Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report

Abstract

Bilateral transverse thoracosternotomy, or “clamshell” thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

Case report

Bilateral transverse thoracosternotomy, known as “clamshell” thoracotomy, is frequently employed during bilateral lung transplantation. The sternum is divided transversely and closed with sternal wires [1,2]. Despite advantages in terms of exposure, clamshell thoracotomy is criticized due to high rates of wound-related morbidity [3]. Patients frequently report chronic sternal pain or “overriding” of the sternum. When dehiscence occurs, patients typically present with persistent chest pain, and repair is recommended [4].

The Sternal Talon (KLS Martin Group, Jacksonville, FL, USA) constitutes a titanium interlocking sternal closure system employed for closure of complex median sternotomies [5]. While the use of Sternal Talons has been well described, their application for repair of transverse sternotomy dehiscence is novel. Here we present a case report of early postoperative transverse sternotomy dehiscence and its management approach.

A 65-year-old male with a history of diabetes, asthma, and chronic hypersensitivity pneumonitis developed hypoxemic respiratory failure and was listed for lung transplant, with lung allocation score of 84.93. Preoperatively, he received a taper of prednisone 10 mg daily. He underwent bilateral sequential lung transplantation in standard fashion on veno-arterial extracorporeal membrane oxygenation via clamshell thoracotomy.

The sternotomy was closed using 3 interrupted uncrossed stainless-steel wires. The operative time was 6 hours with an estimated blood loss of 500 mL. The patient was extubated on postoperative day (POD) 2 and transferred out of the intensive care unit on POD 6. His postoperative course was remarkable for ileus and an episode of hard coughing with subsequent severe incisional pain and a small amount of bleeding from the surgical incision. A computed tomography (CT) scan was obtained on POD 11 and demonstrated sternal dehiscence (Fig. 1A). On examination, sternal instability with a “clicking” sensation was felt upon palpation. He remained symptomatic and underwent a repeat CT scan on POD 18, revealing persistent 1 cm sternal dehiscence without evidence of infection.

Fig. 1.

Sternal dehiscence. (A) Computed tomography scan demonstrating sternal dehiscence. (B) Intraoperative sternal dehiscence at the time of reoperation.

He underwent sternal reconstruction on POD 21. Intraoperatively, a portion of the previous incision was reopened, and the anterior sternum was noted to have dehiscence of approximately 1 cm, as well as anterior-posterior sternal separation (Fig. 1B). The previously placed sternal wires had pulled through, leaving little healthy bone inferiorly to potentially place screws for a standard plate. There was no evidence of osteomyelitis.

The edges of the sternotomy were revised to healthy edges with a sternal saw and the decision was made to employ a Sternal Talon, used off-label. This would permit full- thickness anchoring to the partially cartilaginous inferior sternum. One half of a 2-pronged Sternal Talon was connected to a Recon Talon (Fig. 2). The Recon Talon consists of a connecting “head” and a “tail” with several holes for screws. Two holes were drilled through the inferior sternal segment, after which the “feet” of the Sternal Talon were placed through the holes to seat the Talon device (Fig. 3A–C). The tail of the Recon Talon was shortened with a plate cutter. To ensure optimal sternal apposition, the Talon components were “mated” and the first “click” of the ratchet mechanism was engaged (Fig. 3D). The sternal edges were manually compressed, while the Recon Talon tail was anchored with sternal screws. The ratchet mechanism was tightened, further compressing the sternal edges. For additional stability, 5 mm Mersilene tape was positioned around the ribs surrounding the fourth intercostal space. Bilateral pectoralis major flaps were raised for coverage. A Jackson-Pratt (JP) drain was positioned deep to the muscle flaps, followed by closure of the deep dermis and skin.

Fig. 2.

Sternal Talon (A) connected to a shortened Recon Talon (B).

Fig. 3.

Positions of Sternal and Recon Talons for sternal dehiscence repair. (A) Revised sternal edges with holes drilled through the superior and inferior sternal segments to secure Talon device. (B) Anterior view of the feet of the Sternal Talon through the inferior sternal segment and the tail of the shortened Recon Talon over the superior sternal segment. (C) Lateral view of the feet of the Sternal Talon through the inferior sternal segment and the tail of the shortened Recon Talon over the superior sternal segment. (D) Sternal and Recon Talons engaged.

Postoperatively, the patient progressed well with marked improvement in pain. The JP drain demonstrated minimal output and was removed on POD 5. He was discharged on POD 7 and has since had no recurrent chest pain. Repeat CT chest 2 months postoperatively demonstrated a well- positioned Sternal Talon with no evidence of recurrent dehiscence (Fig. 4).

Fig. 4.

Computed tomography (CT) scans at 2 months postoperatively. (A) CT scout film. (B) CT scan demonstrating the Sternal Talon with well-apposed sternal fragments.

The patient provided written informed consent for the publication of the research details and clinical images.

Discussion

Among the potential complications following lung transplantation, dehiscence of the transverse sternotomy, when a “clamshell” thoracosternotomy is utilized, has been reported in 6.7%–36% of cases [1,3,4]. Morbidities such as chronic steroid use, immunosuppression, malnutrition, and osteoporosis may complicate wound healing, contributing to the said dehiscence rates [6].

A multitude of strategies have been proposed to mitigate dehiscence, such as crossing of the sternal wires, specialized fixation devices, bio-absorbable sternal pins, or avoidance of sternal division altogether [1-3,6]. When dehiscence occurs, several techniques for secondary sternal closure have been described, including use of titanium plates and peristernal cables [4,7]. While prospective data are lacking, each strategy has its purported advantages. More subtle options such as titanium plates are more cost-effective and less bulky. The Sternal Talon technique described is valuable because it provides fixation through a small incision overlying the area of dehiscence. The broad profile of the “legs” and “feet” distributes force over a broader area and may be less prone to tearing through poor-quality tissue, compared to plates and screws. Additionally, in contrast to traditional sternal plates or pins, Sternal Talons enable tightening of the ratchet mechanism and compression of the sternal segments, an important factor for healing. Furthermore, the unique position of the “feet,” so that they engage the underside of the sternum, allows compressive apposition of both sternal tables, unlike screws. Their positioning guards against sternal separation in both the craniocaudal and anterior-posterior planes.

From a technical standpoint, we feel this technique to be straightforward and intuitive. First, measurement of the width and thickness of the sternum intraoperatively is required to select the correct Talon depth. A roughly 5 mm hole is adequate to incorporate the Talon “feet.” While drilling, the inferior sternum can be grasped with penetrating towel clamps, taking care to protect the underlying tissues. Second, the Recon Talon tail should be shortened to some extent based on the quality of the sternal bone; additional screws may be employed in cases of poor bone quality. Third, placement of the Recon Talon requires sternal apposition within the “range” of the ratcheting mechanism. Hence, we recommend first placing the Talon feet, then engaging the ratchet mechanism—only then should the sternal edges be opposed and Recon Talon tail anchored. If the Recon Talon is placed incorrectly, the ratchet may not engage, or upon subsequent tightening, adequate sternal apposition may not be achieved.

Ultimately, transverse thoracosternotomy remains a morbid incision with frequent complications. The novel use of the Sternal Talon system, in the event of sternal separation, provides the thoracic surgeon a valuable option for repairing a potentially difficult complication encountered frequently in practice.

Funding Statement

Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.