Abstract
BackgroundAfter sternotomy, the spectrum for sternal osteosynthesis comprises standard wiring and more complex techniques, like titanium plating. The aim of this study is to develop a predictive risk score that evaluates the risk of sternum instability individually. The surgeon may then choose an appropriate sternal osteosynthesis technique that is risk- adjusted as well as cost-effective.MethodsData from 7.173 patients operated via sternotomy for all cardiovascular indications from 2008 until 2017 were retrospectively analyzed. Sternal dehiscence occurred in 2.5% of patients (n = 176). A multivariable analysis model examined pre- and intraoperative factors. A multivariable logistic regression model and a backward elimination based on the Akaike Information Criterion (AIC) a logistic model were selected.ResultsThe model showed good sensitivity and specificity (area under the receiver-operating characteristic curve, AUC: 0.76) and several predictors of sternal instability could be evaluated. Multivariable logistic regression showed the highest Odds Ratios (OR) for reexploration (OR 6.6, confidence interval, CI [4.5–9.5], p < 0.001), obesity (body mass index, BMI > 35 kg/m2) (OR 4.23, [CI 2.4–7.3], p < 0.001), insulin-dependent diabetes mellitus (IDDM) (OR 2.2, CI [1.5–3.2], p = 0.01), smoking (OR 2.03, [CI 1.3–3.08], p = 0.001). After weighting the probability of sternum dehiscence with each factor, a risk score model was proposed scaling from − 1 to 5 points. This resulted in a risk score ranging up to 18 points, with an estimated risk for sternum complication up to 74%.ConclusionsA weighted scoring system based on individual risk factors was specifically created to predict sternal dehiscence. High-scoring patients should receive additive closure techniques.
Highlights
After sternotomy, the spectrum for sternal osteosynthesis comprises standard wiring and more complex techniques, like titanium plating
Risk factors for sternal dehiscence and uni-variable analysis The data of 7173 patients were analysed and 176 (2.5%) patients were found to suffer from sternal dehiscence due to malunion of the sternum (MUST)
The following factors were risk factors for mal-union of the sternum (MUST) according to the univariable analysis (Table 2)
Summary
The spectrum for sternal osteosynthesis comprises standard wiring and more complex techniques, like titanium plating. As every surgical procedure bears the potential of complications, this approach bears a potential risk of sternal dehiscence and infection that may threaten the outcome of the operation and potentially affect the patient’s physical and his psychological recovery. It is a matter of economics, as complicated postoperative courses are up to 2.8 times more expensive than uncomplicated cases [3, 4]. Even risk score models were created [6,7,8,9], but they were mostly designed not for all indications but only for coronary patients and especially associated with the usage of bilateral internal thoracic arteries (BITA) in coronary artery bypass grafting (CABG) [10]
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