J Thorac Cardiovasc Surg 2006;132:1503
© 2006 The American Association for Thoracic Surgery
Letter to the Editor
Division of Thoracic Surgery, Istituto Nazionale Tumori, Via Venezian 1, 20133, Milan, Italy
To the Editor:
We read with interest the article by Usui and colleagues.1 The authors conclude that polydioxanone cord is not safe to close the sternum. We have tried to address a few relevant issues on this matter.
The mechanical performance of synthetic absorbable sutures is similar to that of stainless steel.2 Nonetheless, clinical use of absorbable sutures to close the sternum has not been widely reported. In 1994, we published a series of 216 consecutive sternotomies using size 1 polyglyconate monofilament sutures (Maxon, Davis and Geck) to close the sternum,3 and in the last 12 years, we adopted the same technique in every patient undergoing median sternotomy, hemiclamshell approach, or transmanubrial approach. No cases of sternal dehiscence were observed in more than 400 consecutive patients, even in the case of resternotomy.
Preoperative risk factors for sternal dehiscence include use of thoracic grafts, diabetes mellitus, chronic obstructive pulmonary disease, obesity, and smoking.2 All patients that had broken sutures in the report by Usui and colleagues1 presented with at least one such risk factor. However, these risk factors usually lead to late complications of sternal wound healing, whereas all 3 events in this report occurred within 2 weeks postoperatively, and macroscopic findings of the broken sutures suggest that failure of polydioxanone cord might be caused by abrasion injury as a result of friction with the bone edges. In fact, early sternal disruptions shortly after surgical intervention are more likely to be related to an inappropriate closure technique or suboptimal use of suture materials. In addition, faulty sternal splitting or paramedian sternotomy can lead to improper approximation of the sternum, the uneven margins of which can injure the sutures.
Usui and colleagues1 did not describe how polydioxanone cord was used to close the sternum. After median sternotomy, we routinely apply only one transsternal stitch of polyglyconate to approximate the manubrium and 2 to 3 double-loop stitches that are passed through the parasternal intercostal spaces, ensuring a double ring for each space. By using this method, the suture strength and sternal stability are enhanced. Furthermore, the absorbable suture should be handled with care because the contact with surgical instruments to clamp the knot or hold the suture in place can seriously damage the monofilament and should be avoided in any circumstance.
Polydioxanone and polyglyconate are similar in performance with respect to bursting strength.3 Both have high tensile strength, minimal tissue reaction, good memory, and elasticity (which are better than steel wire and nylon). However, negative results have been reported only with polydioxanone, and this might indicate a different clinical performance of the 2 materials with respect to sternal closure.1,4
One has to consider, however, that dehiscence of a median sternotomy after cardiothoracic surgery is about 1% in the literature.2 Therefore the figure of 0.8% (3/350) in the report by Usui and colleagues1 should not be thought of as unacceptable.
In conclusion, our long-lasting experience has proved that size 1 polyglyconate monofilament sutures are safe and effective for sternal closure in noncardiac surgery, and we are convinced that monofilament absorbable sutures are at least as good as steel wire to close the sternum after complete or partial sternotomy.
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