Sternal Closure Techniques Research Articles

Biomechanical comparison of bone staple fixation methods with suture material for median sternotomy closure using 3D-printed bone models

ABSTRACT Aim To compare the biomechanical properties of three different sternal closure techniques in a 3D-printed bone model of a sternum from a 30-kg dog. Methods Median sternotomy was performed on a total of 90 three-dimensional (3D) copies of a polycarbonate (PC) model of a sternum, generated from the CT images of the sternum of a 30-kg German Shepherd dog. Three different methods were used to repair the sternotomies: polydioxanone suture (group PDS, n = 30), stainless steel bone staples (group SS, n = 30), and nitinol bone staples (group NS, n = 30). Each repair method was tested by applying tensile force in one of three ways (longitudinally, laterally, or torsionally) resulting in a sample size of n = 10 for each repair method-loading combination. In all experiments, the loads at 1-mm and 2-mm gap formation, failure, and the displacement at the failure point were measured. Results In lateral distraction and longitudinal shear tests, NS and SS staple repairs required application of significantly greater force than PDS across all displacement criteria (1 and 2 mm). NS exhibited significantly greater failure load than PDS. In torsion tests, NS required significantly greater application of force compared to SS or PDS at all displacement criteria (1 and 2 mm) and exhibited a greater failure load than PDS. In terms of displacement at failure point, PDS suture showed more displacement than SS or NS across all experiments (laterally, longitudinally, torsionally). Conclusions In this study, bone staples were mechanically superior to PDS suture in median sternotomy closure using 3D-printed bone model in terms of 1-mm, 2-mm displacement loads, and displacement at failure. NS had a higher failure load than PDS under lateral, longitudinal, and torsional distraction. Clinical relevance These study results imply that bone staples can be considered as an alternative surgical method for median sternotomy closure in dogs.

Practice Patterns in Sternal Closure and Evaluation of Adoption of a Novel Sternal Closure Device.

The technique for sternal closure has remained largely unchanged owing to the efficacy, simplicity, and low cost of stainless-steel sternal wires. Despite their ubiquity, several other closure devices designed to address the complications associated with sternal wires such as sternal bleeding and dehiscence have become popular. We have developed a novel sternal closure device that reduces sternal bleeding and dehiscence. This study quantifies the use of currently available sternal closure devices and determines predicted uptake of the novel device. An electronic survey, designed to determine practice patterns for sternal closure, was distributed to 70 US cardiac surgeons. The survey included a discrete choice section in which surgeons evaluated relative value of device attributes including cost, ease of emergent sternal reentry, and dehiscence risk. There were 70 surgeons from 30 states who completed the survey. The most frequent means of sternal closure was straight sternal wires (35.8%), followed by straight sternal wires plus figure-of-8 sternal wires (18.1%), double wires (10.9%), plates (10.2%), and other (25%). The relative utilization shifted from sternal wires to sternal plates as the risk for dehiscence increased. The adoption of the novel closure device was estimated at 34.6%. The standard stainless-steel sternal wire remains the most common means of sternal reapproximation, but its utilization is lower in patients at high risk for sternal dehiscence. Based on this survey, there is acceptance in the community for a novel sternal closure device designed to address the limitations of traditional sternal closure methods.

The ‘Double Twist’ Technique: A Novel Approach to Secure Sternal Closure and Prevent Dehiscence in Obese Patients After Cardiac Surgery

Sternal wound dehiscence after cardiac surgery, particularly in people with obesity, is a devastating complication. We present a ‘double twist’ technique for sternal closure, which firmly stabilizes the sternal halves without additional risk of wound complications.

This supplemental video is a demonstration of the sternal closure technique utilizing the FlatWire Sternal Closure System.

This supplemental video is a demonstration of the sternal closure technique utilizing the FlatWire Sternal Closure System.

Combined Band and Plate Fixation as a New Individual Option for Patients at Risk of Sternal Complications after Cardiac Surgery: A Single-Center Experience.

Due to the advent of interventional therapies for low- and intermediate-risk patients, case complexity has increased in cardiac surgery over the last decades. Despite the surgical progress achieved to keep up with the increase in the number of high-risk patients, the prevention of sternal complications remains a challenge requiring new, individualized sternal closure techniques. The aim of this study was to evaluate the safety and feasibility, as well as the in-hospital and long-term outcomes, of enhanced sternal closure with combined band and plate fixation using the new SternaLock® 360 (SL360) system as an alternative to sternal wiring. From 2020 to 2022, 17 patients underwent enhanced sternal closure using the SL360 at our institution. We analyzed perioperative data, as well as clinical and radiologic follow-up data. The results were as follows: In total, 82% of the patients were treated with the SL360 based on perioperative risk factors, while in 18% of cases, the SL360 was used for secondary closure due to sternal instability. No perioperative complications were observed. We obtained the follow-up data of 82% of the patients (median follow-up time: 141 (47.8 to 511.5) days), showing no surgical revision, no sternal instability, no deep wound infections, and no sternal pain at the follow-up. In one case, a superficial wound infection was treated with antibiotics. In conclusion, enhanced sternal closure with the SL360 is easy to perform, effective, and safe. This system might be considered for both primary and secondary sternal closure in patients at risk of sternal complications.

Mediastinitis en cirugía cardíaca. Tasa cero en diez años en centro de referencia para cirugía cardíaca. México

IntroductionMediastinitis is one of the most feared complications of cardiac surgery. It's incidence ranges from 0.9 to 5% and sometimes up to 20%. It is characterized by severe infection, retrosternal abscess, osteomyelitis, and gross sternal dehiscence with high mortality. Material and methodsPatients undergoing median sternotomy for cardiac surgery during a ten years period at the Pemex Hospital in Mexico were reviewed. The variables age, sex, diabetes mellitus, hypertension, body mass index, primary surgery, renal involvement, previous dialysis, type of sternal closure, pre-surgical hospital stay, result of cultures and mortality were studied. ResultsOf 2,242 sternotomies, 33 cases were included. There was an average of 3 cases per year. 24 men and 9 women, the majority between 71 and 80years old, 25 diabetic and 24 hypertensives. 45.3% with normal weight or overweight and 54.5% with grade I-II obesity. 27 had a history of ischemia and 6 had a history of simple valve surgery or mixed procedure, 22.2% had a history of urgent reexploration for bleeding. 44.4% of the patients were nephropaths, 2 on hemodialysis.There were two sternal closure techniques, group1 with simple stitches and group2 with Hemi-Robicsek. Type1 was used in 1499 patients, with 1.8% dehiscence, type2 in 743 patients, with 0.6% dehiscence. ConclusionsPost-sternotomy devastating mediastinal infections are increasingly rare in our hospital. A strict adherence to the technique, the sternal closure that we call Hemi-Robicsek, as well as the early detection of dehiscence for resuturing has led us to zero cases of mediastinitis.

Combined technique of sternal closure in patients with high risk of post-sternotomy complications

Combined technique of sternal closure in patients with high risk of post-sternotomy complications

Efficacy of Primary Closure Technique in Treatment of Post-Sternotomy Mediastinitis in Paediatric Group: A Randomized Controlled Trial.

PurposeTo assess the efficacy of primary sternal closure technique compared to vacuum-assisted closure technique in treatment of post-cardiac surgery mediastinitis in paediatric age group. Additionally, assessed postoperative need for IV drug use, hospital stay length, wound and sternal healing and survival. Hypotheses: primary sternal closure is a reliable technique for treatment of poststernotomy mediastinitis following cardiac surgery in paediatric age group.Materials and MethodsA prospective randomized controlled trial included 217 pediatric patients developed post-cardiac surgery mediastinitis from 2016 to 2022. They were randomly divided into primary sternal closure group (A) and vacuum-assisted closure group (B) and operated by two cardiothoracic surgeons. Follow-up of the patients was done for 6-months duration following treatment of mediastinitis to assess postoperative need for hospitalization, IV drug use, wound complications, sternal stability and survival.ResultsThe final analysis included 101 patients in each group. The chance of survival over 6 months after surgery was more for primary sternal closure group (175.2) days versus (157.6) days for the vacuum-assisted closure group, with significant difference Log Rank test p-value (0.005). Duration for IV antibiotics use in the primary closure group was 8.55±3.57 and it was 32.61±8.39 showing high statistically significant difference (p<0.001). Patients in the primary closure group had earlier discharge from hospital 15.77±4.18 than vacuum assisted group 42.61±8.39, with high statistically significant difference (p<0.001). Primary closure group showed better sternal stability and sternotomy wound healing on clinical follow-up.ConclusionPrimary sternal closure technique is a favorable technique over vacuum-assisted closure technique for treatment of paediatric mediastinitis following cardiac surgery. The reinforced sternal closure technique is a reliable technique with promising results regarding IV drugs need, hospitalization duration, survival and sternotomy wound healing.

Review of Biomechanical Studies and Finite Element Modeling of Sternal Closure Using Bio-Active Adhesives.

The most common complication of median sternotomy surgery is sternum re-separation after sternal fixation, which leads to high rates of morbidity and mortality. The adhered sternal fixation technique comprises the wiring fixation technique and the use of bio-adhesives. Adhered sternal fixation techniques have not been extensively studied using finite element analysis, so mechanical testing studies and finite element analysis of sternal fixation will be presented in this review to find the optimum techniques for simulating sternal fixation with adhesives. The optimal wiring technique should enhance bone stability and limit sternal displacement. Bio-adhesives have been proposed to support sternal fixation, as wiring is prone to failure in cases of post-operative problems. The aim of this paper is to review and present the existing numerical and biomechanical sternal fixation studies by reviewing common sternal closure techniques, adhesives for sternal closure, biomechanical modeling of sternal fixation, and finite element modeling of sternal fixation systems. Investigating the physical behavior of 3D sternal fixation models by finite element analysis (FEA) will lower the expense of conducting clinical trials. This indicates that FEA studies of sternal fixation with adhesives are needed to analyze the efficiency of this sternal closure technique virtually.

Quality of Life Post-Sternotomy: Reassessing the Utility of Standard-of-Care Sternal Precautions

<h3>Purpose</h3> Standard sternal precautions are prescribed for six to eight weeks following median sternotomy and include measures such as avoiding >10 lb weight lifting, overhead movements, and driving. However, postoperative complications have declined in large part due to advances in sternal closure techniques from traditional wire cerclage to sternal plating. A single published report from overseas suggested that current precautions may be unnecessarily restrictive and result in increased recovery time and reduced quality of life post sternotomy. To date, there is no published US study that investigated the psychosocial outcomes following median sternotomy. We hypothesize that reduction in sternal precautions will lead to a higher quality of life without compromising sternal integrity. <h3>Methods</h3> In this single-center, prospective 1:1 randomized study, we plan to enroll 64 patients who will undergo sternotomy for open heart surgeries (excluding heart transplant and LVAD implantation) at University of Chicago Medical Center into either standard of care or self-managed precautions groups. The former group requires strict adherence to current institutional sternal precautions, while the latter group will be guided by comfort and/or pain based on self-perceived and self-assessed physical limitations. English-speaking patients between the ages of 18-70 receiving a first-time median sternotomy are eligible for enrollment. For eight weeks post discharge, a quality of life EQ5D questionnaire will be administered weekly via telephone by a medical professional who will separately verify adherence to the assigned protocols as well as document occurrence of major adverse clinical events. <h3>Endpoints</h3> The primary objective of this study is to determine whether patients in the self-managed group can achieve increased quality of life as compared to the standard sternal precautions group following median sternotomy without increase in adverse clinical events. The findings could potentially provide strong evidence for updated and uniform sternal precautions protocols that eliminate outdated restrictions and enhance overall quality of life post sternotomy.

The Simple Technique of Sternal Closure Using An Absorbable Mesh Plate

Several authors have investigated various sternal closure materials and technologies for sternal fixation; nonetheless, the optimal technique for primary sternal closure remains unclear. This study aimed to evaluate the sternal stability of a simple technique using a mesh-type plate (Super Fixorb MX40®; Takiron Co. Ltd., Osaka, Japan), as compared with wire cerclage. A total of 70 patients who underwent cardiovascular surgery through median sternotomy between July 2019 and May 2020 were included. Two pieces of mesh-type plates were placed under the sternum in combination with wiring. The technique for sternal closure was randomly applied, which was mainly based on the surgeon's preferences: mesh plate (mesh group: N = 33) or conventional wire cerclage (wire group: N = 37). Sternal displacement was measured using computed tomography at discharge. Pain scale scores and analgesic use on postoperative day 7 were similar between the two groups. However, the displacement in both the anterior-posterior and lateral directions was significantly smaller in the mesh group. The use of the mesh plate device for sternal closure is simple, safe, easy, and potentially reliable without anterior-posterior sternal displacement.

175 Sternal Closure with Single Compared to Double or Figure-Of-8 Wires in Obese Patients Post Cardiac Surgery: A Systematic Review and Meta-Analysis

Abstract Aim Sternal instability and wound infections are a major cause of morbidity following cardiac surgery, which is further amplified in high-risk patients that include diabetics and patients with high BMI. We compare the different outcomes of different sternal wire closure techniques following median sternotomy for cardiac surgery in obese patients Method A comprehensive electronic literature search was undertaken according to PRISMA guidelines from inception to July 2020 to identify all published data comparing single wire sternal closure to either double wire or figure-of-8 techniques following median sternotomy for cardiac surgery in obese patients, defined as a BMI ≥ 30. Results Eight studies met the final inclusion criteria; single wire versus double wire sternal closure (n = 2) and single wire versus figure-of-8 wire closure (n = 6). Higher rate of sternal instability was noted in single wire vs double wire closure (22/150 (14.7%) patients vs 6/150 (4%) patients, p = 0.003, OR 0.25 [95% CI 0.10-0.63]). Similarly, sternal instability was higher in single wire vs figure-of-8 wire closure technique (33/2422 (1.3%) vs 11/8035 (0.1%), p = 0.04 OR 0.30 [95% CI, 0.09-0.96]) respectively. Conclusions There is benefit in the use of either double or figure-of-8 sternal wire closure techniques over single wire closure in terms of sternal instability. However, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing the optimal sternal closure technique in this high-risk group of patients.

Comparison of Two Sternal Closure Techniques Based on Risk Factors: A Prospective, Observational Study.

Background Stainless steel wires are still commonly used as a sternum closure technique. However, it can cause fatal complications due to rupture and dehiscence. It was anticipated that the sternal Cable System (Pioneer Surgical Technology Inc., Marquette, MI, USA) could provide a better sternal fixation and reduce the possible complications. Materials and Method. A total of 100 patients (57 male, 43 female) at high risk of dehiscence were included in this prospective observational study. Among those with EuroSCORE value of 4 and above, patients with chronic lung disease, chronic kidney disease, diabetes mellitus, obesity, smoking, body mass index, advanced age, and resurgery were operated in two separate centers. Standard steel wires (n: 51) used for sternotomy were compared with the sternal cable (n: 49). Early and late sternal dehiscence rates were compared in the study. The relationship between risk factors causing dehiscence and both methods was assessed statistically. Results Early dehiscence rates were 6.4% in those closed with a sternal cable (n: 3) and 11.8% in those closed with a sternal wire (n: 6) (p < 0.05)). In risky patients, body mass index was the most determining parameter in terms of sternum dehiscence risk. Conclusion In risky patients, we recommend the sternal cable system as a good and reliable closure technique to achieve a more stable and compact sternum.

STERNOTOMY CLOSURE AFTER HISTORY OF MAJOR STERNAL RESECTION FOR MALIGNANT DISEASE

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sternal closure after resections for the benign or malignant disease has always been a topic of discussion based on the need for adequate closure and coverage of the chest. The dreaded complication of deep space infection or sternal dehiscence after a sternal resection is a real concern among the cardiothoracic surgery community as these complications can lead to significant morbidity and mortality. We present a case of a 69-year-old female with a history of a large left inferior sternal resection due to malignant disease undergoing closure of her sternum after an on-pump coronary artery bypass. CASE PRESENTATION: A 69-year-old female with a past medical history of hypertension, depression, and smoking presented to the hospital with a chief complaint of chest pain. The patient was found to have shortness of breath with pain radiating to both of her arms. She was found to have a STEMI with an acute inferior wall infarction on EKG and an elevated troponin of 748. The patient was taken emergently to the cath lab and was found to have multivessel coronary artery disease with a preserved left ventricular function. The patient was continued on heparin and evaluated by the cardiac surgery team. She was taken for coronary artery bypass with bypass of the obtuse marginal and left anterior descending arteries. Upon opening the chest, we noted she had a large piece of her left inferior sternum missing from her previous surgery. The manubrium remained intact, the decision was made at the time of her chest closure to use a sternal locking system on the manubrium and upper portion of her sternum for added strength and support of her previous sternal resection. The patient's postoperative course was uneventful, and she was discharged home. On clinic follow up she had excellent healing of her sternal wound with no signs of dehiscence. DISCUSSION: Closure of a sternotomy site after resection of a large portion of the sternum is a major risk factor for potential noninfectious dehiscence that could lead to infection especially if the bone quality is poor or if there is minimal sternum left to close the chest. There is limited data about the closure of a sternotomy after a major portion of the sternum has been previously resected due to malignant disease in the past. When minimal manubrium or sternum remains after resection, we recommend plating for added strength of the sternal closure. CONCLUSIONS: Sternal dehiscence with complications is a major concern after sternotomy is performed. The risk for sternal dehiscence is even greater when the patient has had a previous sternal resection with minimal sternum remaining. We highly recommend using a sternal plate locking closure device when closing a previous sternum that has had a major sternal resection. The plating system provides stronger closure and will help to avoid the dreaded complication of dehiscence even when there is minimal sternum remaining. REFERENCE #1: Adel M., F. Alhalawani, et al. A review of sternal closure techniques: J Biomater Appl.2013 Nov 483-497 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response

Development of a new sternal dehiscence prediction scale for decision making in sternal closure techniques after cardiac surgery

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.

Titanicking the Clamshell. Anchoring the Bilateral Thoracosternotomy Incision with Titanium Plates, Screws and Sternal Band. Our Experience in Fifty Consecutive Patients of Double Lung Transplantation

Purpose Clamshell incision for double lung transplantation offers unmatched advantages . But prolonged immunosuppresion therapy along with corticosteroids can lead to sternal healing abnormalities, overriding, gaping and cut through injuries on usage of sternal wires for closure . We have modified sternal closure technique using H shaped titanium plates, screws and sternal bands. The review of data on such closure of sternum in fifty consecutive lung transplant shows reduced healing complications of the sternum. Methods Our thoracic organ transplant services team has done 142 double lung transplantation from february 2017 to till date. We have been using H shapped ladder type titanium plates with 2.4 mm cancellous self tapping screws and a single sternal band. We retrospectively reviewed and compared data between fifty conventional closure (stainless steel wire technique) versus titanium plate and sternal band closure in fifty recipients. Results We observed that 15 patients (30%) in conventional Closure group had some sternal healing complications such as over riding(4 patients 8%), complete dehiscence(3 patients 6%), wire cut through(3 patients 6%)wire protruberance (3 patients 6%)and sternal mobility (2 patients 4%). Only one patient (2%)in titanium plate closure had sternal mobility, there were no other complications in the latter subset. Conclusion Titanium plate closure, has lesser healing complications of sternum, making this method a regular closure strategy for all our double lung transplantation recipients.

Sternal closure with single compared with double or figure of 8 wires in obese patients following cardiac surgery: A systematic review and meta-analysis.

Sternal instability and wound infections are major causes of morbidity following cardiac surgery, which is further amplified in high risk patients that include diabetics and patients with high body mass index (BMI). We compare the different outcomes of different sternal wire closure techniques following median sternotomy for cardiac surgery in obese patients. A comprehensive electronic literature search was undertaken according to PRISMA guidelines from inception to July 2020 to identify all published data comparing single wire sternal closure to either double wire or figure-of-8 techniques following median sternotomy for cardiac surgery in obese patients, defined as a BMI ≥ 30. Eight studies met the final inclusion criteria; single wire versus double wire sternal closure (n = 2) and single wire versus figure-of-8 wire closure (n = 6). Higher rate of sternal instability was noted in single wire versus double wire closure (22/150 [14.7%] patients vs. 6/150 [4%] patients, p = 0.003, odd ratio [OR] 0.25 [95% confidence interval [CI] 0.10-0.63]). Similarly, sternal instability was higher in single wire vs figure-of-8 wire closure technique (33/2422 [1.3%] vs. 11/8035 [0.1%], p = 0.04 OR 0.30 [95% CI, 0.09-0.96]), respectively. There is benefit in the use of either double or figure-of-8 sternal wire closure techniques over single wire closure in terms of sternal instability. However, as the studies were limited, larger scale comparative studies are required to provide a solid evidence base for choosing the optimal sternal closure technique in this high risk group of patients.

COMPARISON OF INCIDENCE OF STERNAL WOUND DEHISCENCE AFTER SIMPLE INTERRUPTED STERNAL CLOSURE VS FIGURE-OF-EIGHT STERNAL CLOSURE IN PATIENTS OF CORONARY ARTERY BYPASS GRAFT SURGERY

Objective: To compare the incidence of sternal wound dehiscence between simple interrupted vs. figure-of-eight sternal closure techniques for median sternotomy in patients undergoing coronary artery bypass graft surgery.&#x0D; Study Design: Comparative prospective, randomized control trial.&#x0D; Place and Duration of Study: Study conducted at Department of Cardiac Surgery, Armed Forces Institute of Cardiology Rawalpindi, from Apr to Dec 2019.&#x0D; Methodology: A total of 206 patients were included in study. These patients were divided into two groups; group “A”: cases which will undergo simple interrupted sternal wire closure technique (n1=103). Group “B”: cases which will undergo figure-of-eight sternal wire closure technique (n2 = 103).&#x0D; Results: There were no statistical difference in the pre-operative data of the patients. The incidence of sternal wound dehiscence in simple interrupted closure was 6.79% while in figure of eight closure technique it was noted to be 1.94%. A statistically significant difference was noted in both the closure technique (p&lt;0.05).&#x0D; Conclusions: Figure-of-eight sternal wire closure technique provides better strength and stability to sternum along with reduced incidence of sternal wound dehiscence as compare to simple interrupted wire closure.

M30 Novel Sternal Closure Technique Using the Claw Sternal Fixation System

Median sternotomy is the most common technique used to gain access to the heart in cardiac surgery. Despite evidence suggesting superiority of rigid fixation systems, steel wire cerclage remains the most widespread method for sternal closure. It has been widely reported in literature that poor sternal closure contributes to complications including deep sternal wound infection (DSWI), sternal dehiscence and mediastinitis. The ideal sternal closure technique should immobilise the two cut edges, resist the biomechanical forces placed on the sternum, have low complications, be easy to use, easy to remove on re-entry, minimise pain, and be cost effective.

The Novel Technique of Sternal Closure With Absorbable Mesh for Osteoporotic Patients

After a median sternotomy, sternal instability can result in sternal infection. The usual sternal closure with stainless steel wires may result in sternal instability, especially in osteoporotic patients. An absorbable mesh (Super-FIXSORB-MX®40, Takiron Co Ltd, Osaka, Japan) for reinforcing the sternum has become commercially available. This paper reports a modified sternal closure procedure using this absorbable mesh in combination with heavy braided Polydiaxanon (PDS cord®, Ethicon, Inc., Somerville, NJ, USA) for osteoporotic patients.