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We appreciate the interest expressed by Raja [1Raja S.G. Transcostal sternal closure: ongoing quest for the Holy Grail (letter).Ann Thorac Surg. 2011; 91: 332Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] regarding our article [2Bek 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]. We agree with Raja that sternocostal joints are the point of placement of sternal wires in transcostal sternal closure. Since the publication of the article “Effective Median Sternotomy Closure in High Risk Open Heart Patients” [2Bek 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], we have experienced one sternal dehiscence using transcostal sternal closure. The patient was morbidly obese, so during the primary closure, we used a set of double sternal wires. The 3 manubrial wires were placed using #6 wires, followed by 3 double sternal wires placed through sternocostal joints where ribs 2 through 4 attach to the sternum. Two #6 wires were placed through sternocostal joint where rib 5 attaches to the sternum and costochondral joint.The patient presented 1 month after the operation with mediastinitis and sternal dehiscence. Exploration of the mediastinum showed the patient had multiple transverse sternal fractures. We have not seen disruption of sternocostal joints and have not observed secondary inflammation from stainless steel sternal wires placed through the sternocostal joints.We believe transcostal sternal closure offers a more stable and durable closure than conventional closure because it redistributes fracture force (dehiscence force) to the greater bone volume of the sternum. This technique is especially useful in high-risk patients, including age older than 75 years, a history of osteoporosis, a thin sternum, morbid obesity (body mass index >30 kg/m2), or an off-midline sternotomy. We appreciate the interest expressed by Raja [1Raja S.G. Transcostal sternal closure: ongoing quest for the Holy Grail (letter).Ann Thorac Surg. 2011; 91: 332Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] regarding our article [2Bek 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]. We agree with Raja that sternocostal joints are the point of placement of sternal wires in transcostal sternal closure. Since the publication of the article “Effective Median Sternotomy Closure in High Risk Open Heart Patients” [2Bek 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], we have experienced one sternal dehiscence using transcostal sternal closure. The patient was morbidly obese, so during the primary closure, we used a set of double sternal wires. The 3 manubrial wires were placed using #6 wires, followed by 3 double sternal wires placed through sternocostal joints where ribs 2 through 4 attach to the sternum. Two #6 wires were placed through sternocostal joint where rib 5 attaches to the sternum and costochondral joint. The patient presented 1 month after the operation with mediastinitis and sternal dehiscence. Exploration of the mediastinum showed the patient had multiple transverse sternal fractures. We have not seen disruption of sternocostal joints and have not observed secondary inflammation from stainless steel sternal wires placed through the sternocostal joints. We believe transcostal sternal closure offers a more stable and durable closure than conventional closure because it redistributes fracture force (dehiscence force) to the greater bone volume of the sternum. This technique is especially useful in high-risk patients, including age older than 75 years, a history of osteoporosis, a thin sternum, morbid obesity (body mass index >30 kg/m2), or an off-midline sternotomy. Transcostal Sternal Closure: Ongoing Quest for the Holy GrailThe Annals of Thoracic SurgeryVol. 91Issue 1PreviewI read with great interest the article by Bek and colleagues [1] revisiting the problem of sternal wound dehiscence in high-risk patients undergoing cardiac operations. I must congratulate the authors for describing a novel technique of transcostal sternal closure that involves placing 3 interrupted No. 6 stainless steel wires in the manubrium, as in conventional sternal closure, and 5 remaining interrupted No. 6 stainless steel wires through “costochondral joints” and around the sternum. At the same time, however, I believe that the authors' choice of term “costochondral joints” is anatomically incorrect and perhaps should have been spotted during the process of peer review. Full-Text PDF