HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Valluvan Jeevanandam Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Song, D. H. Articles by Jeevanandam, V. Search for Related Content PubMed PubMed Citation Articles by Song, D. H. Articles by Jeevanandam, V. Related Collections Transplantation - heart

J Thorac Cardiovasc Surg 2003;126:896-897
© 2003 The American Association for Thoracic Surgery

Brief communications

Rigid sternal fixation in the cardiac transplant population

^a Section of Plastic and Reconstructive Surgery, University of Chicago Hospitals, Chicago, Ill, USA
^b Section of Cardiothoracic Surgery, University of Chicago Hospitals, Chicago, IllUSA

Received for publication January 4, 2003; accepted for publication February 12, 2003.

^* Address for reprints: David H. Song, MD, Section of Plastic and Reconstructive Surgery, University of Chicago Hospitals, 5841 S Maryland Ave, MC 6035, Chicago, IL 60637, USA
dsong{at}surgery.bsd.uchicago.edu

Infections delay posttransplantation recovery and are present in the majority of early complications causing transplantation failure. Deep sternal wound infections and mediastinitis result in multiple surgical procedures for the patient and have been shown to increase hospital stay and expenses.^1,2

Risk factors for development of sternal dehiscence and subsequent mediastinitis include chronic obstructive pulmonary disease, reoperation, off-midline sternotomy, renal failure, diabetes, chronic steroid use, morbid obesity, concurrent infection, and acquired or iatrogenic immunosuppression.³ Many patients undergoing cardiac transplantation have 3 or more of these risk factors, designating them as at high risk for sternal dehiscence.

Recognizing instability as the antecedent event to poststernotomy mediastinitis, multiple methods of sternal closure have been proposed. However, these methods have all revolved around different circlage techniques or other nonrigid means of fixation.⁴ We offer the use of rigid fixation in the patient undergoing cardiac transplantation both as a method of sternal fixation after the development of early dehiscence and as a means to prevent sternal infection at the time of initial sternal closure.

Patients and methods

Ten patients undergoing cardiac transplantation (2 women and 8 men) underwent rigid fixation of the sternum over an 18-month period. The mean age was 57 years (range, 46-68 years). Six underwent rigid fixation for sternal salvage after the development of early dehiscence (within the first 10 days). Four underwent fixation as a prophylactic measure. Eight had a sternotomy before transplantation. Ischemic cardiomyopathy was the indication for transplantation in all patients.

There was an average of 1.7 fractures per sternum. Rigid fixation was performed with the SternaLock system (Walter Lorenz Surgical, Jacksonville, Fla). An average of 3.8 plates was applied per sternum.

Results

The average follow-up was 42 weeks (range, 9-76 weeks). There were no complications and no reoperations. All patients achieved successful sternal osteosynthesis (Figure 1).

View larger version (160K): [in this window] [in a new window]   Figure 1. Intraoperative photograph depicting complete reduction.

Rigid fixation is thought to be superior to traditional wire circlage as a method of sternal closure. This is particularly true for patients who are at high risk for the development of poststernotomy mediastinitis. At the top of this list are patients undergoing cardiac transplantation. These patients are immunosuppressed with multiple comorbid illnesses, and many of these patients have had prior sternotomies that predispose them to sternal fractures and subsequent infection. Sternal plating offers greater stability, which maintains successful bony union. A biomechanical analysis on a validated bone analog model has shown sternal separation under normal physiologic forces.⁵ In an immune-suppressed patient population, this sternal separation can quietly lead to dehiscence and devastating infection. Prophylactic treatment and early plate fixation of patients with clinical dehiscence can prevent deep sternal wound infection and subsequent mediastinitis.

Our experience with rigid fixation of the sternum extends to the patient undergoing cardiac transplantation. This population is thought to be at high risk for the development of poststernotomy mediastinitis, a complication that could have devastating consequences. We offer rigid plate fixation as a method of both sternal fixation after early dehiscence and as a means for prophylaxis in the cardiac transplant population.

References

1. Stolf NAG, Fiorelli AI, Bacal F, Camargo LF, Bocchi EA, Freitas A, et al. Mediastinitis after cardiac transplantation. Arq Bras Cardiol. 2000;74:425–430
   
2. Carrier M, Perrault LP, Pellerin M, Marchand R, Auger P, Pelletier GB, et al. Sternal wound infection after heart transplantation: incidence and results with aggressive surgical treatment. Ann Thorac Surg. 2001;72:719–724[Abstract/Free Full Text]
   
3. Golosow LM, Wagner JD, Felley M, Sharp T, Havlik R, Sood R, et al. Risk factors for predicting surgical salvage of sternal wound-healing complications. Ann Plast Surg. 1999;43(1):30–35[Medline]
   
4. Trumble DR, McGregor WE, Magovern JA. Validation of a bone analog model for studies of sternal closure. Ann Thorac Surg. 2002;74(3):739–744[Abstract/Free Full Text]
   
5. Hendrickson SC, Kroger KE, Morea CJ, Aponte RL, Smith PK, Levin LS. Sternal plating for the treatment of sternal nonunion. Ann Thorac Surg. 1996;62(2):512–518[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Valluvan Jeevanandam Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Song, D. H. Articles by Jeevanandam, V. Search for Related Content PubMed PubMed Citation Articles by Song, D. H. Articles by Jeevanandam, V. Related Collections Transplantation - heart