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J Thorac Cardiovasc Surg 1999;117:1144-1149
© 1999 Mosby, Inc.
SURGERY FOR ADULT CARDIOVASCULAR DISEASE |
From the Department of General Surgery, Northside Medical Center, Forum Health,a Youngstown, Ohio, and Cardiothoracic Surgery Research, Cardiovascular and Pulmonary Research Institute, and Department of Thoracic Surgery, Allegheny General Hospital,b Pittsburgh, Pa.
Supported by the Allegheny Heart Institute, Pittsburgh, Pa.
Received for publication Dec 11, 1998. Revisions requested Jan 22, 1999. Revisions received Feb 10, 1999. Accepted for publication Feb 16, 1999. Address for reprints: James A. Magovern, MD, Cardiothoracic Surgery Research, CVPRI, 14th Floor, South Tower, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212.
Objective: Unstable median sternotomy closure can lead to postoperative morbidity. This study tests the hypothesis that separation of the sternotomy site occurs when physiologic forces act on the closure.
Methods: Median sternotomy was performed in 4 human cadavers (2 male) and closed with 7 interrupted stainless steel wires. The chest wall was instrumented to apply 4 types of distracting force: (1) lateral, (2) anterior-posterior, (3) rostral-caudal, and (4) a simulated Valsalva force. Forces were applied in each direction and were limited to physiologic levels (< 400 N). Four sets of sonomicrometry crystals were placed equidistantly along the sternum to measure separation at the closure site.
Results: Sternal separation occurred as a result of the wires cutting through the bone. Less force was needed to achieve 2.0-mm distraction in the lateral direction (220 ± 40 N) than in the anterior-posterior (263 ± 74 N) and rostral-caudal (325 ± 30 N) directions. More separation occurred at the lower end of the sternum than the upper. During lateral distraction, xiphoid and manubrial displacement averaged 1.85 ± 0.14 and 0.35 ± 0.12 mm, respectively. Anterior-posterior distraction caused 1.99 ± 0.04–mm xiphoid displacement and 0.26 ± 0.12–mm manubrial displacement. During a simulated Valsalva force, more separation occurred in the lateral (2.14 ± 0.11 mm) than in the anterior-posterior (0.46 ± 0.29 mm) or rostral-caudal (0.25 ± 0.15 mm) directions.
Conclusions: These data suggest that sternal dehiscence can occur under physiologic loads and that improved sternal stability may be readily achieved via mechanical reinforcement near the xiphoid. Closure techniques designed to minimize wire migration into the sternum should also be developed. (J Thorac Cardiovasc Surg 1999;117:1144-50)
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