Use of new cannulated screws for primary sternal closure in high risk patients for sternal dehiscence

Abstract

Background: Median sternotomy is still the approach of choice for heart surgery and the most common sternal closure is conventional six-wire technique. Mediastinitis is the frightening complication of the median sternotomy and occurs from 1% up to 2.4% of cases with a mortality rate which ranges from 14% up to 47%. Many methods have been suggested to reinforce the sternum with the common goal to improve sternal stability and prevent mediastinitis, but there is not consensus among cardiac surgeons on the optimal way to close the sternum. For this reason, we report our experience with a sternal device that, although not entirely new as a concept, has new technical features and plays a new role in preventing sternal dehiscence, according to the most recent findings on mechanism which leads to sternal dehiscence. Methods:We enrolled 62 high risk patients for sternal dehiscence (patients with 2 well established historical risk factors), and we closed the sternum of the patients with a new surgical option consisting of passing, in a conventional six-wire sternal closure, the last sixth steel wire (Ø 1.0 mm, n° 5) through a couple of titanium cannulated screws (Ø 5.5 mm, self-tap-ping with a length from 10 to 16 mm and 2-mm increments) inserted into the 5th or 6th couple of rib cartilages. Results: Primary chest closure with cannulated screws was performed on 48 males and 14 females. The average age of patients was 67.6 years (range, 43-88 years). The average follow-up was 12.8±16.2 months (range, 1-41 months). Chronic obstructive pulmonary disease (COPD) was the most common preoperative risk factor. The average number of risk factors was 2.4 (range, 2-4). Coronary artery bypass grafting (CABG) was the most common cardiac procedure. There were no peri-operative deaths. BMI >30 Kg/m 2 and diabetes were the associated of risk factors predisposing to superficial skin dehiscence.Conclusions: In our clinical experience with high risk patients, this surgical option suggests that there is evidence of an effective stabilization of standard sternal closure and this option seems a promising technique to prevent the domino effect which starts from the xifoid bone and proceeds to the manubrium with the effect of leading to sternal instability which is the first step to mediastinitis.

The Development of an Automatic Rib Sequence Labeling System on Axial Computed Tomography Images with 3-Dimensional Region Growing

“…The true ribs are located at the top of the rib cage and morphologically long. The 5th, 6th, and 7th ribs in the true ribs converge, attaching roughly to the same sternum site anatomically [40]. This caused on the axial CT image that the rib regions were overlapped with a transverse axis, which resulted in the same label.…”

Efficacy of Primary Closure Technique in Treatment of Post-Sternotomy Mediastinitis in Paediatric Group: A Randomized Controlled Trial

“… 14 Additionally, patients can be mobilized early and can receive physiotherapy to minimize further complications. 4 …”

“… 3 Negative pressure application shows several advantages: 1) Negative pressure enhances wound drainage; 2) Negative pressure application avoids any mediastinal cavity residual and ensures that the mediastinum contains healthy tissue; 3) Negative pressure aids in approximation of the wound edges and stabilization of the chest; and 4) Favorable improvement in local microcirculation have been described, which stimulates the formation of granulation tissue by maintaining a moist environment. 4 …”

“…3 Negative pressure application shows several advantages: 1) Negative pressure enhances wound drainage; 2) Negative pressure application avoids any mediastinal cavity residual and ensures that the mediastinum contains healthy tissue; 3) Negative pressure aids in approximation of the wound edges and stabilization of the chest; and 4) Favorable improvement in local microcirculation have been described, which stimulates the formation of granulation tissue by maintaining a moist environment. 4 A recent approach with early primary closure of post-sternotomy wound over a single chest tube for mediastinal drainage, mostly removed in 1 or 2 days was described. This simple technique offers comfort for the patient with interestingly high rate of success.…”

Comparison of Two Sternal Closure Techniques Based on Risk Factors: A Prospective, Observational Study

“…Preoperative risk factors for sternal dehiscence were indicated as obesity, COPD, osteoporosis, heart failure (New York Heart Association functional class III-IV), corticosteroid, immunosuppression, diabetes mellitus, renal failure, and previous sternotomy [5,6].…”