EComment. Multiple approaches for sternal dehiscence

Abstract

We read with great interest the paper by Kilian et al., investigating the efficacy of a novel technique using specially designed titanium hooks for sternal closure [1]. In the majority of their patients, the Atraumatic Sternum Closure System system was used as a secondary closure device after failure of the standard rewiring technique. The merit of this innovative approach and its feasibility are well discussed in this paper. However, the main benefit of this new system, that is, the application of hooks without dissecting the retrosternal space, has been previously described by Ceresa et al. [2]. The sternal wound is successfully approximated by the application of three Stratos bars fixed to the anterior arches of the second, forth and sixth ribs bilaterally. Each bar consists of two rib clips and a connecting bar. The Stratos system (Strasbourg Thoracic Osteosynthesis system, MedXpert GmbH, Eschbach, Germany) is frequently used for rib fixation and coverage of chest wall defect. It consists of titanium rib clips available in different angles and in two sizes and connecting bars, thus allowing the application of this system for any anatomical situations. As rightly pointed out by the authors, multiple techniques have been used to correct sternal dehiscence including nitinol thermo-reactive sternal clips [3-4] and numerous metal plating systems. One of the most-used plating systems is the new Titanium Sternal Fixation System (Synthes, Switzerland) [5]. It consists of titanium plates available in different lengths, flexible cables and self-tapping cannulated sternal screws. Nevertheless, the surgical management mandates a careful dissection of the deeper aspect of the sternum and extensive lysis of adhesions, especially in the case of longitudinal plating fixation for late sternal dehiscence. Voss et al. [5] stated that sternal plate fixation was possible without adhesiolysis of the retrosternal area, albeit with an increased risk of damaging underlying mediastinal structures. This technique is also time-consuming and costly. In this article, the authors describe a simple, effective and minimally invasive technique for complex sternal closure using new titanium hooks applied parasternally and achieving adequate sternal stabilization. It does not require re-entry into the retrosternal space or extensive mobilization of major pectoralis muscles. Conflict of interest: none declared.