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J Thorac Cardiovasc Surg 2006;132:1243-1244
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Adjusting the indication to polydioxane suture for elective sternal closure

Nicola Luciani, MD, Amedeo Anselmi, MD, Gianfederico Possati, MD

Department of Cardiac Surgery, Catholic University of the Sacred Heart, Rome, Italy

To the Editor:

We read with great interest the report by Dr Usui and coworkers.1Go They reported a large series of 350 patients who had the sternum closed electively with 1-0 polydioxane (PDS; Ethicon, Inc, Somerville, NY) cord suture. They recorded 3 cases of late sternal dehiscence resulting from filament fracture; in 2 they were obliged to carry out sternal refixation in the operating room. One of these patients was obese. As the article photographically demonstrates, the mechanism of rupture involved the filament being torn off by the bone edge. Hence the authors questioned the reliability of PDS in elective sternal closure.

In past years we have had much experience with the use of PDS cord in the elective closure of median sternotomy in patients undergoing cardiac surgery. The complication reported by Usui and colleagues has already been pointed out in a previous article by van Sterkenburg, Brutel de la Riviere, and Vermeulen,2Go who then suspended the use of PDS. In our opinion, the rupture of the suture and the following sternal dehiscence are linked mainly to the force traction applied to the wires. In turn, the latter depends on body size of the patient. We had excellent results with PDS cord suture in elderly, female, petite patients with body surface areas less than 1.5 m2 and at least one risk factor for aseptic sternal dehiscence, including osteoporosis, renal insufficiency, diabetes, and chronic pulmonary disease (Figure 1). This is a subgroup of individuals who frequently have fragile, waferlike, osteoporotic sternal bone, and the probability of steel wire cutting through the bone is high. Among these patients, the PDS sternal suture is more protective against median sternotomy complications than are steel wires, and it reduces the risk of dehiscence and sternal splitting caused by bone cutting. We had a lower incidence of aseptic sternal dehiscence and no cases of PDS wire fracture in this subset of patients.3Go Conversely, among patients with slightly bigger body surface areas (above 1.7 m2), the PDS cord could be used in conjunction with common steel wires. Additionally in our experience, after open-wound treatment of mediastinitis,4Go PDS cord has proved suitable for sternal approximation and bilateral pectoralis major muscle flap plasty (as formerly described by Perkins and associates5Go) with no instances of recurrent dehiscence or infection in nearly 50 cases.


Figure 1
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  		Figure 1. Intraoperative view of PDS suture placement through thin and fragile sternum.

 
Our experience indicates that the occurrence of some cases of fractured PDS suture in a general surgical population should not be a drawback to the liberal use of absorbable suture for elective sternal closure in petite patients. To avoid complications, it is pivotal that candidates to undergo closure with PDS be properly selected. In the obese, the closure of the sternum with PDS is clearly unsafe. Conversely, subgroups of patients exist in whom sternal closure with PDS would be advantageous. In conclusion, Usui and colleagues should be congratulated for their work, which elucidated the limitations of indiscriminate use of PDS for sternal approximation and will help to refine the indications.

References

  1. Usui A, Oshima H, Akita T, Ueda Y. Polydioxanone (PDS) cord has insufficient reliability to securely close the sternum. J Thorac Cardiovasc Surg 2006;131:1174-1175.[Free Full Text]
  2. van Sterkenburg SM, Brutel de la Riviere A, Vermeulen FE. Sternal fixation with resorbable suture material. Eur J Cardiothorac Surg 1990;4:345.[Abstract/Free Full Text]
  3. Luciani N, Anselmi A, Gandolfo F, Gaudino M, Nasso G, Piscitelli M, et al. Polydioxanone sternal sutures for prevention of sternal dehiscence. J Card Surg 2006in press.
  4. Luciani N, Nasso G, Gaudino M, Glieca F, Alessandrini F, Abbate A, et al. Treatment of mediastinitis using an open irrigation and delayed sternal reconstruction with a pectoralis major muscle flap. Ital Heart J 2003;4:468-472.[Medline]
  5. Perkins DJ, Hunt JA, Pennington DG, Stern HS. Secondary sternal repair following median sternotomy using interosseous absorbable sutures and pectoralis major myocutaneous advancement flaps. Brit J Plast Surg 1996;49:214-219.[Medline]

Related Article

Reply to the Editor
Akihiko Usui and Yuichi Ueda
J. Thorac. Cardiovasc. Surg. 2006 132: 1244. [Extract] [Full Text] [PDF]




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