Sternum Dehiscence: A Preventable Complication of Median Sternotomy
Review of 1559 Consecutive Sternotomy Without Dehiscence
DOI:
https://doi.org/10.1532/hsf.3109Keywords:
cardiothoracic surgery; dehiscence; mediastinitis; sternotomy;Abstract
Background: The incidence of sternal dehiscence following cardiothoracic surgery via sternotomy is rare. It causes serious patient dissatisfaction and leads to higher hospital costs. For years, each clinic has made efforts to reduce this complication. Here, we aimed to summarize our techniques to prevent dehiscence.
Material: This retrospective study included two groups operated via median sternotomy from March 2009 to May 2019. The first group included 1,105 consecutive patients who only received sternum wire for sternum closure from March 2009 to October 2013. The second group included 1,559 consecutive patients operated from January 2014 to May 2019; preventive closure techniques were performed for predefined high-risk patients in this group. These closure techniques included polyglyconate (Maxon) or simple longitudinal reinforced sutures, sternal cable or sternoband, sternal plate, and Robiscek technique.
Results: All patients in Group 1, and 63.8% (995/1559) patients in Group 2 received sternal wire only (P < .001). In Group 2, we applied preventive closure techniques to 564 (36.2%) patients. There was no sternal dehiscence in Group 2, whereas 29 (2.6%) patients postoperatively suffered sternal dehiscence in Group 1; this was statistically significant (P = .001, OR:85.5, 95%CI:5.22-1400.4). The overall incidence of mediastinitis was 0.94%. The incidence significantly was lower in Group 2 (P = .004, OR:3.6, 95%CI:1.52-8.82). Sternum-related mortality in Group 2 also was lower (0.54% versus 0.06%, P = .048, OR:8.5, 95% CI: 1.02-70.75).
Conclusion: Sternal dehiscence can be avoided by careful perioperative risk assessment and enhanced closure techniques. The same special consideration may significantly reduce mediastinitis and sternal-related mortality.
References
Abu-Omar Y, Kocher GJ, Bosco P, et al. 2017. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 51:10-29.
Ata EC, Boylu BB. 2018. Sternal Steel Wire Induced Persistant Intermittan Mediastinal Wound Drainage After CABG. Turkiye Klinikleri J Case Rep 26:98-101.
Ata EC, Dereli Y. 2015. Effects of Polyglyconate (Maxon) Suture Reinforced Sternum Closure Technique on Aseptic Sternal Dehiscence in High Risk Patients. Kosuyolu Heart J 18:15-18.
Eklund AM, Lyytikäinen O, Klemets P, et al. 2006. Mediastinitis After More Than 10,000 Cardiac Surgical Procedures. Ann Thorac Surg 82:1784-9.
Elassal, AA, Al-Ebrahim KE, Al-Radi, OO, Jabbad HH, Eldib OS. 2020. Sternal Wound Complications: Objective Reclassification and Surgical Reconsideration. The Heart Surgery Forum 23:E076-E080.
Engelman R, Shahian D, Shemin R, Guy TS, et al. 2007. Antibiotic Prophylaxis in Cardiac Surgery, Part II: Antibiotic Choice. Ann Thorac Surg 83:1569-76.
Evans AS, Weiner MM, Arora RC, et al. 2016. Current approach to diagnosis and treatment of delirium after cardiac surgery. Ann Card Anaesth 19:328-37.
Fu RH, Weinstein AL, Chang MM, et al. 2016. Risk factors of infected sternal wounds versus sterile wound dehiscence. J Surg Res 200:400-7.
Gårdlund B, Bitkover CY, Vaage J. 2002. Postoperative mediastinitis in cardiac surgery – microbiology and pathogenesis. Eur J Cardiothorac Surg 21:825-30.
Gaudino M, Glieca F, Luciani N, et al. 2018. Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study. Cardiothorac Surg 54:702-7.
Giltay EJ, Huijskes RVHP, Kho KH, et al. 2006. Psychotic symptoms in patients undergoing coronary artery bypass grafting and heart valve operation. Eur J Cardiothorac Surg 30:140–7.
Kamiya H, Al-maisary SS, Akhyari P, et al. 2012. The number of wires for sternal closure has a significant influence on sternal complications in high-risk patients. Interact Cardiovasc Thorac Surg 15:665-70.
Lador A, Nasir H, Mansur N, et al. 2012. Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother 67:541-50.
Mehaffey JH, Hawkins RB, Byler M, et al. 2018. Cost of individual complications following coronary artery bypass grafting. J Thorac Cardiovasc Surg:155:875-882.e1.
Nenna A, Nappi F, Dougal J, et al. 2019. Sternal wound closure in the current era: the need of a tailored approach. Gen Thorac Cardiovasc Surg 67:907-16.
Nishimura T, Kurihara C, Sakano Y, et al. 2014. Sternalock plating system for elderly post-sternotomy patients. J Artif Organs 17:288-90.
Norman G, Goh EL, Dumville JC, et al. 2020. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev 5:CD009261.
Olbrecht VA, Barreiro CJ, Bonde PN, et al. 2006. Clinical outcomes of noninfectious sternal dehiscence after median sternotomy. Ann Thorac Surg 82:902-7.
Raman J, Lehmann S, Zehr K, et al. 2012. Sternal closure with rigid plate fixation versus wire closure: a randomized controlled multicenter trial. Ann Thorac Surg 94:1854-61.
Robicsek F, Fokin A, Cook J, Bhatia D. 2000. Sternal instability after midline sternotomy. Thorac Cardiovasc Surg 48:1-8.
Royse AG, El-Ansary D, Hoang W, et al. 2020. A randomized trial comparing the effects of sternal band and plate fixation of the sternum with that of figure-of-8 wires on sternal edge motion and quality of recovery after cardiac surgery, Interactive CardioVascular and Thoracic Surgery 30:863-70.
Schimmer C, Sommer SP, Bensch M, Bohrer T, Aleksic I, Leyh R. 2008. Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur J Cardiothorac Surg 34:132-8.
Shafir R, Weiss J, Herman O, Cohen N, Stern D, Igra Y. 1988. Faulty sternotomy and complications after median sternotomy. J Thorac Cardiovasc Surg 96:310-3.
Shaikhrezai K, Robertson FL, Anderson SE, Slight RD, Brackenbury ET. 2012. Does the number of wires used to close a sternotomy have an impact on deep sternal wound infection? Interact Cardiovasc Thorac Surg 15:219-22.
van Harten AE, Scheeren TW, Absalom AR. 2012. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia 67:280-93.
