Safety of absorbable suture for sternal closure after pulmonary or mediastinal resection

Novel use of interosseous absorbable mattress sutures for secondary sternal fixation: A case series

There is currently no consensus on the treatment of median sternotomy patients presenting secondarily with deep sternal wound infection or symptomatic sternal nonunion. We have developed a novel approach to sternal bone fixation when concerns for open wounds or microbial colonization preclude the use of permanent hardware placement: (1) sternal closure with absorbable interosseous monocortical horizontal mattress sutures followed by (2) multilayered soft tissue closure with pectoralis major advancement or turnover flaps. Benefits of this technique include: closure of retrosternal dead-space, tension offloading of the soft tissue closure, repair of transverse sternal fractures, and preservation of internal mammary artery (IMA) perforators for potential pectoralis turnover flaps. In our early experience, this technique has been successful at promoting functional sternal union - even in secondary closure of high-risk patients contraindicated for permanent hardware placement.

Evolution of degradation mechanism and fixation strength of biodegradable Zn-Cu wire as sternum closure suture: An in vitro study

This work reports the first in vitro study on the in-situ biodegradation behaviour and the evolution of fixation strength of Zn-Cu alloy wires in a simulated sternum closure environment. Zn-Cu wires were used to reapproximate the partial bisected sternum models, and their fixation effect was compared with traditional surgical grade 316 L stainless steel (SS) wires in terms of fixation rigidity, critical load, first/ultimate failure characteristics. The metal sutures were then immersed in Hank's balanced salt solution for 12 weeks immersion period, and their corrosion behaviours assessed. Zn-Cu wires showed similar fixation rigidity at 70.89 ± 6.97 N/mm as SS, but the critical load, first failure and ultimate failure characteristics were inferior to SS. The key challenges that limited the fixation effect of the Zn-Cu wires were poor mechanical strength, short elastic region, and strain softening behaviours, which resulted in poor load-bearing capabilities and reduced the knot security of the sutures. The in-situ biodegradation of the Zn-Cu suture was accompanied by the early onset of localised corrosion within the twisted knot and the section located next to the incision line. Crevice corrosion and strain-induced corrosion were the dominant mechanisms in the observed localised corrosion. The localised corrosion on the Zn-Cu sutures did not lead to a significant shift in fixation rigidity, critical load and the first failure characteristics. The findings suggest that the Zn-based biodegradable metallic wires could be a promising sternum closure suture material once the limitations in mechanical characteristics are addressed.

Sternal closure with absorbable pins and cords in general thoracic surgery

After median sternotomy, the sternum is commonly closed using metal wires, which sometimes cause complications because they are permanent foreign bodies. As an alternative, we used a combination of absorbable sutures and pins for full median sternotomy in 24 adult general thoracic surgery patients. There were three cases of sternal dehiscence detectable by computed tomography, none of which required re-operation. Two of these patients had diabetes mellitus (DM) and the third patient was on corticosteroid therapy. In an appropriately selected patient population that excludes patients with DM or who are undergoing corticosteroid therapy, we have not observed any sternal complications. We concluded that our technique is clinically feasible with appropriate patient selection.

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.

A new proposal of skin-closure system for median sternotomy: usefulness and cosmetic results analysis of MEDIZIP Surgical Zipper in neoplastic immuno-compromised patients

BACKGROUND AND OBJECTIVES

The authors evaluate the effectiveness and the cosmetic results obtained using the new skin closing system MEDIZIP Surgical Zipper in oncological immuno-compromised patients submitted to median sternotomy.

METHODS

In our Institute, from 1999 to 2002, MEDIZIP was used to close the sternal wounds in 45 patients undergoing median sternotomy for bilateral metastasectomy, It took about half a minute (mean time: 32.00 +/- 11.48 sec) to perform the application. To evaluate the cosmetic results, a three-level scale was conceived: level 1: very good, level 2: satisfactory, level 3: inadequate.

RESULTS

Overall forty-two 20 cm-long zippers were used, two 25 cm-long and one 30 cm-long. MEDIZIP remained in situ for an average of 9.98 +/- 2.23 days (median: 9 days; range: 8-13 days). The average time taken for inspection was 70.00 +/- 2.48 sec (median: 70, range: 45-130) and the zipper was removed in a few seconds. No wound infections were observed. We classified 39 patients at level 1 (very good, 87%), and 6 at level 2 (satisfactory, 13%).

CONCLUSIONS

MEDIZIP can be considered an effective skin-closure system which is easily and quickly handled and assures good cosmetic results with non-invasive removal; it proves particularly useful in pediatric patients and in adults affected by neoplastic diseases and undergoing multiple combined anti-cancer treatments.

Double transmanubrial approach and sternotomy for resection of a giant thymic carcinoid tumor

The transmanubrial approach allows excellent unilateral exposure of the thoracic outlet. However, selected patients may require a bilateral cervicomediastinal exposure to completely resect the neoplasm. We report the use of a "double" transmanubrial approach for the resection of a giant mediastinal mass requiring bilateral vascular dissection and superior vena cava system resection and replacement.

Sternal closure with resorbable synthetic loop suture material in children

PURPOSE

The reliability of poly-p-dioxanone (PDS) suture for sternal closure was tested on 264 consecutive sternotomies in the authors' department from April 1987 to May 1998.

METHODS

The reason for sternotomy was tetralogy of Fallot in 65 cases (24.6%), ventricular septal defect (VSD) in 38 cases (14.4%), atrial septal defect (ASD) in 77 cases (29.2%), ASD + VSD in 23 (8.7%), mitral valve replacement in 22 cases (8.3%), aortic valve replacement in 10 cases (3.8%), and other cardiac disorders in 29 cases (11.0%).

RESULTS

Sternal wound infection, sternal dehiscence, and mediastinitis occurred in 1.5% of patients (4 of 264). The overall hospital mortality rate related to the mediastinitis was 1.1% (3 of 264) in the early postoperative period.

CONCLUSION

This absorbable suture and our different technique are a safe alternative to standard sternotomy closure after pediatric open cardiac surgery.

Surgical materials and wound closure techniques

Recent innovations in surgical materials have helped to enhance wound healing and protect surgical wounds from infection. Materials such as polyglyconate have been evaluated in equine tissues and found efficacious. Other materials, such as poliglecaprone 25, appear to have qualities useful to equine surgery but are untested in equine tissues. Care must be taken to fully evaluate a new surgical material because its usefulness in equine tissues may not match that in human or laboratory animal tissues. Furthermore, use of disposable materials in surgery, although considered ideal for maintenance of sterility, may come under more scrutiny in the future as environmental issues gain prominence. We tend to reserve disposable materials for prolonged procedures and for procedures that carry high risk of failure if infection develops.

Secondary sternal repair following median sternotomy using interosseous absorbable sutures and pectoralis major myocutaneous advancement flaps

A consecutive series of 19 patients were treated for median sternotomy dehiscence by secondary sternal closure with interosseous absorbable sutures and superimposed pectoralis major myocutaneous advancement flaps. These patients were selected for this treatment only on the basis of the quality and quantity of remaining bone stock after debridement. Using this technique there have been no failures of primary therapy with a zero 30-day mortality rate. All patients have achieved good functional and aesthetic results with mechanically stable sternums, wounds confined to the chest and elimination of sepsis. This technique has the advantages of being simple, safe and relatively quick and avoids many of the inherent complications and disadvantages of other techniques and flaps commonly used in the management of this complication.