Effective Median Sternotomy Closure After Open Heart Operations

Abstract

We read with interest the putatively novel surgical technique with a median sternotomy closure for high-risk patients by Bek and colleagues [1Bek E.L. Yun K.L. Kochamba G.S. Pfeffer T.A. Effective median sternotomy closure in high-risk open heart patients.Ann Thorac Surg. 2010; 89: 1317-1318Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. In contrast to the conventional sternotomy closure, in which the sternal wires are passed transsternally or parasternally through the intercostal space, this presented sternal closure technique passes the sternal wires transcostally through the costochondral joints. This technique thus describes a modified peristernal reinforcement of the lateral aspect of the sternum, allowing firm closure with less likelihood of the wires cutting through the sternal bone. The authors advocate this technique for high-risk patients, such as those who are older in age, have a history of osteoporosis, or who are morbidly obese. The authors also promote the use of 8 single wires, 3 interrupted wires for the manubrium and possibly 5 wires for the corpus part of the sternum. We affirm the great efficiency of this technique, because we practice this described modified parasternal method using the sometimes even calcified costochondral joints, which offer extra support for many years. This technique is faster than its transsternal counterpart, because the needle passes easily through the costochondral joints without provoking miniaturized fractures, keeping the integrity of the sternal bone. It also redistributes the dehiscence force to the greater bone volume of the sternum because the sternum is anatomically wider at the costochondral joints. We use this technique with probably more stable and secure interrupted single wires [2Casha A.R. Yang L. Kay P.H. Saleh M. Cooper G.J. A biomechanical study of median sternotomy closure techniques.Eur J Cardiothorac Surg. 1999; 15: 365-369Crossref PubMed Scopus (114) Google Scholar, 3Krejca M. Szmagala P. Skarysz J. et al.Force distribution in wire sternum sutures: the consequences for sternal closure rigidity.Med Sci Monit. 2003; 9: BR134-BR144PubMed Google Scholar], and also with figure-of-eight wires according to the surgeon's preference [4Murray K.D. Pasque M.K. Routine sternal closure using six overlapping figure-of-8 wires.Ann Thorac Surg. 1997; 64: 1852-1854Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar]. In contrast to the authors' suggestion, however, we apply this technique as our routine closure method for every patient undergoing median sternotomy and not only for high-risk patients. In conclusion, we congratulate the authors for their novel described technique. The intention of this comment is to promote this parasternal closure using the costochondral joints as a routine closure after median sternotomy, and not only for high-risk patients or patients with an anatomically narrow sternum or off-midline sternotomy. ReplyThe Annals of Thoracic SurgeryVol. 91Issue 1PreviewWe thank Camboni and Schmid for their comments [1] on our article [2] and their affirmation of our transcostal sternal closure technique. We agree with the authors that the transcostal sternal closure technique should be promoted and used routinely on all patients who require a median sternotomy. Transcostal closure maximizes the closure strength with greater sternal volume and greater resistance to fracture. It redistributes the dehiscence force (fracture force) to the greater bone volume of the sternum. Full-Text PDF