Sternal Dehiscence Research Articles

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.
 Study Design: Comparative prospective, randomized control trial.
 Place and Duration of Study: Study conducted at Department of Cardiac Surgery, Armed Forces Institute of Cardiology Rawalpindi, from Apr to Dec 2019.
 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).
 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<0.05).
 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 Vacuum-Assisted System as A Treatment of Deep Sternal Wound Infections Following Cardiac Surgery. Cairo University Hospitals Experience

Background: The vacuum-assisted system in wound closure (VAC) is a new modality, which is recently used widely as a treatment of severely infected wounds. It is a noninvasive way that improves healing of severely infected wounds that fail to respond to conventional ways of treatment. This type of treatment depends on applying air tight controlled negative pressure suction directly to the infected wounds. The mechanism of action of this treatment depends on allowing the growth of healthy granulation tissues of the infected wounds. Objective: To evaluate the effect of vacuum assisted suction in treatment of deep sternal wound infection after cardiac surgery. Patients and Methods: In Cairo University Hospitals, in the period between January 2018 and January 2019, 17 patients (6 men, 11 women) with a median age of 62.5 years (range 50 to 75 years) underwent open heart surgery, which was complicated by sternal dehiscence and deep sternal wound infection. All those patients were subjected to the VAC system before any surgical intervention. Results: All patients involved in this study had complete wound healing without need of any major surgical intervention (muscle or omental flaps) even without wound debridement. The VAC system was applied for a mean of 21.5 days (range 15 to 28 days), VAC system was removed when the wound became completely clean with healthy granulation tissues. After removal of the VAC system, 9 patients (52.9%) were subjected to closure of the skin and subcutaneous tissues by interrupted stitches while the remaining 8 patients (47.1%) the wound was completely closed in all layers up to the skin. Duration of hospital stay varied from 22 to 45 days (median 33.5 days). There were no mortalities among all the patients who were involved in this study. Conclusion: The VAC system is a noninvasive, safe and very effective as a treatment for deep sternal wound infections following cardiac surgery.

Clinical results of nitinol plate implentation for reconstruction of sternal dehiscence

Clinical results of nitinol plate implentation for reconstruction of sternal dehiscence

A novel technique in sternal closure after cardiac surgery for high-risk patients: a pilot study

BackgroundSternal closure after cardiac surgery is a very important step, especially in high-risk patients such as obese, old age, osteoporotic females, diabetic, and after coronary artery bypass grafting. Poor sternal fixation is one of the postoperative complications that can result in increased morbidity and mortality.Patients and methodsThe idea of this technique is to take the advantage of peristernal circulage by use of heavy stainless-steel wires, which direct the dispersion forces on the body of the sternum, and also to use a trans-sternal wires to control the up and down movement of each part of the sternum.ResultsThis technique was applied in six patients, comprising three females and three males. Intraoperative evaluation of the sternal stability by the surgeon revealed completely stable sternum. Moreover, postoperative examination and follow-up till 2 months revealed completely stable sternum.ConclusionThis technique is a simple, easy, and effective method for prevention of sternal dehiscence after sternotomy.

BİR ÜNİVERSİTE HASTANESİ KLİNİĞİNDE YAPILAN İLK 200 AÇIK KALP AMELİYATI SONUÇLARI: KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, KALP-DAMAR CERRAHİSİ

Amaç: Çalışmanın amacı, kliniğimizde yapılan ilk 200 açık kalp ameliyatının sonuçlarını değerlendirmektir.Gereç ve Yöntemler: Yapılan 200 kalp ameliyatı hastane kayıt sistemi taranarak geriye dönük olarak incelendi. Hastaların yaş, cinsiyet, komorbiditeleri, ameliyat tipleri, hastane ve yoğun bakımda yatış süreleri, morbidite ve mortalite oranları değerlendirildi.Bulgular: Hastaların 128’i kadın,72’si erkekti. Yaşları 38-90 yıl arasında olup, ortalama 68±5 yıldı. Komorbit faktörleri olarak, kronik obstrüktif akciğer hastalığı, hipertansiyon, diabetes mellitus, hiperlipidemi, serebro-vasküler hastalık, periferik arter hastalığı ve kronik böbrek yetmezliği ve miyokart enfarktüsü görüldü. Toplam 162 koroner arter bypass grefti (KABG) yapıldı. Bunlardan 24 tanesi çalışan kalpte gerçekleştirildi. Eş zamanlı olarak 5 karotis endarterektomi ve 15 koroner endarterektomi yapıldı. Dört KABG ve mitral kapak replasmanı (MVR), 2 KABG ve aort kapak replasmanı (AVR), 6 AVR, 12 MVR, 4 AVR ve MVR, 3 MVR ve tricuspit anuloplasti yapıldı. İki hastaya aort diseksiyonu nedeniyle asenden aort replasmanı ve 3 hastanın asenden aort anevrizmasına supra koroner aort replasmanı yapıldı. İki hastaya kardiyak yaralanma nedeniyle sağ ventrikül tamiri yapıldı.Düşük kardiyak debi nedeniyle 10 hastaya intra-aortik balon pompası takıldı. Komplikasyon olarak 38 hastada atrial fibrilasyon, 4 hastada akut böbrek yetmezliği, 3 hastada serebrovaskuler olay gelişti. Hastaların 4’ünde postoperatif kanama ve 3’ünde sternal dehisens nedeniyle revizyon yapıldı. Bir hastada mediastinit görüldü. Yoğun bakımda kalış süresi ortalama 2,2±1,7 gün olup, hastanede kalış süresi 7,5±4 gündü. Hastane mortalitesi 8 hastada (%4) görüldü.Sonuç: Kırıkkale Üniversitesi Tıp Fakültesi Araştırma ve Uygulama Hastanesi kalp ve damar cerrahisi kliniği, açık kalp ameliyatlarının literatüre uygun morbidite ve mortalite oranları ile yapıldığı bir merkez olmuştur.

STERNAL CLOSURE USING STEEL WIRES BY FIGURE OF EIGHT VERSUS INTERRUPTED SIMPLE SUTURES IN ADULT CARDIAC SURGERIES

Background: Median sternotomy is a commonly performed incision with distinct advantages in adult cardiac surgeries. The stainless-steel encircling wire used as either interrupted simple sutures or as figure of eight sutures is the current standard method of median sternotomy closure. Although sternotomy closure is straight forward, it is not without complications and if not recognized early can lead to complete sternal breakdown, sternal wound infection, and mediastinitis.Aim of the Work: Comparison of the incidence of sternal stability, dehiscence and other sternal complications and the hospital stay.Patients and Methods: One hundred consecutive patients who underwent sternal closure by steel wires in adult cardiac surgeries. Intervention: closure by steel wires using either; figure of eight sutures n (50) group I or simple interrupted sutures n (50) group II in adult cardiac surgeries in a specialized health care center between January 2018 till end of January 2019.Results: Body mass index (BMI) as a risk factor between groups was statistically significant in relation to stability. 12% and 6% of patients with prolonged mechanical ventilation had sternal instability in group (I) and (II), respectively. 10 patients with prolonged ICU stay suffered sternal instability 9 were from group I and1 was from group II (P value 0.022), so the techniques of closure should be considered whenever needed for prolonged ICU stay. Regarding the instability of sternum associated with prolonged post-operative hospital stay; it was found that 50% and 23.07% in group I and II which was statistically significant in relation to instability (P value 0.0382). The overall sternal dehiscence rate was 10%; 8 cases in the in figure- of-8 sutures group and 2 in the simple interrupted sutures group. This was a statistically significant difference in rates of sternal dehiscence between the 2 groups (p 0.046).Conclusion: It is concluded that simple interrupted suturing is more effective than figure-of-8 sternal suturing in preventing sternal dehiscence.

Feasibility and outcome of mitral valve repair in patients with infective endocarditis

BackgroundValve repair is the treatment of choice for native mitral valve regurgitation. The feasibility of repair when the defect is caused by acute infective endocarditis (IE) is debated. This study aims to compare the outcome of repair and replacement procedures, to report the rate of repair in a single surgical center, and to review the literature on this topic.ResultsWe retrospectively analyzed 108 patients with native mitral IE, potentially eligible for surgical repair. Of these 108, 90 (83%) underwent surgery, and 18 were treated conservatively. Among the 90 surgical patients, 57 (63%) underwent valve replacement and 33 valve repair (37%). The mean follow-up duration was 3 years. The two primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the post-operative incidence of major adverse events (hospitalization for any cause, pacemaker implantation, new onset of atrial fibrillation, sternal dehiscence), left ventricular systolic function (LVSF), and valvular function at 1-year echocardiographic follow-up. All-cause mortality was lower for valve repair, although not significantly (p = 0.86), as well as nonfatal adverse events (p = 0.92) and relapse rate (p = 0.20) at 3 years. We did not find differences between the two groups at echocardiographic follow-up, neither for left ventricular systolic function (p = 0.22), nor for valvular continence (p = 0.28).ConclusionsIn our experience, the mid-term outcome of repair in IE is comparable to valve replacement and should be considered whenever possible, as in degenerative valve disease. The review of the literature supports this strategy.

Valve repair in patients with infective endocarditis

Abstract Background Valve repair is considered the treatment of choice for native mitral and tricuspid valve regurgitation but the rate of feasibility when the defect is caused by acute infective endocarditis (IE) is debated. We report the experience of valve repair versus replacement following IE in a high-volume surgical center. Methods We retrospectively analyzed 351 consecutive patients (123 women) admitted to our department with definite diagnosis of IE. IE occurred on native valves in 219 patients (62%) and on prosthetic valves in 132 (38%). Among native valves, IE involved the aortic valve in 105 cases (48%), mitral valve in 97 cases (44%) and tricuspid valve in 17 (8%). Since only native mitral and tricuspid valves are elegible for surgical repair, we limited the analysis to this subset (114 patients); of them, 92 (80.7%) underwent surgery (the final cohort) and 22 were treated conservatively, 13 due to absence of surgical indication and 9 due to prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence). Results Mean age at surgery was 61.9 years (SD 14.5). Mean vegetation length was 11.6 mm (SD 8.8). Endocarditis was left-sided in 80 (87%). Among the 92 surgical patients, 58 (63%) underwent valve replacement and 34 valve repair (37%). Mortality was similar between valve repair and replacement (15 vs 12%). Adverse events rate (19% vs 16%) and relapse were not statistically different between repair and replacement procedures. Conclusions The present study shows that a sizeable subgroup of consecutive patients with native mitral or tricuspid IE are amenable to valve repair in expert hands. Outcome of repair in IE is comparable to valve replacement mid-term, and should be considered whenever possible, as in degenerative valve disease. Funding Acknowledgement Type of funding source: None

Predictors of adverse prognosis in patients with infective endocarditis in a surgical referral center

Abstract Background Despite optimal medical and surgical treatment, mortality in infective endocarditis (IE) remains high. Aim of this study was to identify predictors of long term mortality for any cause, adverse event rate, relapse rate and valvular dysfunction at follow-up, in a high-volume surgical center. Methods We retrospectively analyzed 358 consecutive patients (127 women) admitted to our department with definite diagnosis of IE not device-related. IE occurred on native valves in 224 patients (63%); the infection involved the aortic valve in 192 (54%), mitral valve in 139 (39%) and tricuspid valve in 26 (7%). Overall 285 (80%) patients underwent surgery and 73 (20%) were treated conservatively, 38 due to absence of surgical indication and 35 due to refusal or prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were all-cause mortality, freedom from recurrent endocarditis, postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), worsening of left ventricular ejection fraction (LVEF) and valvular dysfunction. Results Mean age was 65 years (SD 15.2). Mean vegetation length was 8.9 mm (SD 7.6). Endocarditis was left-sided in 332 (93%). Average follow-up was 6 months. At univariable analysis, mortality was associated with female gender (p=0.031), age (p<0.001), higher EuroSCORE 2 (p<0.001), chronic renal failure (p<0.001), diabetes (p=0.002), brain embolism on presentation (p=0.05), double valve infection (p=0.008), low ejection fraction (p<0.001), paravalvular extension (p=0.031), prosthetic infection (p=0.018), exclusion from surgery if indicated (p<0.001), high procalcitonin levels (p=0.035); factors associated with a significantly lower mortality were streptococcal infection (p=0.04; OR 0.34) and early surgery (p=0.009, OR 0.55). At multivariable analysis independent predictors of all-cause mortality were lower EF, EuroSCORE2, procalcitonin levels and diabetes. Non-fatal adverse events were associated with renal failure (p 0.035, OR 2.8). Relapse rate was associated with S aureus infection (p=0.005, OR 3.8), right-sided endocarditis (p<0.001, OR 6.7) and drug abuse (p<0.001, OR 9.4). Conclusions The present study shows that low EF, EuroSCORE2, procalcitonin levels and diabetes are independent predictors of death in patients with IE. Non-fatal adverse events are more frequent in patients with renal failure. Relapse rate is higher in drug abusers. These informations may help personalize follow-up strategies after acute admission for IE. Funding Acknowledgement Type of funding source: None

THEORETICAL MODEL OF STERNUM EXTERNAL FIXATION FUNCTIONING IN PHYSICAL THERAPY OF PATIENTS FOLLOWING CARDIAC SURGERY VIA STERNOTOMY

Abstract. The purpose is to develop and analyze a theoretical model of sternum external fixation functioning as sternal precaution after cardiac surgery via sternotomy.
 Methods: theoretical modeling based on literature data.
 Results. The literature data, measuring the impact of sternum external fixation on the development of complications after cardiac surgery via sternotomy, do not present a proper report of the functioning mechanism or mechanical model of the interaction between the sternum and sternum external fixation. The first stage of theoretical model development included selecting the criteria based on the sternum anatomy, physiology of respiration, results of scientific research, which enabled to define key aspects of the theoretical model.The second stage included studying interaction of non-elastic SEF and sternum during a deep breath and a cough acting as main elements of inspiratory muscle training after cardiac surgeries; performing a similar algorithm of studying elastic type of SEF, which enabled to investigate and analyze preventive potential of SEF in relation to sternal dehiscence in the lateral direction. The third stage included the analysis of SEF restricting potential for anteroposterior stabilisation of the sternum. Since the use of sternum external fixation should not impede pulmonary function recovery after cardiac surgery and cannot restrict chest circumference increase with inhalation, sternum external fixation cannot properly function as sternal precaution when chest circumference is increased due to sternal edge dehiscence as well. The restricting effect of inelastic sternum external fixation will be possible only in case of a large dehiscence, when its size is bigger than the chest circumference increase during normal and deep breathing. Only when the circumference of inelastic sternum external fixation corresponds to the chest circumference after a full exhalation, the effect restricting dehiscence development will be possible. However, this condition is not practically feasible and does not comply with the need for pulmonary function recovery. As an example a barrel with iron rings that prevent it from expanding and emerging of dehiscence between the boards. However, this is not practically possible and is inconsistent with physiology of respiration. The restricting effect of elastic sternum external fixation will be possible in case the force of compression is greater than the force expanding the sternum during a cough, which will completely restrict inhaling and disable its practical use. The use of sternum external fixation must be biomechanically justified. The fact that the sternum is covered with soft tissues (muscles, which are joined with the bones of the sternum, shoulder blade and humerus; subcutaneous fat, which increases with excessive body weight) also reduces sternum external fixation effectiveness, as the existence of a soft and movable layer between the fixing parts and fixing means is a negative factor. On the other hand, dehiscence is a rare case among patients who do not use SEF. This confirms the priority of the sternal closure stability after sternotomy and the factors affecting it: the strength of bone tissue, the diameter of the wire, used during sternotomy, and the number of sutures.
 Conclusions. The theoretical model analyzed in this study confirms either the insignificant role of sternum external fixation or its complete absence in the prevention of sternal dehiscence in the lateral direction and anteroposterior displacement of sternum edges after sternotomy.

OUTCOMES AND SAFETY OF STERNAL CLOSURE USING NON-ABSORBABLE POLYESTER BRAIDED SUTURE: SINGLE TERTIARY CARE CENTER EXPERIENCE OF 5 YEARS.

Introduction: Median sternotomy is done as regular practice in cardiac surgery, which can lead to morbidity and mortality after sternal closure. Inappropriate sternal closure can lead to sternal dehiscence, sternal wound infection and mediastinitis. Aim: Efficacy and outcomes of sternal closure in adults weighing 2.5 kgs to 50 kgs using non-absorbable polyester braided suture. Methods: Total of 1091 patients underwent standard median sternotomy, weighing between 2.5 kgs to 50 kgs had sternal closure using non absorbable, braided, sterile, surgical suture composed of Poly ethylene terephthalate [polyester]. A retrospective analysis was done to review outcomes and complications related to this sternal closure technique. Results: Nineteen patients developed superficial surgical site infection and sternal sinus were seen in eight patients, whereas one patient had sternal dehiscence during immediate post-operative period. No sternal sutures were broken during the sternal closure and no case of mediastinitis was seen. Follow-up analyses of patients were done for 6 months after open heart surgery. Conclusion: Sternal closure using non-absorbable polyester braided suture is a safe and effective method with very less chances of post sternal wound complications in patients weighing between 2.5 kgs to 50 kgs.

Braided Polyester versus Standard Wire in Sternal Closure in High Risk Patients

Objective: The aim of this study was to compare braided polyester sternal closure versus standard wire closure in high-risk patients who are more susceptible to have deep sternal wound infections and mediastinitis after cardiac surgeries. Patients and Methods: Between February 2017 and December 2019 risk factors for postoperative deep wound infections and mediastinitis and mortality was collected for 100 adult patients undergoing open-heart surgery under cardiopulmonary bypass. Patients were divided to two groups, those who underwent sternal closure using either braided polyester or standard metal wire. Follow-up data on sternal wound healing and deep sternal wound infections were assessed for up to two months after surgery in the Outpatient Clinics. Results: The followingriskfactors wereassociatedwithahigherincidenceofdeepsternalwoundinfectionsandmediastinitis in both groups. There was no mortality in both groups, the number of deep sternal infection and mediastinitis with sternal dehiscence was 4 patients from group A (Ethibond) and 5 from group B (standard wire). Conclusion: This study showed that braided polyester could be used safely in sternal closure the same as standard wire in high risk patients.

Use of ciNPWT in cardiac surgery: single center observational study

Surgical site infections and complications (SSI, SSC) are relatively rare but potentially devastating events; particularly in cardiac surgery because of the importance of the structures involved.
 In accordance with the main international guidelines, that recommend the use of negative pressure therapy in closed surgical wounds (ciNPWT) in high-risk patients, we selected a group of 112 patients at high risk of developing surgical site complications, presenting in the clinic from January 2018 to December 2019.
 We applied 165 single-use negative pressure dressings in our cohort and kept them for seven days ($\pm$ 1). All the wounds were closed by primary intention without edema or hematoma. Three cases of postoperative bleeding required us to pause the negative pressure therapy. After discharge, five patients at particularly high risk developed sternal wound dehiscence.
 In conclusion, the use of ciNPWT, applied following a dedicated algorithm, gave good results in the prevention of SSI or SSC. Some limitations in the results are determined by the specific requirements of cardiac surgery.

Sliding doors: sternal dehiscence on stage

Sliding doors: sternal dehiscence on stage

Sternum Dehiscence: A Preventable Complication of Median Sternotomy.

The incidence of sternal dehiscence following cardiothoracic surgery via sternotomy is rare. It causes serious patient dissatisfaction and leads to higher hospital costs. For years, each clinic has made efforts to reduce this complication. Here, we aimed to summarize our techniques to prevent dehiscence. This retrospective study included two groups operated via median sternotomy from March 2009 to May 2019. The first group included 1,105 consecutive patients who only received sternum wire for sternum closure from March 2009 to October 2013. The second group included 1,559 consecutive patients operated from January 2014 to May 2019; preventive closure techniques were performed for predefined high-risk patients in this group. These closure techniques included polyglyconate (Maxon) or simple longitudinal reinforced sutures, sternal cable or sternoband, sternal plate, and Robiscek technique. All patients in Group 1, and 63.8% (995/1559) patients in Group 2 received sternal wire only (P < .001). In Group 2, we applied preventive closure techniques to 564 (36.2%) patients. There was no sternal dehiscence in Group 2, whereas 29 (2.6%) patients postoperatively suffered sternal dehiscence in Group 1; this was statistically significant (P = .001, OR:85.5, 95%CI:5.22-1400.4). The overall incidence of mediastinitis was 0.94%. The incidence significantly was lower in Group 2 (P = .004, OR:3.6, 95%CI:1.52-8.82). Sternum-related mortality in Group 2 also was lower (0.54% versus 0.06%, P = .048, OR:8.5, 95% CI: 1.02-70.75). Sternal dehiscence can be avoided by careful perioperative risk assessment and enhanced closure techniques. The same special consideration may significantly reduce mediastinitis and sternal-related mortality.

Surgical reconstruction of the sternum following cardiac surgery complicated by mediastinitis—implantation of a custom-made sternal implant: a case report

: Mediastinitis represents an uncommon but potentially life-threatening complications following median sternotomy. There remains a lack of consensus regarding the optimal treatment option(s). Custom tridimensional titanium printing provides an effective method for construction of complex prothesis. We report the case of a 49-year-old female with previous sternal dehiscence and deep wound infection following coronary artery bypass grafts, necessitating sternectomy. A year later, she presented with chronic severe pain and audible crepitations of her ribs/clavicles. Lack of identification of a mechanical cause, poor localisation and suboptimal medical pain management culminated in the consideration for a novel approach for sternal reconstruction. By way of bridging the final placement of the titanium prothesis, the patient underwent placement of a methyl methacrylate spacer. The surgical approach involved the removal of the temporary spacer, with tissue samples taken to guide post-operative antimicrobial therapy. Concurrently, the reaming, irrigation and aspiration technique of bone marrow harvesting, for seeding of the central web structure of the implant, was employed under fluoroscopic guidance. Following adequate dissection under the pectoral muscle, and debridement of the anterior chest wall, final placement of the prothesis was made via bicortical fixation to the ribs. Finally, the mobilised pectoral muscles were sutured medially and fixed to the previously placed rectus abdominis flap. Three-dimensional printing of a custom prosthesis offers a novel and effective approach to full reconstruction; maintaining pulmonary mechanics and stability of the anterior chest wall

Long-Term Metabolic Assessment of Cryopreserved Sternal Allograft: A Case Series

Sternal resection and reconstruction with cryopreserved allografts provides a safe alternative to traditional methods of anterior chest wall reconstruction. Despite favorable results, successful integration of the graft sternum has never been demonstrated owing to the invasiveness of bone biopsy. We describe our experience of using 18F-sodium fluoride positron emission tomography/computed tomography scans as a noninvasive method of evaluating graft integration. Seven patients underwent surgery and radiologic follow-up. Surgical indications were sternal metastases (n= 5) and sternal dehiscence (n= 2). Sternal reconstruction was performed using a cryopreserved cadaveric sternal allograft fixed in place with titanium plates and screws. Follow-up with 18F-sodium fluoride positron emission tomography/computed tomography scans was performed at 1 and 2 years after surgery. Three patients underwent total sternectomy. Two underwent partial upper sternectomy involving the manubrium, clavicle (1 patient only), and upper sternal body; and 2 had partial sternectomy of the sternal body and xiphoid process. Focal tracer accumulation occurred at the junctions between native bone and graft bone. The median maximum standardized uptake value at 1 year was 16.8 (range, 11.2 to 37.9; interquartile range, 13.6 to 19.4), and at 2 years it was 10.8 (range, 6.1 to 30.2; interquartile range, 8.9 to 15.1). In 6 cases accumulation was lower at the second scan, whereas in 1 patient the accumulation was higher at the second scan. Sternal reconstruction with cryopreserved allograft is safe and well tolerated. The 18F-sodium fluoride positron emission tomography/computed tomography scans are a useful and promising noninvasive method of demonstrating the metabolic activity of the graft and its incorporation into the host skeleton during follow-up.

Prevention of Sternal Wound Infections in Women Using an External Sternum Fixation Corset.

Purpose: Deep sternal wound infection (DSWI) and mediastinitis are devastating complications after median sternotomy. Previous studies demonstrated an effective prevention of sternal wound infection (SWI) using an external sternal corset in high-risk cardiac surgery patients. The aim of this study is to assess the preventive effect of the Stern-E-Fix corset in high-risk poststernotomy female patients.Methods: A total of 145 high-risk female patients undergoing cardiac surgery through median sternotomy were retrospectively analyzed. Patients were divided into group A (n = 71), who received the Stern-E-Fix corset (Fendel & Keuchen GmbH, Aachen, Germany), and group B (n = 74), who received the elastic thorax bandage (SanThorax) postoperatively for 6 weeks. The mean follow-up period was 12 weeks.Results: Incidence of SWI was 7% in group A vs. 17.6% in group B (p = 0.025). One patient presented with DSWI in group A vs. seven patients in group B (p = 0.063). No patient developed mediastinitis in group A vs. four patients in group B (p = 0.121). In all, 4.2% of group A patients required operative wound therapy vs. 16.2% of group B patients (p = 0.026). The length of hospital stay was significantly longer in group B (p = 0.006).Conclusion: Using an external supportive sternal corset (Stern-E-Fix) yields a significantly better and effective prevention against development of sternal dehiscence, DSWI, and mediastinitis in high-risk poststernotomy female patients.

Wire Cerclage Versus Cable Closure After Sternotomy for Dehiscence and DSWI: A Systematic Review and Meta-Analysis.

Cable closure has been introduced as a potential alternative to traditional wire cerclage (WC) for closure of median sternotomy. To evaluate whether cable closure improves patient outcomes, we conducted a systematic review and meta-analysis of the literature. Ovid versions of Medline and Embase, and Google Scholar were used for the literature search. This yielded 7 studies (n = 2,758), which compared traditional WC to cable closure systems. Outcomes included deep sternal wound infection, sternal dehiscence, postoperative pain score, and sternal wound infection. We found significantly lower incidence of sternal dehiscence for cable closure compared to WC (risk ratio [RR] 0.14, 95% confidence interval [CI]: 0.03 to 0.59, P < 0.01, I 2 = 0%) but no difference in DSWI (RR 0.97, 95% CI: 0.39 to 2.42, P = 0.95, I 2 = 33%). Cable closure was also associated with lower pain when compared with the WC group (mean difference -1.04 points, 95% CI: -1.89 to -0.19, P = 0.02, I 2 = 87%). This study suggests that cable closure results in less incidence of sternal dehiscence and pain compared to WC. Nonetheless, there remains a limited number of studies on this topic and further high-quality studies are required to confirm the results of this meta-analysis.