Rigid Sternal Fixation in Cardiac Surgery

Most cardiac surgeons use wire cerclage for sternotomy closure because of the perceived low rate of sternal wound complications and low cost of wires. Wire cerclage brings the cut edges of bone back together by wrapping a wire or band around or through the 2 portions of bone, then tightening the wire or band to pull the 2 parts together. This achieves approximation and compression but does not eliminate side-by-side movement, and thus rigid fixation is not achieved with wire cerclage.

In 2 multicenter randomized clinical trials, sternotomy closure with rigid plate fixation resulted in significantly better sternal healing, fewer sternal complications, and no additional cost compared with wire cerclage at 6 months after surgery. Patient-reported outcome measures demonstrated significantly less pain, better upper-extremity function, and improved quality-of-life scores, with no difference in total 90-day cost. Limitations of these studies include a sample size designed to test the primary end point of improved sternal healing but not the secondary end points of pain and function; in addition, the studies were limited by unblinded radiologists. Additional research demonstrated decreased mediastinitis, painful sternal nonunion relief after median sternotomy, and superior bony healing when compared with wire cerclage. Based on these studies, the consensus concluded that rigid sternal fixation has benefits in patients undergoing sternotomy and should be especially considered in individuals at high risk, such as those with a high body mass index, previous chest wall radiation, severe chronic obstructive pulmonary disorder, or steroid use. Rigid sternal fixation can be useful to improve or accelerate sternal healing and reduce mediastinal wound complications (class IIa, level B-R).

Source: JAMA