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Cauley RP, Rahmani B, Adebagbo OD, Park J, Garvey SR, Chen A, Nickman S, Tobin M, Valentine L, Weidman AA, Singhal D, Dowlatshahi A, Lin SJ, Lee BT. Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review. J Reconstr Microsurg 2025; 41:248-260. [PMID: 38782025 DOI: 10.1055/a-2331-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount. METHODS Herein we aim to understand efforts supporting the nascent field of preventive surgery, including (1) enhanced risk stratification, (2) medical optimization and prehabilitation, (3) surgical mitigation techniques, and (4) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized. RESULTS Although multiple risk mitigation methods have demonstrated clear benefits, including prophylactic surgical procedures and earlier involvement of plastic surgery, their use is widely variable across institutions. Many current risk assessment tools are suboptimal for supporting more algorithmic approaches to reduce surgical risk. CONCLUSION Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.
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Affiliation(s)
- Ryan P Cauley
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Rahmani
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Oluwaseun D Adebagbo
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Tufts University School of Medicine, Boston, Massachusetts
| | - John Park
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Shannon R Garvey
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Chen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sasha Nickman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Micaela Tobin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren Valentine
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Allan A Weidman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arriyan Dowlatshahi
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Samuel J Lin
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Lee D, Laikhter E, Bustos VP, Shiah E, Comer CD, Manstein SM, Lin SJ, Cauley R. Why Has Rigid Primary Sternal Fixation Adoption Stalled? Plast Surg (Oakv) 2024:22925503241241343. [PMID: 39553529 PMCID: PMC11562127 DOI: 10.1177/22925503241241343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2024] Open
Affiliation(s)
- Daniela Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eric Shiah
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Carly D. Comer
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel M. Manstein
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel J. Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Bieler D, Franke A, Völlmecke M, Hentsch S, Markewitz A, Kollig E. [Treatment regimen for deep sternal wound infections after cardiac surgical interventions in an interdisciplinary approach]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:211-220. [PMID: 38085276 PMCID: PMC10891204 DOI: 10.1007/s00113-023-01394-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 02/24/2024]
Abstract
The aim of this article is to present the importance of a structured and situation-adapted approach based on the diagnostic and therapeutic strategy in the interdisciplinary treatment of 54 patients with deep sternal wound infections (DSWI) after cardiac surgical interventions and the results achieved. The patients were 41 men and 13 women with an average age of 65.1 years, who developed a DSWI after a cardiac surgical intervention during the period 2003-2016. The treatment strategy included a thorough debridement including the removal of indwelling foreign material, the reconstruction with a stable re-osteosynthesis after overcoming the infection and if necessary, situation-related surgical flaps for a defect coverage with a good blood supply and mandatory avoidance of dead spaces. A total of 146 operations were necessary (average 2.7 operations/patient, range 1-7 operations). In 24.1 % of the cases a one-stage approach could be carried out. In 41 patients negative pressure wound therapy (NPWT) with programmed sponge changing was used for wound conditioning (mean 5 changes, standard deviation, SD± 5.6 changes over 22 days, SD± 23.9 days, change interval every 3-4 days in 40.7% of the cases). In 33 patients a bilateral myocutaneous pectoralis major flap was used, in 4 patients a vertical rectus abdominis myocutaneous (VRAM) flap and in 7 patients both were carried out. A total of 43 osteosynthesis procedures were carried out on the sternum with fixed-angle titanium plates. Of the patients 7 died during intensive care unit treatment (total mortality 13 %, n = 5, 9.3 % ≤ 30 days) or in the later course. Of the patients 47 (87.1 %) could be discharged with a cleansed infection. In 2 patients the implant was removed after 2 years due to loosening.
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Affiliation(s)
- D Bieler
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland.
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland.
| | - A Franke
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | - M Völlmecke
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | - S Hentsch
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | | | - E Kollig
- Klinik für Unfallchirurgie und Orthopädie, Wiederherstellungs- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstraße 170, 56072, Koblenz, Deutschland
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Park JM, Son J, Kim DH, Son BS. A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation. Yonsei Med J 2023; 64:730-737. [PMID: 37992745 PMCID: PMC10681828 DOI: 10.3349/ymj.2023.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 11/24/2023] Open
Abstract
PURPOSE Clamshell incision offers excellent exposure and access to the pleural spaces and is a standard incision for lung transplantation. However, due to its high sternal complication rate, the clamshell incision is considered a procedure that requires improvement. In this study, we aimed to investigate the outcomes of transverse sternotomy with clamshell incision in comparison to sternum-sparing bilateral anterolateral thoracotomy (BAT). MATERIALS AND METHODS In total, 134 bilateral sequential lung transplants were performed from May 2013 to June 2022. The clamshell incision was used between May 2013 and December 2017, and the BAT was introduced in January 2018. Thirty-four patients underwent clamshell surgery, and 100 patients underwent BAT. We retrospectively compared patient characteristics and perioperative and postoperative outcomes between the two groups. RESULTS The clamshell group required an operation time of 745.18±101.76 min, which was significantly longer than that of the BAT group at 669.90±134.09 min (p=0.003). The mechanical ventilation period after surgery was 17.26±16.04 days in the clamshell group, significantly longer than the 11.35±12.42 days in the BAT group (p=0.028). Intensive care unit stay was also significantly longer in the clamshell group (21.54±15.23 days vs. 15.03±14.28 days; p=0.033). In-hospital mortality rates were 26.5% in the clamshell group and 22.0% in the BAT group. CONCLUSION Less-invasive lung transplantation via sternum-sparing BAT is a safe procedure with low morbidity and favorable outcomes. Preventing sternal instability enables more stable breathing after surgery, earlier weaning from mechanical ventilation, and faster recovery to routine activities.
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Affiliation(s)
- Jong Myung Park
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
- Transplantation Research Center, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
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Vasanthan V, Hassanabad AF, Kang S, Dundas J, Ramadan D, Holloway D, Adams C, Ahsan M, Fedak PWM. Novel hardening bone putty enhances sternal closure and accelerates postoperative recovery. J Thorac Cardiovasc Surg 2023; 166:e430-e443. [PMID: 36272766 DOI: 10.1016/j.jtcvs.2022.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/02/2022] [Accepted: 09/10/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Regaining and maintaining sternal stability are key to recovery after cardiac surgery and resuming baseline quality of life. Montage (ABYRX) is a moldable, calcium phosphate-based putty that adheres to bleeding bone, hardens after application, and is resorbed and replaced with bone during the remodeling process. We evaluate the feasibility, safety, and efficacy of enhanced sternal closure with this novel putty to accelerate recovery in patients after sternotomy. METHODS A single-center, single-blinded, randomized controlled trial was performed (NCT03365843). Patients undergoing elective cardiac surgery via sternotomy received sternal closure with either Montage bone putty and wire cerclage (enhanced sternal closure; n = 33) or wire cerclage alone (control; n = 27). Standardized patient-reported outcomes assessed health-related quality of life (EQ-5D Index) and physical disability (Health Assessment Questionnaire). A Likert-type 11-point scale quantified pain. Spirometry assessed respiratory function. Patients reached 6-week follow-up, with 1-year follow-up for safety end points. RESULTS There were no device-related adverse events. Enhanced sternal closure improved physical functional recovery (reduced Healthcare Index and Quality) and quality of life (increased EQ-5D Index) at day 5/discharge, week 2, and week 4. Enhanced sternal closure reduced incisional pain while resting, breathing, sleeping, and walking at day 5/discharge. Enhanced sternal closure reduced chest wall and back pain at day 3 and day 5 discharge. A higher proportion of patients with enhanced sternal closure recovered to 60% of their baseline forced vital capacity by day 5/discharge. Enhanced sternal closure shortened hospital stay. CONCLUSIONS Enhanced sternal closure improves and accelerates postoperative recovery compared with conventional wire closure. Earlier discharge may provide substantial cost benefits for the healthcare system.
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Affiliation(s)
- Vishnu Vasanthan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean Kang
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jameson Dundas
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Darlene Ramadan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel Holloway
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Corey Adams
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Muhammad Ahsan
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Shell D. The role of cardiac surgery in radiation-associated heart disease: a scoping review. Gen Thorac Cardiovasc Surg 2023; 71:629-638. [PMID: 37166740 DOI: 10.1007/s11748-023-01939-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/04/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Thoracic irradiation is an important tool in the treatment of breast cancer, non-Hodgkin's lymphoma, and other cancers of the chest. The heart is commonly involved in these radiation fields, and young patients can present with severe cardiac pathologies requiring surgical intervention. However, this population poses a high surgical risk due to involvement of mediastinal tissues, and there are no consensus guidelines on best practice management. AIM This review aims to summarise the current experience of surgical correction of radiation-associated heart disease. We explore outcomes, technique modifications and alternative therapies for the three primary procedures performed: coronary artery bypass grafting, valvular intervention and pericardiectomy. METHODS OVID Medline and PubMed databases were comprehensively searched to identify all studies involving surgery in patients with prior chest radiotherapy. All relevant studies within the past 25 years have been discussed. CONCLUSION Irradiated patients have heightened peri-operative risk, but other than redo surgery, these operations are not as treacherous as once thought. Involvement of all layers of the heart, especially the myocardium, is such that long-term mortality suffers despite optimal surgical correction. The goal of surgery in this cohort should be for a quick and safe operation, rather than a technically difficult procedure aimed at longevity.
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Affiliation(s)
- Daniel Shell
- Department of Cardiothoracic Surgery, St Vincent's Hospital Melbourne, St Vincent's Health Australia, Melbourne, Australia.
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Tamura K, Sakurai S. Comparison of postoperative exercise capacity of patients who underwent sternal closure with SternaLock Blu and those with traditional sternal wire closure following cardiovascular surgery via sternotomy. Indian J Thorac Cardiovasc Surg 2023; 39:471-475. [PMID: 37609624 PMCID: PMC10441876 DOI: 10.1007/s12055-023-01532-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 08/24/2023] Open
Abstract
Purpose This study aimed to evaluate the efficacy of postoperative exercise capacity of SternaLock Blu (Zimmer Biomet, USA) for post-sternotomy patients who underwent cardiovascular surgery. Methods We investigated 116 patients, including 35 women (mean age 70.3 ± 10.0 years), who underwent cardiovascular surgery by median sternotomy. Patients were candidate for using SternaLock Blu, such as obesity (body mass index > 30/kg/m2), insulin-dependent diabetes mellitus, steroid administrating, undergoing coronary bypass artery grafting used bilateral internal thoracic artery. These patients were categorized into those with SternaLock Blu (S group, n = 47) or with sternal wires only (N group, n = 69) for closing sternotomy, and their data were analyzed. Results Max Prince Henry Pain Scale (PHPS) was significantly low in the S group than in the N group (N vs. S = 2.7 ± 1.4 vs. 1.6 ± 1.7%, p < 0.001). Postoperative 6-min walk was significantly longer in the S group than in the N group (N vs. S = 346.2 ± 101.6 vs. 408.6 ± 104.6 m, p = 0.018). The length of intensive care unit (N vs. S = 4.9 ± 0.9 vs. 4.0 ± 1.2 days, p < 0.001) and hospitalization (N vs. S = 18.0 ± 5.0 vs. 15.2 ± 3.8 days, p = 0.006) were significantly shorter in the S group than in the N group. Conclusions SternaLock Blu could keep exercise capacity, and might help reduce postoperative pain and medical treatment period for patients who underwent cardiovascular surgery.
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Affiliation(s)
- Kiyoshi Tamura
- Department of Cardiovascular Surgery, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama, 340-8560 Japan
| | - Shogo Sakurai
- Department of Cardiovascular Surgery, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama, 340-8560 Japan
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Blake A, Condrey M, Hansen L, Mehan V. Management of Sternal Wounds, Infections, and Sternal Non-Union with Plate Fixation: Result from a Single Site Experience. Surg Infect (Larchmt) 2023; 24:131-140. [PMID: 36735615 DOI: 10.1089/sur.2022.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background: Patients with sternal wounds, infection, or non-union after cardiac surgery continue to have increased morbidity and mortality rates compared with those without sternal complications. Reconstructive methods have largely centered on soft tissue approaches, including muscle or omental flaps, which result in functional loss. Some data show early positive advantages using sternal rigid plate fixation (SRPF), however, it is debated in the setting of active infection. The goal of this study is to examine the outcomes of SRPF in patients with and without infections. Patients and Methods: This is a retrospective study of consecutive patients who underwent SRPF by a single plastic surgeon from April 2013 to August 2021. Patients treated without SRPF, lacking at least six months of follow-up, or those plated more than once were excluded. Ninety-seven patients were included. Demographic and peri-operative factors associated with sternal infection after SRPF were evaluated. Results: Sixty-eight patients were clinically infected/culture positive or open (INFECTED), and 29 were clean/primary plating (CLEAN). Sixteen percent of the INFECTED cases (11/68) returned with infection. Fourteen percent of the CLEAN cases (4/29) had subsequent infections. Additionally, we did note a decrease in rates of infections overall (p < 0.0001) as experience and frequency of plate fixation increased (p < 0.0001). Regardless of infection status, all but one patient had a healed and stable sternum at the end of data collection. Conclusions: There is no statistically significant difference between wound class prior to SRPF and development of infection after SRPF. Even in infected settings, patients can be treated successfully with SRPF. Further study is needed.
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Affiliation(s)
| | - Megan Condrey
- Dominion Plastic Surgery, Falls Church, Virginia, USA
| | - Leslie Hansen
- Dominion Plastic Surgery, Falls Church, Virginia, USA
| | - Vineet Mehan
- Dominion Plastic Surgery, Falls Church, Virginia, USA
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Xie LF, He J, Wu QS, Qiu ZH, Jiang DB, Gao HQ, Chen LW. Do obese patients with type A aortic dissection benefit from total arch repair through a partial upper sternotomy? Front Cardiovasc Med 2023; 10:1086738. [PMID: 36776260 PMCID: PMC9915564 DOI: 10.3389/fcvm.2023.1086738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/11/2023] [Indexed: 02/14/2023] Open
Abstract
Background Minimal research has been performed regarding total arch replacement through partial upper sternotomy in patients with acute type A aortic dissection who are obese, and the safety and feasibility of this procedure need to be further investigated. The present study investigated the potential clinical advantages of using a partial upper sternotomy versus a conventional full sternotomy for total arch replacement in patients who were obese. Methods This was a retrospective study. From January 2017 to January 2020, a total of 65 acute type A aortic dissection patients who were obese underwent total arch replacement with triple-branched stent graft. Among them, 35 patients underwent traditional full sternotomy, and 30 patients underwent partial upper sternotomy. The perioperative clinical data and postoperative follow-up results of the two groups were collected, and the feasibility and clinical effect of partial upper sternotomy in total arch replacement were summarized. Results The in-hospital mortality rates of the two groups were similar. The total operative time, cardiopulmonary bypass, aortic cross-clamp, cerebral perfusion, and deep hypothermic circulatory arrest times were also similar in both groups. The thoracic drainage and postoperative red blood cell transfusion volumes in the partial upper sternotomy group were significantly lower than those in the full sternotomy group. Mechanical ventilation time was shorter in the partial upper sternotomy group than that in the full sternotomy group. Additionally, the incidences of pulmonary infection, hypoxemia, and sternal diaphoresis were lower in the partial upper sternotomy group than those in the full sternotomy group. Conclusion This study showed that total arch replacement surgery through a partial upper sternotomy in patients with acute type A aortic dissection who are obese is safe, effective, and superior to full sternotomy in terms of blood loss, postoperative blood transfusion, and respiratory complications.
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Affiliation(s)
- Lin-Feng Xie
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jian He
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qing-Song Wu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhi-Huang Qiu
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - De-Bin Jiang
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hang-Qi Gao
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Liang-wan Chen
- Department of Cardiovascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China,Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China,Fujian Provincial Special Reserve Talents Laboratory, Fujian Medical University Union Hospital, Fuzhou, China,*Correspondence: Liang-wan Chen,
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Cauley RP, Barron S, Slatnick B, Maselli A, Kang C, Delvalle D, Chu L, Morris D. An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience. J Reconstr Microsurg 2022; 38:671-682. [DOI: 10.1055/s-0042-1743167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Background Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.
Methods A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.
Results One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5–15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).
Conclusion Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.
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Affiliation(s)
- Ryan P. Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sivana Barron
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brianna Slatnick
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amy Maselli
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christine Kang
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Diana Delvalle
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Louis Chu
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Donald Morris
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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11
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Right ventricular laceration caused by sternal wire fracture following cardiac surgery: a case report. Indian J Thorac Cardiovasc Surg 2022; 38:418-421. [DOI: 10.1007/s12055-022-01333-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022] Open
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Basha MAA, Shemais DS, Abdelwahed ES, Elfwakhry RM, Zeid AF, Abdalla AAEHM, Aly SA, Abdelrahman DS, Elshenawy AA, Mansour W, Elbanna KAA, El Tahlawi M, Elnahal N. Computed Tomography Imaging Assessment of the Effect of Vancomycin Paste on Poststernotomy Healing. Int J Gen Med 2021; 14:9287-9296. [PMID: 34880667 PMCID: PMC8648099 DOI: 10.2147/ijgm.s343124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To assess vancomycin paste effect on poststernotomy healing in high-risk coronary artery bypass grafting (CABG) patients compared to bone wax using the 6-point computed tomography (CT) score. Additionally assessed the reliability of this score and its relationship to the occurrence of infection. PATIENTS AND METHODS A prospective comparative analysis included 126 high-risk CABG patients. The patients were randomly assigned into bone wax or vancomycin paste for sternal haemostasis. All patients were submitted to CT examinations 6-months postoperative. Two radiologists independently reviewed all CT scans to assess sternal healing using the 6-point CT score. The CT healing score of the two groups was compared. The kappa statistics were used to calculate the inter-reader agreement (IRA) of the 6-point CT score. RESULTS The final analysis included 61 patients in each group. The main CT score for sternal healing was 3.9±0.4 in the vancomycin group and 3.3±0.8 in the bone wax group. Patients in the vancomycin group had a higher statistically significant improvement in CT healing score than those in the bone wax group (p<0.001). There was no statistically significant relationship (p = 0.79) between the occurrence of infection and the 6-point CT score in the vancomycin group. The overall IRA of the 6-point CT score was good in two groups (κ = 0.79 in the vancomycin group and = 0.78 in the bone wax group). CONCLUSION Vancomycin paste had a better CT healing score and can be used as a sternal haemostatic material instead of bone wax. The 6-point CT healing score is a reliable diagnostic tool for evaluating sternal healing.
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Affiliation(s)
| | - Dina Said Shemais
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Essam Saad Abdelwahed
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Ayman Fathy Zeid
- Department of Radiodiagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Sameh Abdelaziz Aly
- Department of Radiodiagnosis, Faculty of Human Medicine, Benha University, Benha, Egypt
| | | | - Anwar A Elshenawy
- Department of Surgical Oncology, Faculty of Human Medicine, Aswan University, Aswan, Egypt
| | - Waleed Mansour
- Department of Chest Medicine, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Mohammad El Tahlawi
- Department of Cardiology, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Nezar Elnahal
- Department of Cardiothoracic Surgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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13
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. SUMMARY Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.
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14
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Sidhu VPS, Bilwani F, Towler MR, Papini M. Adhesion of bioactive glass-based adhesive to bone. J Mech Behav Biomed Mater 2021; 126:105018. [PMID: 34864572 DOI: 10.1016/j.jmbbm.2021.105018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/23/2021] [Accepted: 11/28/2021] [Indexed: 11/26/2022]
Abstract
Understanding the failure modes and the fracture resistance is critical in evaluating the performance of an adhesive for sternal fixation. In this paper, a fracture mechanics testing methodology was used to assess the adhesion of a bioactive glass-based adhesive to bovine bone in terms of a measured mode I critical strain energy release rate (GIC). Reinforced double cantilever beam (DCB) samples were observed to produce repeatable values of GIC. The measured GIC was found to increase significantly from 5.41 to 12.60 J/m2 with an increase in adhesive thickness from 390 to 990 μm because of the constraint from the two adherends regulating the plastic zone size ahead of the crack. The specimens failed cohesively in all cases demonstrating that there was good adhesion to bone, a condition necessary to restrict micromotion and thus provide rigid sternal fixation when used along with sternal wires. It was also found that when the bone was flooded with liquid during adhesive application a much lower GIC of between 0.69 and 1.15 J/m2 was measured. Overall, the results demonstrate that the fracture mechanics approach can be used to provide a quantitative measure of the adhesion of the bioactive glass-based adhesive to the bone and that the adhesive should only be applied to clean bone in a dry environment.
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Affiliation(s)
- Varinder Pal Singh Sidhu
- Department of Mechanical & Industrial Engineering, Ryerson University, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Faizan Bilwani
- Department of Mechanical & Industrial Engineering, Ryerson University, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Mark R Towler
- Department of Mechanical & Industrial Engineering, Ryerson University, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marcello Papini
- Department of Mechanical & Industrial Engineering, Ryerson University, Toronto, Ontario, Canada.
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15
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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Seyrek Y, Akkuş M. What is the impact of a previously failed Robicsek repair in the subsequent treatment of sternal dehiscence with thermoreactive nitinol clips? J Card Surg 2021; 36:3232-3239. [PMID: 34137076 DOI: 10.1111/jocs.15743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND In this study, we conducted a retrospective review of patients at our institution with noninfectious sternal dehiscence (NISD) after median sternotomy who received thermoreactive nitinol clips (TRNC) treatment during a 10-year period. The purpose of the study was to analyze the impact of previous Robicsek repair on the later treatment of sternal dehiscence with TRCN to establish which method was better in high-risk patients with NISD. METHODS Between December 2009 and January 2020, out of 283 patients with NISD who underwent refixation, we studied 34 cases who received TRNC treatment. We divided these 34 cases into two groups: patients who had a previously failed Robicsek procedure before TRNC treatment (group A, n = 11) and patients who had been directly referred to TRCN treatment (group B, n = 23). High-risk patients were defined as those having three or more risk factors. RESULTS Postoperative complication rate was significantly higher in group A (p = .026). Hospitalization duration was significantly longer in group A due to the higher complication rate (p = .001). Operative time was significantly shorter and blood loss was significantly lower in group B (p = .001). CONCLUSION The Robicsek procedure is considered an effective method in the treatment of NISD but, in case of its failure, subsequent TRNC treatment might become cumbersome in high-risk patients. In our study, a previously failed Robicsek procedure caused significantly higher morbidity, additional operative risk and lower success rate in later TRNC treatment of high-risk cases. Ultimately, we speculate that a direct TRNC treatment for NISD is favorable in high-risk patients.
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Affiliation(s)
- Yunus Seyrek
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Akkuş
- Department of Thoracic Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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17
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Mehrvar C, Deignan E, Hurtig M, Cohen G, Zalzal P, Safir O, Alhalawani A, Papini M, Towler MR. In vivo analysis of a proprietary glass-based adhesive for sternal fixation and stabilization using rabbit and sheep models. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2021; 32:53. [PMID: 33914176 PMCID: PMC8084842 DOI: 10.1007/s10856-021-06527-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/09/2021] [Indexed: 06/12/2023]
Abstract
Wire cerclage remains the standard method of care for sternal fixation, following median sternotomy, despite being beset with complications. An emerging treatment option has been to augment the wires with an adhesive. A patented ionomeric glass (mole fraction: SiO2:0.48, ZnO:0.36, CaO:0.12, SrO:0.04) has been used to formulate GPC+, a glass polyalkenoate cement (GPC), by mixing it with poly(acrylic) acid (PAA) and de-ionized water. In a human cadaver study, this material, when applied with wire cerclage, was able to significantly reduce sternal instability. However, the material has yet to be tested in pertinent animal models. Here, after a series of physical and mechanical tests to confirm suitability of the experimental material for implantation, three samples of GPC+ were implanted in either the tibia or femur of three different rabbits, alongside sham defects, for two different time modalities. A further seven samples of GPC+ and one poly(methyl methacrylate) control (PMMA) were implanted in either the tibia or femur of two different sheep. The sheep containing the PMMA was sacrificed at 8 weeks and the other at 16 weeks, to evaluate time dependent biological response. Upon sacrifice, microCT images were acquired and histology slides prepared for analysis. All three GPC+ samples implanted in the rabbit model, for the two time modalities, were characterized by minimal bone resorption along with a mild inflammatory response. Five of the seven GPC+ materials implanted in the sheep model (all three implanted for 8 weeks and two of those implanted for 16 weeks) were associated with mild to moderate immune response, comparable to that observed with PMMA, as well as mild bone resorption. The remaining two GPC + materials (implanted in the sheep model for 16 weeks) exhibited no bone resorption or inflammatory response and appeared to stimulate increased bone density at the implant site. These results suggest that GPC + can be a viable bone adhesive for use in hard tissue applications such as sternal fixation and stabilization. Experiments performed to synthesize & test Sr-doped glass adhesive for sternal fixation. (1) Sr-doped ionomeric glass fired, ground down and mixed with aqueous polyacrylic acid to produce the adhesive. (2) Adhesive characterized and tested by a suite of laboratory-based tests to ensure suitability for implantation. (3) Adhesive implanted into a rabbit model (distal femur, 12 weeks post implantation) where micro-CT images confirmed an excellent bone/cement interface, no evidence of bone resorption and some bone remodelling. (4) Adhesive subsequently implanted into a sheep model; at 16-weeks, a continuous bone-adhesive interface is seen suggesting no bone resorption. There was an increase in the peri-implant radiodensity, suggesting enhanced mineral content of the bone surrounding the GPC+ implant.
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Affiliation(s)
- Cina Mehrvar
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON, M5B 2K3, Canada
| | - Emily Deignan
- Ontario Veterinary College, University of Guelph, 50 Stone Rd E, Guelph, ON, N1G 2W1, Canada
| | - Mark Hurtig
- Ontario Veterinary College, University of Guelph, 50 Stone Rd E, Guelph, ON, N1G 2W1, Canada
| | - Gideon Cohen
- Division of Cardiac Surgery, Sunnybrook Hospital, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Paul Zalzal
- Oakville Trafalgar Memorial Hospital, 3001 Hospital Gate, Oakville, ON, L6M 0L8, Canada
- Faculty of Medicine, Department of Surgery, McMaster University, 1200 Main St W, Hamilton, ON, L8N 3Z5, Canada
| | - Oleg Safir
- Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Ave, Toronto, ON, M5G 1X5, Canada
| | - Adel Alhalawani
- Department of Biomedical Engineering, The University of Akron, 302 E Buchtel Ave, Akron, OH, 44325, USA
| | - Marcello Papini
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON, M5B 2K3, Canada
| | - Mark R Towler
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON, M5B 2K3, Canada.
- Li Ka Shing Institute, St. Michael's Hospital, Bond Street, Toronto, ON, M5B1W8, Canada.
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Morimoto K, Matsushita T, Masuda S, Kurata A. The Novel Technique of Sternal Closure With Absorbable Mesh for Osteoporotic Patients. Heart Lung Circ 2020; 30:e65-e67. [PMID: 33341398 DOI: 10.1016/j.hlc.2020.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 10/16/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Kazuki Morimoto
- Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Maizuru, Kyoto, Japan.
| | - Tsutomu Matsushita
- Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Maizuru, Kyoto, Japan
| | - Shinsuke Masuda
- Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Maizuru, Kyoto, Japan
| | - Atsushi Kurata
- Division of Cardiovascular Surgery, Yamato Seiwa Hospital, Yamato, Kanagawa, Japan
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Abstract
Enhanced recovery after surgery (ERAS) protocols recognize early postoperative mobilization as a driver of faster postoperative recovery, return to normal activities, and improved long-term patient outcomes. For patients undergoing open cardiac surgery, an opportunity for facilitating earlier mobilization and a return to normal activity lies in the use of improved techniques to stabilize the sternal osteotomy. By following the key orthopedic principles of approximation, compression, and rigid fixation, a more nuanced approach to sternal precaution protocols is possible, which may enable earlier patient mobilization, physical rehabilitation, and recovery.
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20
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Zia A, Hasan M, Ilyas S, Siddiqui HU, Tappuni B, Marsia S, Zubair MM, Raza S, Mustafa RR, Baloch ZQ, Deo SV, Sharma UM, Sheikh MA. Reining in Sternal Wound Infections: The Achilles' Heel of Bilateral Internal Thoracic Artery Grafting. Surg Infect (Larchmt) 2020; 21:323-331. [DOI: 10.1089/sur.2018.142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Aisha Zia
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marium Hasan
- Department of Urology, The Kidney Centre, Karachi, Pakistan
| | - Sidra Ilyas
- Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
| | - Hafiz Umair Siddiqui
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bassman Tappuni
- Department of Thoracic & Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shayan Marsia
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - M. Mujeeb Zubair
- Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Sajjad Raza
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Rami R. Mustafa
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Salil V. Deo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Umesh M. Sharma
- Community Division of Hospital Medicine, Mayo Clinic Health System, Rochester, Minnesota, USA
| | - Mohammad Adil Sheikh
- Department of Medicine, Detroit Medical Center/Wayne State University, Detroit, Michigan, USA
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Kuroki H, Arai H, Srisont S, Oi K, Tomita M, Mizuno T. Corrugated Sheet of Unsintered Hydroxyapatite Poly-L-Lactide for Sternal Fixation: A Preclinical Study. Ann Thorac Cardiovasc Surg 2020; 26:40-46. [PMID: 31827020 PMCID: PMC7046929 DOI: 10.5761/atcs.oa.19-00250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: To stabilize the sternum after median sternotomy, unsintered hydroxyapatite poly-L-lactide (u-HA/PLLA) sternal pins are frequently used in Japan. However, sternal pins are ineffective in the fragile bone marrow. Thus, a corrugated sheet made of u-HA/PLLA was developed as a new sternal fixation device. Methods: To examine the effects of the device, we measured the shear force using a sternal model and cadaver. The shear force of the corrugated sheet, sternal pin, and simple wire was compared. The device size was determined after reviewing the sternal computed tomography (CT) of 128 patients. Results: The shear force of the model with the corrugated sheet (286 [256–295] N) was higher than that with sternal pins (135 [134–139] N, p = 0.03) and simple wire (94 [90–104] N, p = 0.03) at 2-mm displacement. In the cadaver test, the shear force of the sternal halves with the device was about two times higher than that without the device. Retrospective CT showed that 18-mm wide device applies to 99% male and 87% female patients at the fourth intercostal level. Conclusion: The corrugated sheet might provide a stronger fixation effect in the fragile bone marrow. The device width was modified to 18 mm to be applicable for most Japanese patients.
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Affiliation(s)
- Hidehito Kuroki
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Smith Srisont
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Keiji Oi
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Makoto Tomita
- Clinical Research Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Fan C, Tang M, Wu S, Yuan S, Borovjagin AV, Yang J. Reabsorbable Pins can Reinforce an Early Sternal Stability After Median Sternotomy in Young Children with Congenital Heart Disease. Pediatr Cardiol 2019; 40:1728-1734. [PMID: 31549187 DOI: 10.1007/s00246-019-02212-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/16/2019] [Indexed: 10/25/2022]
Abstract
We evaluated the efficacy of bioresorbable sternal reinforcement device (poly-L-lactide sternal pins) on sternal healing after median sternotomy in young children (with body weight less than 10 kg) with congenital heart disease (CHD). Data from 85 patients, who underwent CHD surgery through median sternotomy from October 2016 to May 2018, were collected and analyzed. Sternal pins were utilized in 85 patients (10 mm × 1 mm × 1 mm for patients with body weights less than 5 kg and 15 mm × 2 mm × 2 mm for those weighing between 5 and 10 kg) in addition to sternum closure with Ethicon PDSTMII running sutures (Group A), while 84 patients received the Ethicon sternal closure (Group B) with no pins. The occurrence of sternal dehiscence, anterior-posterior displacement, and high-low displacement was evaluated by physical examination and three-dimensional computed tomography at one month postoperatively. No anterior-posterior sternal displacement (0%) was observed in Group A, while 10 anterior-posterior displacements (11.9%) were observed in Group B (P < 0.01). The number of sternal caudal-cranial displacements in Groups A and B was 4 (4.71%) and 5 (5.35%), respectively (P = 0.870). While no sternal dehiscence (0%) was observed in Group A, 7 out of 84 patients (8.33%) in Group B exhibited obvious sternal dehiscence (P < 0.01). The bioresorbable poly-L-lactide sternal pins reduced an anterior-posterior sternal displacement and sternal dehiscence, which was accompanied by a significant improvement of an early sternal fixation.
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Affiliation(s)
- Chengming Fan
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Mi Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Sijie Wu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China
| | - Shuwen Yuan
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Anton V Borovjagin
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinfu Yang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Middle Renmin Road 139, Changsha, 410011, China.
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Nenna A, Nappi F, Dougal J, Satriano U, Chello C, Mastroianni C, Lusini M, Chello M, Spadaccio C. Sternal wound closure in the current era: the need of a tailored approach. Gen Thorac Cardiovasc Surg 2019; 67:907-916. [PMID: 31531834 DOI: 10.1007/s11748-019-01204-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/04/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Median sternotomy remains the most common access to perform cardiac surgery procedures. However, the experience of the operating surgeon remains a crucial factor during sternal closure to avoid potential complications related to poor sternal healing, such as mediastinitis. Considering the lack of major randomized controlled trials and the heterogeneity of the current literature, this narrative review aims to summarize the different techniques and approaches to sternal closure with the aim to investigate their reflections into clinical outcomes and to inform the choice on the most effective closure method after median sternotomy. METHODS A literature search through PubMed, Embase, EBSCO, Cochrane database of systematic reviews, and Web of Science from its inception up to April 2019 using the following search keywords in various combinations: sternal, sternotomy, mediastinitis, deep sternal wound infection, cardiac surgery, closure. RESULTS Single wire fixation methods, at present, seems the most useful method to perform sternal closure in routine patients, although patients with a fragile sternum might benefit more from a figure-of-eight technique. In high-risk patients (e.g. chronic pulmonary disease, obesity, bilateral internal mammary artery harvesting, diabetes, off-midline sternotomy), rigid plate fixation is currently the most effective method, if available; alternatively, weave techniques could be used. CONCLUSION The choice among the sternal closure techniques should be mainly inspired and tailored on the patient's characteristics, and correct judgement and experience play a pivotal role. A decisional algorithm has been proposed as an attempt to overcome the absence of specific guidelines and to guide the operative approach. This operative approach might be used also in non-cardiac procedure in which median sternotomy is required, such as in case of thoracic surgery.
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Affiliation(s)
- Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy.
| | - Francesco Nappi
- Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Jennifer Dougal
- Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Umberto Satriano
- Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Camilla Chello
- Dermatology, University of Rome "La Sapienza", Rome, Italy
| | - Ciro Mastroianni
- Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy
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Measurement of Adhesion of Sternal Wires to a Novel Bioactive Glass-Based Adhesive. J Funct Biomater 2019; 10:jfb10030037. [PMID: 31405006 PMCID: PMC6787671 DOI: 10.3390/jfb10030037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 07/29/2019] [Accepted: 08/05/2019] [Indexed: 11/17/2022] Open
Abstract
Stainless steel wires are the standard method for sternal closure because of their strength and rigidity, the simplicity of the process, and the short healing time that results from their application. Despite this, problems still exist with sternal stability due to micromotion between the two halves of the dissected and wired sternum. Recently, a novel glass-based adhesive was developed which, in cadaveric trials and in conjunction with wiring, was shown to restrict this micromotion. However, in order to avoid complications during resternotomy, the adhesive should adhere only to the bone and not the sternal wire. In this study, sternal wires were embedded in 8 mm discs manufactured from the novel glass-based adhesive and the constructs were then incubated at 37 °C for one, seven, and 30 days. The discs were manufactured in two different thicknesses: 2 and 3 mm. Wire pull-out tests were then performed on the constructs at three different strain rates (1, 0.1, and 0.01 mm/min). No statistically significant difference in pull-out force was found regardless of incubation time, loading rate, or construct thickness. The pull-out forces recorded were consistent with static friction between the wire and adhesive, rather than the adhesion between them. Scanning electron micrographs provided further proof of this. These results indicate that the novel adhesive may be suitable for sternal fixation without complicating a potential resternotomy.
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Surgical outcomes of sternal rigid plate fixation from 2005 to 2016 using the American College of Surgeons-National Surgical Quality Improvement Program database. Arch Plast Surg 2019; 46:336-343. [PMID: 31336422 PMCID: PMC6657184 DOI: 10.5999/aps.2018.01102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 05/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Sternal rigid plate fixation (RPF) has been adopted in recent years in high-risk cases to reduce complications associated with steel wire cerclage, the traditional approach to sternal closure. While sternal RPF has been associated with lower complication rates than wire cerclage, it has its own complication profile that requires evaluation, necessitating a critical examination from a national perspective. This study will report the outcomes and associated risk factors of sternal RPF using a national database. Methods Patients undergoing sternal RPF from 2005 to 2016 in the American College of Surgeons-National Surgical Quality Improvement Program were identified. Demographics, perioperative information, and complication rates were reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications. Results There were 381 patient cases of RPF identified. The most common complications included bleeding (28.9%), mechanical ventilation >48 hours (16.5%), and reoperation/readmission (15.2%). Top risk factors for complications included dyspnea (odds ratio [OR], 2.672; P<0.001), nonelective procedure (OR, 2.164; P=0.010), congestive heart failure (OR, 2.152; P=0.048), open wound (OR, 1.977; P=0.024), and operating time (OR, 1.005; P<0.001). Conclusions Sternal RPF is associated with increased rates of three primary complications: blood loss requiring transfusion, ventilation >48 hours, and reoperation/readmission, each of which affected over 15% of the study population. Smokers remain at an increased risk for surgical site infection and sternal dehiscence despite RPF’s purported benefit to minimize these outcomes. Complications of primary versus delayed sternal RPF are roughly equivalent, but individual patients may perform better with one versus the other based on identified risk factors.
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26
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Mehrvar C, Kuzyk P, Cohen G, Safir O, Zalzal P, Alhalawani A, Towler MR, Papini M. Novel adhesives for sternal fixation and stabilization: A biomechanical analysis. Clin Biomech (Bristol, Avon) 2019; 62:66-71. [PMID: 30703691 DOI: 10.1016/j.clinbiomech.2019.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 01/14/2019] [Accepted: 01/23/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerclage wires remain the current standard of care following median sternotomy, despite significant complications including dehiscence and infection. This study uses a human cadaveric model to investigate the use of glass polyalkenoate cements formulated from two glasses, A (mole fraction: SiO2:0.48, ZnO:0.36, CaO:0.12, SrO:0.04) and B (mole fraction: SiO2:0.48, ZnO:0.355, CaO:0.06, SrO:0.08, P2O5:0.02, Ta2O5:0.005), to improve wired sternal fixation. METHODS Median sternotomies were performed on fifteen cadaveric sterna. Fixation was performed with either traditional wire cerclage or adhesive-enhanced wire cerclage; the adhesive based on either Glass A or Glass B. Cyclic tensile loading of 10 N to 100 N was applied. Every 30 cycles, the maximum load was increased by 100 N up to a maximum of 500 N. Two adhered sterna were tested beyond 500 N. Mid-sternal displacement was measured to assess fixation stability. FINDINGS Displacement for adhesive-enhanced sternal closures were significantly less (p < 0.05) than standard wire cerclage. There was no significant difference between adhesives. Up to 500 N, no adhesive-enhanced sternum experienced a pathological sternal displacement (>2 mm), while three out of five of traditional wire fixations did. Of the two adhered samples tested beyond 500 N, one showed pathological displacement at 800 N and the other at 1100 N. Failure of adhered sterna appeared to initiate within the trabecular bone rather than in the adhesive. INTERPRETATION The adhesives were capable of providing immediate bone stability, significantly reducing sternal displacement. In vivo investigations are warranted to determine the effect the adhesives have on bone remodelling.
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Affiliation(s)
- Cina Mehrvar
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON M5B 2K3, Canada
| | - Paul Kuzyk
- Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Ave, Toronto, ON M5G 1X5, Canada
| | - Gideon Cohen
- Division of Cardiac Surgery, Sunnybrook Hospital, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada
| | - Oleg Safir
- Division of Orthopaedic Surgery, Mount Sinai Hospital, 600 University Ave, Toronto, ON M5G 1X5, Canada
| | - Paul Zalzal
- Oakville Trafalgar Memorial Hospital, 3001 Hospital Gate, Oakville, ON L6M 0L8, Canada; Faculty of Medicine, Department of Surgery, McMaster University, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada
| | - Adel Alhalawani
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON M5B 2K3, Canada
| | - Mark R Towler
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON M5B 2K3, Canada
| | - Marcello Papini
- Department of Mechanical and Industrial Engineering, Ryerson University, 350 Victoria St, Toronto, ON M5B 2K3, Canada.
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27
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Liao JM, Chan P, Cornwell L, Tsai PI, Joo JH, Bakaeen FG, Luketich JD, Chu D. Feasibility of primary sternal plating for morbidly obese patients after cardiac surgery. J Cardiothorac Surg 2019; 14:25. [PMID: 30691502 PMCID: PMC6350305 DOI: 10.1186/s13019-019-0841-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 01/14/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Morbidly obese patients (body mass index [BMI] ≥ 35 kg/m2) who undergo cardiac surgery involving median sternotomy have a higher-than-normal risk of sternal dehiscence. To explore a potential solution to this problem, we examined the utility of transverse sternal plating for primary sternal closure in morbidly obese cardiac surgical patients. METHODS We retrospectively reviewed data from cardiac surgical patients who underwent single primary xiphoid transverse titanium plate reinforcement for primary sternal closure from August 2009 to July 2010 (n = 8), and we compared their outcomes with those of patients with BMI ≥35 kg/m2 who underwent cardiac surgery without sternal plate reinforcement from April 2008 to July 2009 (n = 14). All cases were performed by the same surgeon. RESULTS The 2 groups of patients had similar demographics and comorbidities (P > 0.05 for all). All patients with sternal plate reinforcement reported sternal stability at last follow-up (at a median of 27 months postoperatively; range, 8.4-49.3 months), whereas 1 patient (7.1%) who underwent standard closure developed sterile sternal dehiscence (P = 0.4). Postoperative patient-controlled analgesia (PCA) morphine usage was significantly higher for patients without sternal plate reinforcement than for patients who had sternal plate reinforcement (3.6 mg/h vs 1.3 mg/h, P = 0.008). No patient in the sternal plate group had wound seroma or perioperative complications attributable to sternal closure technique. CONCLUSION Single xiphoid transverse plate reinforcement for primary sternal closure is a feasible option for morbidly obese patients, who are otherwise at high risk of developing sternal dehiscence. Using this technique may decrease postoperative narcotics usage. Morbidly obese patients (body mass index ≥35 kg/m2) have a higher-than-normal risk of sternal dehiscence after cardiac surgery. In a pilot study, we found that those who underwent transverse sternal plating (n = 8) had no sternal dehiscence and required less postoperative analgesia than patients who underwent standard wire closure (n = 14).
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Affiliation(s)
- Joshua M. Liao
- Department of Medicine, University of Washington, Seattle, WA USA
| | - Patrick Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Lorraine Cornwell
- Department of Surgery, University of Hawaii, Honolulu, HI USA
- Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX USA
| | - Peter I. Tsai
- Department of Surgery, University of Hawaii, Honolulu, HI USA
| | - Joseph H. Joo
- College of Medicine, Texas A&M University, Bryan, TX USA
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH USA
| | - James D. Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
- University of Pittsburgh Medical Center Heart & Vascular Institute, 200 Lothrop Street, C-700, Pittsburgh, PA 15213 USA
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28
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Hautalahti J, Joutsen A, Goebeler S, Luukkaala T, Khan J, Hyttinen J, Laurikka J. Vibration transmittance measures sternotomy stability - a preliminary study in human cadavers. J Cardiothorac Surg 2019; 14:2. [PMID: 30616661 PMCID: PMC6323770 DOI: 10.1186/s13019-018-0823-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stability is essential for the normal healing of a sternotomy. Mechanical vibration transmittance may provide a new means of early detection of diastasis in the sternotomy and thus enable the prevention of further complications. We sought to confirm that vibration transmittance detects sternal diastasis in human tissue. METHODS Ten adult human cadavers (8 males and 2 females) were used for sternal assessments with a device constructed in-house to measure the transmittance of a vibration stimulus across the median sternotomy at the second, third, and fourth costal cartilage. Intact bone was compared to two fixed bone junctions, namely a stable wire fixation and an unstable wire fixation with a 10 mm wide diastasis mimicking a widely rupturing sternotomy. A generalized Linear Mixed Model with the lme function was used to determine the ability of the vibration transmittance device to differentiate mechanical settings in the sternotomy. RESULTS The transmitted vibration power was statistically significantly different between the intact chest and stable sternotomy closure, stable and unstable closure, as well as intact and unstable closure (t-values and p-values respectively: t = 6.87, p < 0.001; t = 7.41, p < 0.001; t = 14.3, p < 0.001). The decrease of vibration transmittance from intact to stable at all tested costal levels was 78%, from stable to unstable 58%, and from intact to unstable 91%. The vibration transmittance power was not statistically significantly different between the three tested costal levels (level 3 vs. level 2; level 4 vs. level 2; level 4 vs. level 3; t-values and p-values respectively t = - 0.36, p = 0.723; t = 0.35, p = 0.728; t = 0.71, p = 0.484). CONCLUSIONS Vibration transmittance analysis differentiates the intact sternum, wire fixation with exact apposition, and wire fixation with a gap. The gap detection capability is not dependent on the tested costal level. The method may prove useful in the early detection of sternal instability and warrants further exploration.
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Affiliation(s)
- Juha Hautalahti
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland. .,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland.
| | - Atte Joutsen
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,BioMediTech Institute and Faculty of Biomedical Sciences and Engineering, Tampere University of Technology, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Sirkka Goebeler
- Forensic Medicine, National Institute for Health and Welfare, Biokatu 16, O-building, FI-33520, Tampere, Finland
| | - Tiina Luukkaala
- Science Center, Tampere University Hospital, Teiskontie 35, FI-33521, Tampere, Finland.,Health Sciences, Faculty of Social Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jahangir Khan
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jari Hyttinen
- BioMediTech Institute and Faculty of Biomedical Sciences and Engineering, Tampere University of Technology, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
| | - Jari Laurikka
- Department of Cardiothoracic Surgery, Tampere Heart Hospital Co., Ensitie 4, FI-33520, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, FI-33520, Tampere, Finland
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Cataneo DC, dos Reis TA, Felisberto G, Rodrigues OR, Cataneo AJM. New sternal closure methods versus the standard closure method: systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 28:432-440. [DOI: 10.1093/icvts/ivy281] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daniele C Cataneo
- Division of Thoracic Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Tarcisio A dos Reis
- Post-Graduation Program on Medicine, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Gilmar Felisberto
- Post-Graduation Program on General Basis of Surgery, Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
| | - Olavo R Rodrigues
- Department of Surgery, Mogi das Cruzes University, São Paulo, Brazil
| | - Antônio J M Cataneo
- Department of Surgery, Botucatu School of Medicine, São Paulo State University, UNESP, São Paulo, Brazil
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30
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Allen KB, Icke KJ, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M. Sternotomy closure using rigid plate fixation: a paradigm shift from wire cerclage. Ann Cardiothorac Surg 2018; 7:611-620. [PMID: 30505745 DOI: 10.21037/acs.2018.06.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Rigid plate fixation (RPF) is the cornerstone in managing fractures and osteotomies except for sternotomy, where most cardiac surgeons continue to use wire cerclage (WC). Results of a multicenter randomized trial evaluating sternal healing, sternal complications, patient reported outcome measures (PROMs), and costs after sternotomy closure with RPF or WC are summarized here. Methods Twelve US centers randomized 236 patients to either RPF (n=116) or WC (n=120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a validated 6-point scale (greater scores represent greater healing). Secondary endpoints assessed through 6 months included sternal complications and PROMs. Costs from the time of sternal closure through 90 days and 6 months were analyzed by a health economic core laboratory. Results RPF compared to WC resulted in better sternal healing scores at 3 (2.6±1.1 vs. 1.8±1.0; P<0.0001) and 6 months (3.8±1.0 vs. 3.3±1.1; P=0.0007) and higher sternal union rates at 3 [41% (42/103) vs. 16% (16/102); P<0.0001] and 6 months [80% (81/101) vs. 67% (67/100); P=0.03]. There were fewer sternal complications with RPF through 6 months [0% (0/116) vs. 5% (6/120); P=0.03] and a trend towards fewer sternal wound infections [0% (0/116) vs. 4.2% (5/120); P=0.06]. All PROMs including sternal pain, upper extremity function (UEF), and quality-of-life scores were numerically better in RPF patients compared to WC patients at all follow-up time points. Although RPF was associated with a trend toward higher index hospitalization costs, a trend towards lower follow-up costs resulted in total costs that were $1,888 less at 90 days in RPF patients compared to WC patients (95% CI: -$8,889 to $4,273; P=0.52) and $1,646 less at 6 months (95% CI: -$9,127 to $4,706; P=0.61). Conclusions Sternotomy closure with RPF resulted in significantly better sternal healing, fewer sternal complications, improved PROMs and was cost neutral through 90 days and 6 months compared to WC.
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Affiliation(s)
- Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | | | | | | | | | | | | | - Marc Gerdisch
- Franciscan St. Francis Health, Indianapolis, IN, USA
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Rashed A, Verzar Z, Alotti N, Gombocz K. Xiphoid-sparing midline sternotomy reduces wound infection risk after coronary bypass surgery. J Thorac Dis 2018; 10:3568-3574. [PMID: 30069354 DOI: 10.21037/jtd.2018.06.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Because of its advantages, full midline sternotomy has remained the main approach for cardiac surgery. However, the development of post-sternotomy wound infections is its primary disadvantage. We evaluated the impact of xiphoid process (XIP)-sparing midline sternotomy regarding reducing the risk of deep sternal wound infections (DSWIs). Methods Data from 446 patients who underwent coronary artery bypass grafting by one surgeon, from January 2007 through May 2017, were retrospectively analyzed. Patients were divided into preliminary (from 2007-2011; n=202) and contemporary (January 2012-May 2017; n=244) groups. Traditional midline sternotomy was performed in the preliminary group, while xiphoid-sparing midline sternotomy was performed in the contemporary group. To adjust for differences in baseline and operative characteristics, the inverse probability of treatment weighting (IPTW) was applied. The generalized linear model was used to compare xiphoid-sparing and conventional sternotomy regarding the development of sternal wound infections. Results The sternal infection rates were 0.8% and 4.5% in the xiphoid-sparing and standard sternotomy groups, respectively (P=0.014). After adjustment for the IPTW, the xiphoid-sparing group showed a decreased risk for DSWIs (odds ratio 0.171, 95% confidence interval, 0.036-0.806, P=0.026) compared to the traditional sternotomy group. Conclusions XIP-sparing midline sternotomy may be an alternative approach in coronary artery bypass surgery and seemed to reduce the risk of post-sternotomy wound infections in this study.
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Affiliation(s)
- Aref Rashed
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Zsofia Verzar
- Department of Emergency Medicine, Pecs University of Science, Pecs, Hungary
| | - Nasri Alotti
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Karoly Gombocz
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
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32
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Rashed A, Gombocz K, Alotti N, Verzar Z. Is sternal rewiring mandatory in surgical treatment of deep sternal wound infections? J Thorac Dis 2018; 10:2412-2419. [PMID: 29850147 DOI: 10.21037/jtd.2018.03.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Deep sternal wound infections (DSWIs) are a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. We compared treatment outcomes after conventional sternal rewiring and reconstruction with no sternal rewiring in patients with a sternal wound infection. Methods We retrospectively enrolled patients who developed a DSWI after an open-heart procedure with median sternotomy at the Department of Cardiac Surgery, at the St. Rafael Hospital, Zalaegerszeg, Hungary, between 2012 and 2016. All patients received negative pressure wound and antibiotic therapy before surgical reconstruction. Patients were divided into groups determined by the reconstruction technique and compared. Subjects were followed up for 12 months, and the primary end-points were readmission and 90-day mortality. Results Among 3,177 median sternotomy cases, 60 patients developed a DSWI, 4 of whom died of sepsis before surgical treatment. Fifty-six patients underwent surgical reconstruction with conventional sternal rewiring (23 cases, 41%) or another interventions with no sternal refixation (33 cases, 59%). Eighty-one percent of sternal wound infections followed coronary bypass surgery (alone or combinated with another procedures), and 60% were diagnosed after hospital discharge. Staphylococcus aureus was cultured in 30% of all wounds and, 56.5% of cases reconstructed by sternal rewiring vs. 26.5% with no sternal rewiring, (P=0.022). Hospital readmission occurred in 63.6% of the sternal rewiring group vs. 14.7% of the no sternal rewiring group. The rate of death before wound healing or the 90th postoperative day was 21.7% in the sternal rewiring group vs. 0% in the no sternal rewiring group. The median hospital stay was longer in the sternal rewiring group than in the other group (51 vs. 30 days, P=0.006). Conclusions Sternal rewiring may be associated with a higher rate of treatment failure than other forms of treatment for sternal wound infections.
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Affiliation(s)
- Aref Rashed
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Karoly Gombocz
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Nasri Alotti
- Department of Cardiac Surgery, St. Rafael Zala County Hospital, Zalaegerszeg, Hungary
| | - Zsofia Verzar
- Department of Emergency Medicine, Pecs University of Science, Pecs, Hungary
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Vestergaard RF, Søballe K, Hasenkam JM, Stilling M. Sternal instability measured with radiostereometric analysis. A study of method feasibility, accuracy and precision. J Cardiothorac Surg 2018; 13:41. [PMID: 29776382 PMCID: PMC5960092 DOI: 10.1186/s13019-018-0735-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 05/10/2018] [Indexed: 11/21/2022] Open
Abstract
Background A small, but unstable, saw-gap may hinder bone-bridging and induce development of painful sternal dehiscence. We propose the use of Radiostereometric Analysis (RSA) for evaluation of sternal instability and present a method validation. Methods Four bone analogs (phantoms) were sternotomized and tantalum beads were inserted in each half. The models were reunited with wire cerclage and placed in a radiolucent separation device. Stereoradiographs (n = 48) of the phantoms in 3 positions were recorded at 4 imposed separation points. The accuracy and precision was compared statistically and presented as translations along the 3 orthogonal axes. 7 sternotomized patients were evaluated for clinical RSA precision by double-examination stereoradiographs (n = 28). Results In the phantom study, we found no systematic error (p > 0.3) between the three phantom positions, and precision for evaluation of sternal separation was 0.02 mm. Phantom accuracy was mean 0.13 mm (SD 0.25). In the clinical study, we found a detection limit of 0.42 mm for sternal separation and of 2 mm for anterior-posterior dislocation of the sternal halves for the individual patient. Conclusion RSA is a precise and low-dose image modality feasible for clinical evaluation of sternal stability in research. Trial registration ClinicalTrials.gov Identifier: NCT02738437, retrospectively registered.
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Affiliation(s)
- Rikke Falsig Vestergaard
- Dept. of Cardio-Thoracic Surgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark.
| | - Kjeld Søballe
- Dept. of Orthopedic Surgery, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus C, Denmark.,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - John Michael Hasenkam
- Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
| | - Maiken Stilling
- Dept. of Orthopedic Surgery, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus C, Denmark.,Dept. of Clinical Medicine, Aarhus University, Incuba/Skejby, Bygning 2, Palle Juul-Jensens Boulevard 82, 8200, Aarhus N, Denmark
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Rigid Plate Fixation Versus Wire Cerclage: Patient-Reported and Economic Outcomes From a Randomized Trial. Ann Thorac Surg 2018; 105:1344-1350. [DOI: 10.1016/j.athoracsur.2017.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 10/10/2017] [Accepted: 12/12/2017] [Indexed: 11/23/2022]
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Hui DS, Lizalek JM, Chawa VS, Lee R. Operative techniques for improving surgical exposure in basic cardiac surgery. J Vis Surg 2018; 4:80. [PMID: 29780726 DOI: 10.21037/jovs.2018.03.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/23/2018] [Indexed: 12/26/2022]
Abstract
Operative exposure is key to ensuring surgical efficiency and patient safety in cardiac surgery. As the population ages and the prevalence of obesity increases, cardiac surgeons will be challenged to consider obese patient physiology and body habitus, surgical exposure and sternotomy closure techniques, and postoperative medical management to ensure optimal outcomes. In this article, we describe techniques to improve operative exposure in both obese and non-obese patients undergoing basic cardiac surgery and highlight the roles of surgical team members to ensure patient safety and provide optimal anesthetic management. We describe pre-operative techniques regarding incision-site marking and alternative positioning techniques on the operating table to improve visualization and decrease risk of upper extremity injury. We summarized the roles of surgical team members regarding patient positioning, especially in those that are obese, and the challenges associated for anesthesia staff pre- and intraoperatively. Procedural techniques regarding sternotomy management and closure, cannulation, internal mammary harvest, and mitral valve exposure are discussed. Cardiac surgical teams must consider the risks associated with the obese patient population undergoing cardiac surgery procedures and employ techniques pre-, intra-, and postoperatively in a multidisciplinary fashion. Safe and efficacious techniques are paramount to optimal patient outcomes.
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Affiliation(s)
- Dawn S Hui
- Center for Comprehensive Cardiovascular Care, Saint Louis University, Saint Louis, MO, USA
| | - Jason M Lizalek
- Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Vikram S Chawa
- Department of Anesthesiology and Critical Care Medicine, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Richard Lee
- Center for Comprehensive Cardiovascular Care, Saint Louis University, Saint Louis, MO, USA
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Tam DY, Nedadur R, Yu M, Yanagawa B, Fremes SE, Friedrich JO. Rigid Plate Fixation Versus Wire Cerclage for Sternotomy After Cardiac Surgery: A Meta-Analysis. Ann Thorac Surg 2018; 106:298-304. [PMID: 29577921 DOI: 10.1016/j.athoracsur.2018.02.043] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/22/2018] [Accepted: 02/14/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Traditionally, wire cerclage has been used to reapproximate the sternum after sternotomy. Recent evidence suggests that rigid plate fixation for sternal closure may reduce the risk of sternal complications. METHODS The Medline and Embase databases were searched from inception to February 2017 for studies that compared rigid plate fixation with wire cerclage for cardiac surgery patients undergoing sternotomy. Random effects meta-analysis compared rates of sternal complications (primary outcome, defined as deep or superficial sternal wound infection, or sternal instability), early mortality, and length of stay (secondary outcomes). RESULTS Three randomized controlled trials (n = 427) and five unadjusted observational studies (n = 1,025) met inclusion criteria. There was no significant difference in sternal complications with rigid plate fixation at a median of 6 months' follow-up (incidence rate ratio 0.51, 95% confidence interval [CI]: 0.20 to 1.29, p = 0.15) overall, but a decrease when including only patients at high risk for sternal complications (incidence rate ratio 0.23, 95% CI: 0.06 to 0.89, p = 0.03; two observational studies). Perioperative mortality was reduced favoring rigid plate fixation (relative risk 0.40, 95% CI: 0.28 to 0.97, p = 0.04; four observational studies and one randomized controlled trial). Length of stay was similar overall (mean difference -0.77 days, 95% CI: -1.65 to +0.12, p = 0.09), but significantly reduced with rigid plate fixation in the observational studies (mean difference -1.34 days, 95% CI: -2.05 to -0.63, p = 0.0002). CONCLUSIONS This meta-analysis, driven by the results of unmatched observational studies, suggests that rigid plate fixation may lead to reduced sternal complications in patients at high risk for such events, improved perioperative survival, and decreased hospital length of stay. More randomized controlled trials are required to confirm the potential benefits of rigid plate fixation for primary sternotomy closure.
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Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rashmi Nedadur
- Division of Cardiac Surgery, Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Monica Yu
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Jan O Friedrich
- Critical Care and Medicine Departments, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
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Nezafati P, Shomali A, Kahrom M, Omidvar Tehrani S, Dianatkhah M, Nezafati MH. ZipFix Versus Conventional Sternal Closure: One-Year Follow-Up. Heart Lung Circ 2018; 28:443-449. [PMID: 29548913 DOI: 10.1016/j.hlc.2018.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 12/22/2017] [Accepted: 01/26/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND The present study aimed to compare postoperative complications commonly revealed after sternotomy closure by new sternal ZipFix™ (Synthes GmbH, Oberdorf, Switzerland) implant and conventional steel wire. METHODS Among the initial 360 subjects, 326 patients enrolled in this randomised control trial who were candidates for cardiac surgery from April 2014 to March 2015. After the surgery, the sternal closure was randomly done with poly-ether-ether-ketone (PEEK) based sternal ZipFix (ZF) on the sternal body (n=168) or with conventional wires (CWs) (n=158). Patients were followed postoperatively as well as 1, 3, 6, and 12 months after discharge regarding postoperative complications such as pain severity, dehiscence, and infection including incisional infections (superficial or deep), and organ/space infection (mediastinitis or osteomyelitis). RESULTS The mean age of the ZF and CW groups were 63.58±10.9 and 62.42±7.1years, respectively (p=0.262). In addition, there was no significant difference between the two groups' baseline characteristics (p>0.05). Our study showed higher mean pain severity score in the conventional closure group compared with ZipFix closure group at all study time points (p<0.001). Infection was seen in 2.76% of the overall participants with no significant difference of incisional and organ infection between the two groups throughout the study. After 1-month follow-up, five patients in the CW group had sternal dehiscence whereas no patients in ZF had dehiscence (p<0.001). CONCLUSIONS Our trial demonstrates greater clinical advantages in terms of pain and sternal dehiscence post surgery by using sternal ZipFix compared to conventional steel wire.
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Affiliation(s)
- Pouya Nezafati
- Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
| | | | - Mahdi Kahrom
- Cardiac Surgery, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
| | | | - Minoo Dianatkhah
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
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Madjarov JM, Katz MG, Kane PN, Madzharov S, Robicsek F. Early Surgical Reconstruction of Sternum with Longitudinal Rigid Polymer Plating after Acute Chest Trauma. Ann Thorac Cardiovasc Surg 2018; 24:324-327. [PMID: 29491197 PMCID: PMC6300427 DOI: 10.5761/atcs.cr.17-00156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: The surgical management of the patients with traumatic sternal fractures remains controversial. The aim of this study was to evaluate the effectiveness of an early surgical reconstruction of a displaced sternal fracture utilizing longitudinal rigid polymer fixation in the settings of an acute chest trauma. Methods: To perform the sternal fixation, we utilized a longitudinal rigid plating system. The plate is made of polyether ether ketone (PEEK), an organic thermoplastic polymer. Results: We used the entire length of the plate on each side of the fracture, secured in multiple places with 6–8 screws. Once the plates have been fully secured we tighten all the screws with a screwdriver. We demonstrated that the method minimizes pain and prevents the development of pulmonary complications. Conclusion: This technique provides cosmetically acceptable results, minimizing risk of sternal nonunion, and decreases length of hospitalization.
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Affiliation(s)
- Jeko M Madjarov
- Department of Cardiovascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC, USA
| | - Michael G Katz
- Cardiovascular Research Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter N Kane
- Department of Cardiovascular Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Svetozar Madzharov
- Department of Cardiovascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC, USA
| | - Francis Robicsek
- Department of Cardiovascular Surgery, Sanger Heart & Vascular Institute, Charlotte, NC, USA
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A New Device for Securing Sternal Wires After Median Sternotomy: Biomechanical Study and Retrospective Clinical Assessment. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:40-46. [PMID: 29303867 DOI: 10.1097/imi.0000000000000425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Morbidity due to sternotomy continues to be a significant clinical problem. Poor approximation of the sternum may lead to complications such as sternal dehiscence, infection, and pain. A device to assist in tensioning and twisting standard steel wires during sternal closure has been developed (TORQ sternal closure device). Manually tightened interrupted wire closures were compared with those tightened and secured with the aid of the device. Performance of the device was assessed clinically. METHODS Four cardiovascular surgeons performed manual and device-assisted closures on a biofidelic model. Closure force was measured to determine the residual force and its intraoperator variation. A retrospective review of patients treated before and after the introduction of the device was conducted. Predicted and actual outcomes were compared for the two groups (manual closure and device-assisted closure). RESULTS Biomechanical testing measured a 75% increase in residual closure force (P < 0.001) and a significant reduction in the variability of the closure force (P = 0.045) for device-assisted closures compared with manual closures. In the retrospective study, 3 of 173 manually closed patients had sterile sternal dehiscence and 1 of 173 had a deep sternal wound infection. In the device closure group, 2 of 127 had a sterile sternal dehiscence and no deep sternal wound infections were reported. No other device-related serious adverse events were reported. CONCLUSIONS Biomechanical data showed stronger, more consistent closure forces with the device. The retrospective data attest to the performance of the device.
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40
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Danter MR, Saari A, Gao M, Cheung A, Lichtenstein SV, Abel JG. A New Device for Securing Sternal Wires after Median Sternotomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew R. Danter
- Department of Cardiac and Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Min Gao
- Providence Health Care Research Institute, Vancouver, BC Canada
| | - Anson Cheung
- Division of Cardiovascular Surgery, St. Paul's Hospital, Vancouver, BC Canada
| | | | - James G. Abel
- Division of Cardiovascular Surgery, St. Paul's Hospital, Vancouver, BC Canada
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Kaul P. Sternal reconstruction after post-sternotomy mediastinitis. J Cardiothorac Surg 2017; 12:94. [PMID: 29096673 PMCID: PMC5667468 DOI: 10.1186/s13019-017-0656-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022] Open
Abstract
Background Deep sternal wound complications are uncommon after cardiac surgery. They comprise sternal dehiscence, deep sternal wound infections and mediastinitis, which will be treated as varying expressions of a singular pathology for reasons explained in the text. Methodology and review This article reviews the definition, prevalence, risk factors, prevention, diagnosis, microbiology and management of deep sternal wound infections and mediastinitis after cardiac surgery. The role of negative pressure wound therapy and initial and delayed surgical management is discussed with special emphasis on plastic techniques with muscle and omental flaps. Recent advances in reconstructive surgery are presented. Conclusions Deep sternal wound complications no longer spell debilitating morbidity and high mortality. Better understanding of risk factors that predispose to deep sternal wound complications and general improvement in theatre protocols for asepsis have dramatically reduced the incidence of deep sternal wound complications. Negative pressure wound therapy and appropriately timed and staged muscle or omental flap reconstruction have transformed the outcomes once these complications occur.
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Affiliation(s)
- Pankaj Kaul
- Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK.
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Liang M, Liu J, Miao Q, Ma G, Liu X, Li X, Zhang C. Use of freeze-dried bone allografts in osteoporotic patients undergoing median sternotomy. Cell Tissue Bank 2017; 19:27-33. [DOI: 10.1007/s10561-017-9670-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/20/2017] [Indexed: 01/10/2023]
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Singh M, Kobraei EM, Nuutila K, Wee JO, Caterson EJ. Delayed haemothorax and fracture of titanium plate rib fixation following oncologic chest wall reconstruction. ANZ J Surg 2017; 89:E28-E30. [PMID: 28470673 DOI: 10.1111/ans.13963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 11/21/2016] [Accepted: 02/06/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mansher Singh
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward M Kobraei
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristo Nuutila
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward J Caterson
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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44
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Rigid Sternal Fixation Versus Modified Wire Technique for Poststernotomy Closures. Ann Plast Surg 2017; 78:537-542. [DOI: 10.1097/sap.0000000000000901] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Allen KB, Thourani VH, Naka Y, Grubb KJ, Grehan J, Patel N, Guy TS, Landolfo K, Gerdisch M, Bonnell M, Cohen DJ. Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage. J Thorac Cardiovasc Surg 2017; 153:888-896.e1. [DOI: 10.1016/j.jtcvs.2016.10.093] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 10/11/2016] [Accepted: 10/12/2016] [Indexed: 11/26/2022]
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Krinner S, Grupp S, Oppel P, Langenbach A, Hennig FF, Schulz-Drost S. Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries? J Thorac Dis 2017; 9:1054-1064. [PMID: 28523160 DOI: 10.21037/jtd.2017.03.37] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants. METHODS 11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred. RESULTS Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years.. CONCLUSIONS A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.
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Affiliation(s)
- Sebastian Krinner
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Sina Grupp
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Pascal Oppel
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Andreas Langenbach
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Friedrich F Hennig
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
| | - Stefan Schulz-Drost
- Department of Orthopedic and Trauma Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany.,Department of Pediatric Surgery, University Hospital of Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany
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47
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Zipping up after a median sternotomy: Are we at the end of the wire? J Thorac Cardiovasc Surg 2016; 153:897-898. [PMID: 27938901 DOI: 10.1016/j.jtcvs.2016.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 11/20/2022]
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Lazar HL, Salm TV, Engelman R, Orgill D, Gordon S. Prevention and management of sternal wound infections. J Thorac Cardiovasc Surg 2016; 152:962-72. [PMID: 27555340 DOI: 10.1016/j.jtcvs.2016.01.060] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 12/01/2015] [Accepted: 01/12/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston Medical Center, Boston, Mass.
| | - Thomas Vander Salm
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Richard Engelman
- Division of Cardiac Surgery, Baystate Medical Center, Springfield, Mass
| | - Dennis Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Steven Gordon
- Division of Infectious Diseases, The Cleveland Clinic, Cleveland, Ohio
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Dunne B, Murphy M, Skiba R, Wang X, Ho K, Larbalestier R, Merry C. Sternal cables are not superior to traditional sternal wiring for preventing deep sternal wound infection. Interact Cardiovasc Thorac Surg 2016; 22:594-8. [PMID: 26912576 DOI: 10.1093/icvts/ivw017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 01/08/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Deep sternal wound infection is a devastating complication of cardiac surgery. In the current era of increasing patient comorbidity, newer techniques must be evaluated in attempts to reduce the rates of deep sternal wound infection. METHODS A randomized controlled trial comparing sternal closure with traditional sternal wires in figure-8 formation with the Pioneer cabling system® from Medigroup after adult cardiac surgery was performed. RESULTS A total of 273 patients were enrolled with 137 and 135 patients randomized to sternal wires and cables group, respectively. Baseline characteristics between the two groups were well balanced. Deep sternal wound infection occurred in 0.7% of patients in the wires group and 3.7% of patients in the cables group (absolute risk difference = -3.0%, 95% confidence interval: -7.7 to 0.9%; P = 0.12). Patients in the cables group were extubated slightly earlier than those in the sternal wires group postoperatively (9.7 vs 12.8 h; P = 0.03). There was, however, no significant difference in hospital and follow-up pain scores or analgesia requirements. CONCLUSIONS The Pioneer sternal cabling system appears to facilitate early extubation after adult cardiac surgery, but it does not reduce the rate of deep sternal infectionAustralian New Zealand Clinical Trials Registry: ANZCTR-ACTRN12615000973516.
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Affiliation(s)
- Ben Dunne
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Mark Murphy
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Rohen Skiba
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Xiao Wang
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Kwok Ho
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
| | - Christopher Merry
- Department of Cardiothoracic Surgery, Western Australian Cardiothoracic Research and Audit Group, Fiona Stanley Hospital, Perth, WA, Australia
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Fu RH, Weinstein AL, Chang MM, Argenziano M, Ascherman JA, Rohde CH. Risk factors of infected sternal wounds versus sterile wound dehiscence. J Surg Res 2016; 200:400-7. [DOI: 10.1016/j.jss.2015.07.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 11/24/2022]
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