Effect of internal fixation of the sternum using bioabsorbable pins in small children

A prospective randomized controlled study to assess the effectiveness of super FIXSORB WAVE® for sternal stabilization after sternotomy

BACKGROUND

We developed a new sternal fixation device, Super FIXSORB WAVE®, a corrugated plate made of u-HA/PLLA, to improve sternal stability after sternotomy. This present study aimed to evaluate the new device clinically.

METHODS

This prospective, single-blinded, multicenter trial randomized 69 patients to either wire cerclage only (group C, n = 30) or wire cerclage plus Super FIXSORB WAVE® (group W, n = 39). The primary endpoint was a degree of sternal displacement at six months. Displacement of the sternal halves in the anteroposterior and lateral directions was measured using computed tomography horizontal section images at the third costal and fourth intercostal levels. The secondary endpoints were sternal pain and quality-of-life over 6 months.

RESULTS

Group W showed significantly reduced sternal anteroposterior displacement at both the third costal (0 [0-1.9] mm vs. 1.1 [0-2.1] mm; P = 0.014) and fourth intercostal (0 [0-1.0] mm) vs. 1.0 [0-1.8] mm; P = 0.015) levels than group C. In group W, lateral displacement was suppressed without a significant increase from 2 weeks to 6 months, while it increased in group C. There was no significant difference in postoperative sternal pain and quality-of-life between the two groups. No adverse events, such as infection, inflammation, or foreign body reaction, were observed with this device.

CONCLUSIONS

Using Super FIXSORB WAVE®, sternal displacement was significantly suppressed in both the anteroposterior and lateral directions. The use of this device results in safe and easy sternal reinforcement without any adverse events, and sternal healing can be accelerated.

CLINICAL TRIAL REGISTRY NUMBER

This study was registered in the Japan Registry of Clinical Trials (February 21, 2019; jRCTs032180146).

Analysis of Factors Influencing Thoracic Deformities after Median Sternotomy in Infants Who Underwent Congenital Cardiac Surgery

Objective. To investigate the incidence of thoracic deformities after median sternotomy in infants who underwent congenital cardiac surgery and determine its influencing factors. Methods. This was a single-center retrospective study. A total of 156 infants who underwent congenital cardiac surgery with median sternotomy in a provincial hospital in China from September 2020 to January 2022 were included. Depending on whether thoracic deformities occurred, the patients were classified into the thoracic deformity group and the no thoracic deformity group. Relevant data were retrieved through an electronic medical record system, and statistical comparisons and analyses were performed. Results. The incidence of postoperative thoracic deformities in this cohort was 10.9%. Sternal pins for auxiliary sternal fixation were used in eighty-nine infants. After analysis, it was found that age at operation (1.9 ± 0.9 vs. 3.7 ± 1.2, $P<0.001$ ) and weight-for-age Z-scores (−2.0 ± 0.7 vs. −1.4 ± 0.7, $P=0.001$ ) of the thoracic deformity group were significantly lower than those of the no thoracic deformity group. In addition, sternal pin use was significantly higher in the no thoracic deformity group than in the thoracic deformity group (61.9% vs. 17.6%, $P=0.001$ ). Univariable analysis showed that age at operation (OR, 4.74; 95% CI, 2.38–9.46; $P<0.001$ ) and weight-for-age Z-scores (OR, 4.40; 95% CI, 1.74–11.12; $P=0.002$ ) were significant risk factors for postoperative thoracic deformity. Using sternal pins for auxiliary sternal fixation was an important protective factor (OR, 7.57; 95% CI, 2.08–27.59; $P=0.003$ ). Conclusions. In this study, 10.9% of infants undergoing congenital cardiac surgery through a median sternotomy developed thoracic deformities after surgery. Younger age at operation and poor nutritional conditions may be risk factors for postoperative thoracic deformity. Sternal pin-assisted fixation has a positive effect on the prevention of thoracic deformities.

Mechanical simulation study of reapproximated sternum rigidity comparing sternal fixation devices

BACKGROUND

A reliable sternal fixation is one of the most basic parts of cardiac surgery requiring sternotomy for preventing wound complications and promoting early recovery. Although various products have been released to the markets, the characteristics of each device are still unclear.

METHODS

A simulation study was conducted to compare the properties of two sternal fixation device: a commonly used monofilament stainless-steel wire and a newly designed cable comprised of several titanium alloys strands. Sternum models made of monomer casting nylon were tied with each material and displaced in longitudinal, antero-posterior, and horizontal directions. Resistance against each directional external force was measured and compared.

RESULTS

The titanium cable showed a higher resistance to every directional displacement since slight deviations and a twofold higher maximum strength than the stainless wire.

CONCLUSION

An in vitro simulation study revealed the titanium cable system provide stronger sternum fixation than stainless-steel wire.

Sternal wound closure in the current era: the need of a tailored approach

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.