Sternal Dehiscence Research Articles

Rekonstrukce komplikované sternální dehiscence transverzálními titanovými AO dlahami se spongioplastikou

Rekonstrukce komplikované sternální dehiscence transverzálními titanovými AO dlahami se spongioplastikou

Effective Median Sternotomy Closure in High-Risk Open Heart Patients

We describe a novel surgical technique with a median sternotomy closure in high-risk open heart patients. In contrast to conventional sternal closure, in which sternal wires are passed through the intercostal space, the novel technique in sternal closure passes sternal wires transcostally or through costo-chondral joints.

Pneumopericardial Tamponade in a Patient With Partial Sternal Dehiscence

We present a rare case of sudden pneumopericardial tamponade in a patient with partial sternal dehiscence after cardiac surgery. Urgent decompression was needed in the management of the condition. Vacuum-assisted closure therapy was also used to prevent the problem from recurring. When there is acute hemodynamic deterioration in a patient with sternal wound dehiscence, pneumopericardial tamponade should be considered as a possible complication.

Traumatic fracture of nitinol thermoreactive sternal clips

Median sternotomy can be associated with significant morbidity, including non-union, dehiscence and mediastinitis. The use of flexible thermoreactive sternal clips has been introduced recently as an alternative method of sternal closure and is advocated in patients at increased risk of sternal breakdown. It is associated with a decreased incidence of sternal complications as well as allowing faster sternal closure and easy removal on resternotomy. This report describes the case of a fractured thermoreactive clip following trauma, resulting in sternal dehiscence necessitating sternal rewiring.

Closure of median sternotomy: an overview of different sternal closure techniques

Objectives: Sternal dehiscence and subsequent mediastinitis are among the most severe complications of median sternotomy. Sternal dehiscence usually occurs when the wire cuts through the bone and causes multiple fractures of the sternum. This occurs in 0.3% to 5% of all cases and is associated with a mortality rate of 14% to 47%, especially if mediastinitis supervenes. Stabile fixation is particularly crucial in the growing population with several risk factors for sternal instability.

Sternal reconstruction with plates and cables in complicated sternal dehiscence

Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. To treat such patients, the principles of rigid plate and screw osteosynthesis gained from orthopedic surgery have been recommended by several authors for sternal refixation. We present our closure technique of dehiscent infected sternum with a new sternal closure system (Synthes, Switzerland) consisting of cannulated screws, steel cables and reconstruction plates.

Repair of spontaneous right ventricular rupture following sternal dehiscence. A novel technique

Spontaneous rupture of the right ventricle during the early postoperative period is a serious and potentially lethal complication. The inherent friability of the ventricular tissue makes repair difficult since myocardium is frequently weakened by infarction, mediastinitis or trauma caused by an unstable sternum or broken sternal wires. We present a novel yet simple technique for repairing the ruptured anterior wall of the right ventricle in a patient three weeks following coronary artery bypass surgery.

Figure-of-Eight vs. Interrupted Sternal Wire Closure of Median Sternotomy

Sternal dehiscence is a rare but devastating complication following median sternotomy for cardiac surgery. The optimal technique for sternal closure is unclear. We conducted this prospective randomized trial to compare the incidence of sternal dehiscence after figure-of-8 and simple interrupted suturing in patients undergoing coronary artery bypass grafting. Between January 2007 and June 2008, 98 patients had figure-of-8 suturing and 97 had interrupted sutures. The mean age of the patients was 60.9 +/- 7.6 years. The overall sternal dehiscence rate was 8%; 7 cases in the in figure-of-8 group and 9 in the interrupted group. Thirteen patients had no wound infection and healed with conservative treatment. Only 3 patients had sternal dehiscence with infection: 2 with simple interrupted closure and 1 with figure-of-8 sternal closure. There was no significant difference in rates of sternal dehiscence between the 2 groups. It was concluded that figure-of-8 sternal suturing is equally effective as simple interrupted suturing in preventing sternal dehiscence.

Migrated Sternal Wire into the Right Ventricle: Case Report in Cardiothoracic Surgery

Migrating wires as a result of sternal nonunion present clinical challenges. Cardiac Computed Tomographic Angiography helps locate these wires precisely, enabling detailed surgical planning. Sternal wire migration is an infrequent complication following median sternotomy. It is usually encountered among patients with sternal dehiscence. Understanding the location and spatial relationships of structures to the wire can be challenging. (64 slice) with high spatial and temporal resolution affords the possibility of enhancing presurgical planning.

Use of VAC therapy and sternal plating in the treatment of sternotomy wound dehiscence

Sternal dehiscence has a high morbidity and mortality. Many treatment modalities have evolved. Early wound management and closure has a positive outcome. Vacuum-assisted closure (VAC) therapy has proven to be effective, and recently the closure of the sternum with internal plate fixation appears to be beneficial. We present a small series with their combined usage. We retrospectively reviewed eight cases of sternal wound dehiscence or sepsis referred to our unit for further management for the period January 2006 to December 2007. The subjects consisted of five males and three females with their ages ranging from 47 to 74 years (mean = 63 years). All patients had a premorbid history of hypertension and hyperlipidemia and five of diabetes. The patients were managed with a combination of serial debridement, VAC therapy, and sternal internal plate fixation and bilateral pectoralis major advancement flap. In three patients, final closure was obtained after sternal plating. Two patients achieved final closure by VAC therapy only. Three patients died of multiple-organ failure while undergoing wound bed preparation. We believe the use of VAC therapy and definitive wound closure using sternal plating, as part of a staged treatment, is an effective method for managing sternotomy wound dehiscence.

A Large Tracheo-esophageal Fistula Secondary to an Aortic Aneurysm

Purpose: Purpose: To present a unique case of tracheo-esophageal fistula (TEF) from a benign cause. Case: 76 yo female presented with a cough, shortness of breath and fever. History included atrial fibrillation, arterial hypertension, COPD and repair of an ascending aortic aneurysm in 2001, complicated by sternal dehiscence. She had previously been admitted 3 times for recurrent pneumonia. She also reported progressive severe dysphagia and coughing with solids and liquids the last few months. Initially, her oxygen saturation was 94% on room air and coarse breath sounds with rhonchi were heard bilaterally. White blood cell count was normal with a left shift; serum chemistries were normal but there was hypocarbia and hypoxia on arterial blood gas. The CT-scan of the chest showed the thoracic aortic aneurysm (7.5x6cm, unchanged), obstruction of the left mainstem bronchus and consolidation of the left lower lung. Radiographic contrast study showed reflux of contrast agent and quick filling of the left bronchial tree. Esophagogastroduodenoscopy (EGD) showed a large TEF at 25cm. The bronchial cartilage had eroded into the esophageal lumen. Her operative risk was high and conservative management was recommended. An endobronchial stent was placed, and she was to undergo subsequent esophageal stenting. However, her left lung volume decreased due to distal migration of the stent and it was removed. Discussion: The combination of dysphagia and recurrent pulmonary infections in the same location in the elderly is suggestive of primary esophageal disease, e.g. achalasia, esophageal cancer or TEF. The diagnostic work-up for dysphagia can start either with EGD or a contrast radiological evaluation. The majority of aspiration pneumonias, however, would be expected to manifest in the right upper lobe. Thus, EGD may be the preferred initial diagnostic test, when TEF is suspected, and it may also be therapeutic. The majority of TEFs are due to underlying malignant disease, most commonly esophageal or lung cancer. Benign TEFs are commonly due to erosion of the endotracheal tube balloon during prolonged intubation, trauma or post-surgical. Chronic compression of the bronchus into the esophagus and subsequent fistula formation from a chronic aneurysm of the ascending aorta is unusual. Surgical repair is the preferred treatment for benign TEFs. Our patient presented prohibitive operative risks and endoluminal therapy was attempted. With the advent of removable silicone stents benign TEFs can be treated nonsurgically.

Sternal Stabilization by Interlocking Wires: An Alternative Simple Technique for High-Risk Patients

Sternal dehiscence following midline sternotomy is associated with significant morbidity and mortality in high-risk patients. A novel simple technique of sternal stabilization after midline sternotomy by interlocking wires was introduced in high-risk patients with morbid obesity, diabetes, osteoporosis, chronic obstructive pulmonary disease, bilateral internal thoracic artery harvesting, or various combinations of the above. A sternal stabilization by interlocking wires was performed in 25 consecutive high-risk patients. Stable sternum was achieved in all patients despite multiple risk factors. We describe a simple technique of interlocking wires that provides excellent stabilization of the sternum after midline stenotomy in high-risk patients. This technique utilizes the benefit of figure-eight wires, provides the continuity of the weave and effectively prevents cutting of the wires through the sternum without compromising its blood supply.

Resuture using Shirodkar tape for sternal dehiscence after extended thymectomy via median sternotomy

Sternal dehiscence is one complication after median sternotomy. We followed a patient with sternal dehiscence for 6 months after extended thymectomy via median sternotomy. His diagnosis was myasthenia gravis without thymoma and with complicating diabetes mellitus. Sixteen days after the operation chest radiography revealed that one of six sternal wires was cut, although sternal dehiscence was not apparent. Six months after the operation, chest radiography revealed that five of six wires were cut. The patient experienced sternal dehiscence, could not cough, and felt pain at the median wound site. We implemented a resuture technique of the sternum using Shirodkar tape for postoperative sternal dehiscence. After the second operation, sternal dehiscence was not apparent. He was able to cough and had no respiratory deficiency. One year after the second operation, chest computed tomography revealed no sternal dehiscence. Shirodkar tape is extremely useful and is low in price.

Deep Superior Epigastric Artery Perforators: Anatomical Study and Clinical Application in Sternal Reconstruction

Mah, Eldon M.B.B.S.; Rozen, Warren M. M.B.B.S., Ph.D.; Ashton, Mark W. F.R.A.C.S.; Flood, Stephen F.R.A.C.S. Author Information

Sternal plating for primary and secondary sternal closure; can it improve sternal stability?

BackgroundSternal instability with mediastinitis is a very serious complication after median sternotomy. Biomechanical studies have suggested superiority of rigid plate fixation over wire cerclage for sternal fixation. This study tests the hypothesis that sternal closure stability can be improved by adding plate fixation in a human cadaver model.MethodsMidline sternotomy was performed in 18 human cadavers. Four sternal closure techniques were tested: (1) approximation with six interrupted steel wires; (2) approximation with six interrupted cables; (3) closure 1 (wires) or 2 (cables) reinforced with a transverse sternal plate at the sixth rib; (4) Closure using 4 sternal plates alone. Intrathoracic pressure was increased in all techniques while sternal separation was measured by three pairs of sonomicrometry crystals fixed at the upper, middle and lower parts of the sternum until 2.0 mm separation was detected. Differences in displacement pressures were analyzed using repeated measures ANOVA and Regression Coefficients.ResultsIntrathoracic pressure required to cause 2.0 mm separation increased significantly from 183.3 ± 123.9 to 301.4 ± 204.5 in wires/cables alone vs. wires/cables plus one plate respectively, and to 355.0 ± 210.4 in the 4 plates group (p < 0.05). Regression Coefficients (95% CI) were 120 (47–194) and 142 (66–219) respectively for the plate groups.ConclusionTransverse sternal plating with 1 or 4 plates significantly improves sternal stability closure in human cadaver model. Adding a single sternal plate to primary closure improves the strength of sternal closure with traditional wiring potentially reducing the risk of sternal dehiscence and could be considered in high risk patients.

Imaging Appearances of the Sternum and Sternoclavicular Joints

The sternum and sternoclavicular joints--critical structures of the anterior chest wall--may be affected by various anatomic anomalies and pathologic processes, some of which require treatment. Pectus excavatum and pectus carinatum are common congenital anomalies that are usually benign but may warrant surgical treatment if they cause compression of vital internal structures. By contrast, developmental variants such as the sternal foramen are asymptomatic and do not require further evaluation or treatment. Arthritides of the sternoclavicular joint (osteoarthritis, septic arthritis, and seronegative arthropathies) are common and must be differentiated before an appropriate management method can be selected. The recognition of complications of sternotomy (eg, sternal dehiscence, secondary osteomyelitis) is critical to avoid life-threatening sequelae such as acute mediastinitis. Likewise, the detection of sternal fractures and sternoclavicular dislocations is important, especially where they impinge on vital structures. In addition, sternal malignancies (most commonly, metastases and chondrosarcoma) must be distinguished from benign neoplasms. To achieve accurate and timely diagnoses that facilitate appropriate treatment, radiologists must be familiar with the appearances of these normal anatomic variants and diseases of the sternum.

Technique to Prevent Inadvertent Paramedian Sternotomy

Previous reports documented the relationship between inadvertent paramedian sternotomy and postoperative sternal instability and dehiscence.We describe a modification of the technique of median sternotomy in order to prevent inadvertent paramedian sternotomy and related wound complications.

Sternal Weave in High-Risk Patients to Prevent Noninfective Sternal Dehiscence

Dehiscence of the sternum is a serious and potentially devastating complication. The purpose of this prospective study was to determine whether a prophylactic sternal weave would decreased the incidence of noninfective sternal dehiscence, compared to routine sternal closure, in a high-risk group. Between 2000 and 2007, 200 patients undergoing median sternotomy for cardiac surgery, with one or more risk factors including New York Heart Association functional class III/IV, chronic obstructive pulmonary disease, osteoporosis, obesity, and off-midline sternotomy, were randomly assigned to group A (sternal weave closure, 100 patients) or group B (routine sternal wire closure, 100 patients). No patient in either group with a single risk factor had sternal dehiscence. The incidence of noninfective sternal dehiscence was significantly less in group A than group B in patients with 2 or more risk factors (2.5% vs. 12.5%). Routine sternal closure is sufficient in patients with a single risk factor, whereas a prophylactic sternal weave should be carried out in all patients with 2 or more risk factors, to decrease postoperative morbidity.

Complicated Sternal Dehiscence: Reconstruction With Plates, Cables, and Cannulated Screws

Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. For sternal refixation, the principles of rigid plate and screw osteosynthesis gained from orthopedic surgery have been recommended by several authors. We present a new system for sternal reconstruction consisting of reconstruction plates, steel cables, and cannulated screws.

Reconstruction of the Thorax With Ley Prosthesis After Resection of the Sternum

The Ley prosthesis is a titanium plate, which has been used in the past few years for sternum stabilization after postoperative mediastinitis and sternal dehiscence. There is no previous description of the use of this device in chest wall reconstruction after tumor resection. We describe the surgical technique for reconstruction of the skeletal defects with the Ley prosthesis in 3 patients operated on for a sternal chondrosarcoma. We propose the application of the Ley prosthesis for optimal reconstruction of skeletal tissue after sternal resection.