. Seventeen patients were treated with staged procedures.

RESULTS

Early sternal closure and coverage with pectoralis major advancement flaps can be associated with a low mortality (0%), low morbidity (13%; n = 4: three superficial wound infections, one seroma), and shortened hospital stay (median, 22 days, compared with a median of 82 days in patients managed with conservative staged treatment; p < 0.05). Sternal stability with excellent functional and aesthetic results has been achieved in all patients.

CONCLUSIONS

The combination of aggressive early surgical debridement, sternal closure, and the placement of bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity and a short hospital stay.

Routine sternal closure using six overlapping figure-of-8 wires

Contemporary cardiac surgery patients have an increased incidence of risk factors that adversely affect sternal healing. We recommend routine closure of all sternotomy incisions using six overlapping figure-of-8 wire sutures. This augmented closure is simple and effective in counteracting all forces that would delay or disrupt sternal union.

Pericostal sutures to reinforce sternal closure after cardiac surgery

BACKGROUND AND AIM OF THE STUDY

An increasing number of elderly and medically complex patients are undergoing cardiac surgery and are at increased risk for sternal dehiscence. A technique of sternal closure reinforcement with pericostal wires is described, and results are reviewed.

METHODS

After placement of the standard peristernal wires, one or two sets of pericostal wires were placed around ribs in the mid-portion of the sternotomy to reinforce the closure. A retrospective study over a 6-year period was carried out to determine the incidence of sternal dehiscence and any associated complications. Pericostal wires were used in well over 50% of cases.

RESULTS

The incidence of sternal dehiscence was 4 out of 1048 operations (0.38%). No adverse effects of the pericostal wires were identified.

CONCLUSIONS

Frequent use of pericostal wires is associated with a low incidence of sternal dehiscence.

Simplified method of reinforced sternal closure

A simplified method of reinforcement for closure of the precarious sternum is described. This method uses a longitudinal sternal wire on each side, which lies within the transverse wires when they are approximated. The longitudinal wires serve as impenetrable reinforcements for the sternal halves, resulting in tight, secure approximation and preventing the transverse wires from tearing through the bone. The technique has been found quick and extremely effective.

Modified Robicsek technique for complicated sternal closure

A modification of the technique described by Robicsek and associates for treatment of sternum separation after open heart operation is described. The technique consists of placing four interlocking steel wires parasternally on both sides and then including them in the usual transverse peristernal wires.

Reinforced sternal closure

A technique of reinforced sternal closure with stainless steel struts is described. Stable sternum avoids severe complications such as mediastinitis and sternal dehiscence.