A Retrospective Application of Deep Sternal Wound Dehiscence and Malunion Risk Scores on Sternal Nonunion Patients

Abstract

Background:

More than 750,000 median sternotomies are performed annually in the United States, with wire cerclage as the standard closure technique. However, cerclage may not ensure optimal stability in high-risk patients, leading to complications such as dehiscence, mediastinitis, and nonunion. Sternal rigid plate fixation offers improved outcomes but remains underused, in part, due to a lack of clear indications. Recent risk models quantify the risk of sternal dehiscence, but have not been validated to guide closure decisions. We evaluated 2 risk calculators to guide prophylactic plating decisions and identified overlooked risk factors.

Methods:

A retrospective chart review was conducted on patients referred to a single plastic surgeon for symptomatic sternal nonunion between 2017 and 2024. Demographics, comorbidities, and surgical outcomes were collected, and 2 risk-score calculators for deep sternal wound infection and malunion were assessed.

Results:

Forty-six patients with symptomatic sternal nonunion were identified. Comorbidities were prevalent, including diabetes (56.52%), obstructive sleep apnea and gastroesophageal reflux disease (54.25% each), and chronic kidney disease (36.9%). Postdischarge, 43.48% reported coughing-related sternal pain, and 34.78% reported poor compliance with sternal precautions. The deep sternal wound infection calculator recommended plating for 13 patients, whereas the malunion risk score recommended it for 24 patients, with only 10 patients recommended for plating by both systems.

Conclusions:

Current risk calculators may overlook critical patient factors, limiting their predictive accuracy for sternal complications. These findings highlight the need for more comprehensive risk assessment tools to improve patient selection for prophylactic sternal rigid plate fixation and optimize sternal closure techniques.

Takeaways

Question: Can existing risk-score calculators effectively guide prophylactic sternal rigid plate fixation (SRPF) decisions in patients undergoing median sternotomy?

Findings: Two risk calculators (deep sternal wound infection and MUST score) showed significant discrepancies in recommending prophylactic SRPF and overlooked factors such as obstructive sleep apnea, gastroesophageal reflux disease, cough, and poor adherence to sternal precautions, all of which were prevalent in the study population.

Meaning: Current risk assessment tools may not fully capture critical patient factors, indicating the need for more comprehensive models to improve patient selection for prophylactic SRPF and optimize sternal closure techniques.

INTRODUCTION

Median sternotomy is a cornerstone procedure in cardiac surgery and is performed on more than 750,000 patients annually in the United States.^1,2 Traditionally, wire cerclage has been the standard method for sternal closure. Although effective for most patients, this technique falls short in providing optimal stability and healing, particularly for high-risk individuals.²

Poststernotomy complications—including dehiscence, mediastinitis, and nonunion—occur in 2%–5% of patients, with wire cerclage–associated mortality rates as high as 15%.² In response, sternal rigid plate fixation (SRPF) has emerged as a promising alternative for sternotomy closure, offering superior internal stability with fewer complications.^1,2 However, the adoption of SRPF in cardiac surgery has been slow, in part due to the absence of clearly defined indications for its use.³

Currently, the cardiothoracic surgery guidelines do not provide clear indications for prophylactic SRPF in patients undergoing median sternotomy. Without a standardized framework for decision-making,^4,5 the decision to use SRPF is influenced by surgeon discretion, availability of a trained plastic surgeon, and relative risk indicators such as obesity, diabetes, osteoporosis, and advanced age.⁶ Consequently, there are inconsistencies in patient care and potential underuse of SRPF in high-risk patients.

Recent developments in risk stratification models, such as those proposed by Cauley et al⁷ and Nooh et al,⁸ offer potential approaches to quantify the risk of sternal dehiscence and guide closure method selection. These models incorporate various patient and intraoperative variables to predict complications. However, their potential utility to guide prophylactic SRPF decisions has not been externally validated.⁹ Our study aimed to address these gaps by (1) evaluating the potential use of existing risk calculators as tools for guiding prophylactic plating decisions, (2) identifying possible risk factors unaccounted for by current risk-score calculators, (3) assessing combinations of factors that should mandate SRPF use and consultation with plastic surgery, and (4) contributing to the ongoing discussion of indications for primary sternal plating. We retrospectively analyzed patients who required SRPF following failed primary closure with wire cerclage and calculated their risk scores for deep sternal wound infection (DSWI) and malunion (nonunion) to determine whether either calculator could have justified primary closure with SRPF. This study has the potential to aid in the establishment of absolute indications for SRPF, reduce several sternal complications, and ultimately enhance the quality of care for patients undergoing cardiac surgery.

METHODS

A retrospective chart review was performed for all patients referred to a single surgeon in the Plastic Surgery Division at the University of Massachusetts Memorial Medical Center in Worcester, Massachusetts, for evaluation of sternal nonunion between January 2017 and December 2024. The inclusion criteria were patients who had undergone sternal exploration, debridement, and reconstruction for symptomatic sternal nonunion following median sternotomy for cardiac disease. The reconstructive surgical procedure for all patients involved debridement of the fibrotic sternal margins to healthy, bleeding bone edges, removal of the fractured wires, and sternal closure using rigid plate fixation with KLS Martin plates and locking screws.

Two independent reviewers used standardized data collection methods. Variables of interest included patient characteristics immediately before the index procedure, including age, sex, body mass index (BMI), glycated hemoglobin (HbA1c) level, use of oral medication or insulin for diabetes management, peripheral vascular disease (PVD) status, creatinine level, smoking status (current or former), chronic obstructive pulmonary disease (COPD) status, and intraoperative variables (length of surgery, grafting, and need for exploration). Additional data collected included the length of hospital stay, hospital course, postdischarge course, and comorbidities. Cardiology follow-up appointments, emergency department visits, and hospital admission records after sternotomy were reviewed to identify potential events contributing to sternal complications.

The relationship between calculated risk scores and patient outcomes was also assessed. The study protocol was approved by the University of Massachusetts Memorial Medical Center institutional review board, and patient confidentiality was maintained throughout the data collection and analysis processes.

Risk-Score Calculations

The risk-score calculator by Cauley et al⁷ focuses on deep sternal wound dehiscence requiring operative debridement. This model incorporates key risk factors including BMI, sex, PVD, smoking status, HbA1c, and creatinine levels. The score ranges from 0 to 25 points, with risk categories defined as minimal (0–7), low (8–10), intermediate (11–13), and high (14–24). For intermediate-risk patients, enhanced sternal closure using SRPF and/or bilateral pectoralis major advancement flaps should be considered, whereas for high-risk patients, these methods are strongly recommended (Table 1).⁷

Table 1.

Two Risk Assessment Tools for Sternal Complications After Cardiac Surgery: (1) Deep Sternal Wound Dehiscence Risk Score and (2) MUST Score

Deep Sternal Wound Dehiscence Risk Score	MUST Score
Variable (points)	Variable (points)
BMI, kg/m2	BMI, kg/m2
<26 (0)	>35 (4)
26–29 (2)	25–35 (1)
30–37 (4)	Sex
>38 (7)	Male (1)
Sex	Diabetes
Male (0)	Noninsulin-dependent (1)
Female (4)	Insulin-dependent (2)
HbA1c	Smoking
<5.7 (0)	Current (2)
5.7–6.6 (2)	Former (1)
6.7–9 (3)	COPD (1)
>9 (8)	Age > 60 y (2)
Current or recent smoker	Reexploration (5)
No (0)	Operative duration > 300 min (1)
Yes (2)	Previous cardiac operation >6 mo (−1)
PVD
No (0)
Yes (3)
Creatinine
≤1.2 (0)
>1.2 (1)
Score interpretation:	Score interpretation:
0–7: Minimal risk	0–4: Low risk
→ Standard closure (wires)	Single wires
8–10: Low risk	5–7: Intermediate risk (<1%)
→ Standard closure with incisional wound VAC	Special wiring method
11–13: Intermediate risk	8–10: High risk (<5%)
→ Incisional wound VAC + enhanced closure (SRPF) at clinician’s discretion if:	Wires + bands or SRPF
• Mechanical concerns (eg, macromastia, morbid obesity, barrel chest)	11–13: Very high risk (<15%)
• Poor bone quality	SRPF
14–25: High risk	14–18: Extremely high risk (<30%)
→ Incisional wound VAC + strongly consider enhanced closure (SRPF)	SRPF

Both scores provide risk categories with corresponding recommended interventions.

HbA1c, hemoglobin A1c; VAC, vacuum-assisted closure.

In contrast, the malunion of the sternum (MUST) score model by Nooh et al⁸ predicted the risk of sternal instability due to malunion. Although it shares some risk factors with the DSWI model (BMI, diabetes, smoking status, and sex), it also considers variables such as COPD and intraoperative factors such as reexploration, operation duration exceeding 300 minutes, and previous cardiac operations within the past 6 months. The MUST score ranges from 0 to 18 points, with risk categories defined as low (0–4), intermediate (5–7), high (8–10), very high (11–13), and extremely high (14–18). Consideration of enhanced closure techniques (wires + bands, or SRPF) is recommended for patients scoring 8 points or more, whereas SRPF is highly recommended for scores greater than 11 points (Table 1).⁸

RESULTS

Forty-six patients were identified who presented with symptomatic nonunion, requiring operative debridement, wire removal, placement of rigid plates, and bilateral pectoralis major myocutaneous flap closure. Of these patients, 37 were men and 9 were women (19.56%), with a mean age of 63.97 years. Forty-one (89.13%) patients underwent coronary artery bypass grafting (CABG) procedures, with an average of 3 vessels grafted per patient, whereas the other 5 (10.87%) patients had aortic or mitral valve replacement.

Comorbidities were prevalent in the cohort, with 11 (23.91%) patients having a history of PVD and 15 (32.61%) having COPD. Diabetes mellitus type 2 was present in 26 (56.52%) patients, of whom 22 (47.82%) were insulin-dependent. The cohort comprised 19 current smokers (41.30%) and 12 former smokers (26.08%). Obstructive sleep apnea (OSA) and gastroesophageal reflux disease (GERD) were the most common comorbidities, affecting 25 of 46 (54.25%) patients. Chronic kidney disease was observed in 17 (36.9%) patients. Additionally, fall risk factors, such as joint pain, neuropathy, alcohol abuse, seizure disorders, narcolepsy, and tremor, were present in 20 of 46 (43.47%) patients.

Twenty (43.4%) patients had an A1c greater than 6.5%. Nine (19.56%) patients had a creatinine level greater than 1.21 mg/dL immediately before CABG. Two (4.35%) patients had undergone cardiac surgery more than 6 months before their index cardiac surgery, and 6 (13.04%) patients had procedures lasting longer than 300 minutes. Four (8.70%) patients required postoperative chest reexploration (Table 2).

Table 2.

Demographic and Clinical Characteristics of 46 Patients Who Underwent Cardiac Surgery

Patients	Total (N = 46), n (%)
Age, y	63.97
Female	9 (19.56)
BMI, kg/m2
25–35	32 (69.56)
>35	14 (30.43)
Average BMI	32.57
Noninsulin-dependent diabetes mellitus	4 (8.69)
Insulin-dependent diabetes mellitus	22 (47.82)
PVD	11 (23.91)
Hypertension	42 (91.30)
Hyperlipidemia	42 (91.30)
Current smoker	19 (41.30)
Former smoker	12 (26.08)
Cardiac surgery lasting > 300 min	6 (13.04)
Reexploration required	4 (8.70)
Previous cardiac operation > 6 mo	2 (4.35)
COPD	15 (32.61)
Creatinine > 1.21	9 (19.56)
Chronic renal disease	17 (36.95)
OSA	25 (54.25)
OSA compliant with CPAP	9 (19.57)
Fall risk factors	20 (43.47)
Noncompliance with sternal precautions postcardiac surgery	16 (34.78)
Mechanical trauma postcardiac surgery	7 (15.22)
Chronic cough postcardiac surgery	20 (43.48)
Use of ACE inhibitors	14 (30.43)
Use of acid reflux medication	19 (41.30)
Use of respiratory medication (inhalers, steroids, cough medication)	18 (39.13)
Frequent use of oral steroids	3 (6.52)

In terms of medication use, 14 (30.43%) patients were taking angiotensin-converting enzyme (ACE) inhibitors, specifically lisinopril. Furthermore, 18 (39.13%) patients used inhalers for respiratory disease, and 19 (41.30%) patients were taking medications for acid reflux (Table 2).

The initial postoperative course following index sternotomy was uncomplicated in 35 of the 46 (76.1%) patients, with a mean hospital stay of 6 days. However, several patients experienced complications of varying severities.

Three patients experienced atrial fibrillation that was treated medically. One patient experienced fluid overload leading to hypercarbia, which required bilevel positive airway pressure intervention. Another patient developed pericarditis, one experienced Clostridium difficile infection, and another had confusion and agitation.

Five patients had particularly challenging postoperative courses: 1 required bilevel positive airway pressure treatment, lung wedge resection, and sternal debridement due to complications such as subcutaneous emphysema and sternal dehiscence. Another patient developed acute kidney injury necessitating dialysis, along with a stroke that required reintubation and atrial fibrillation managed with cardioversion. On postoperative day 2, another patient experienced a stroke with difficulty finding words. On day 3, the patient became pale, diaphoretic, hypotensive, and bradycardic, leading to transfusion of 2 units of packed red blood cells. Brain magnetic resonance imaging on postoperative day 5 revealed encephalomalacia with blood degradation products in the left temporal lobe. Additionally, 1 patient required an emergency return to the operating room for a thrombus in the left internal mammary artery graft.

Another patient had wires removed, and plates were placed during the same hospital admission due to a heart block requiring pacemaker insertion 2 days after CABG. This patient also experienced heparin-induced thrombocytopenia and required return to the operating room for hematoma removal, repeat debridement, vacuum-assisted closure, dressing changes, and wire removal. Ultimately, complications led to plating during the same hospital stay.

Postdischarge follow-up notes revealed several significant events among the patients. Twenty (43.48%) patients reported cough exacerbations associated with severe sternal pain. Seven (15.22%) patients experienced mechanical trauma (falls, motor vehicle accidents, and seizures). Sixteen (34.78%) patients reported engaging in activities that violated weight restrictions and sternal precautions and were able to identify a specific event that triggered sternal discomfort and audible clicking. Additionally, 1 (2.17%) patient was involved in a car accident, and another (2.17%) sustained a punch to the chest during an altercation.

Risk-Score Calculations

The DSWI risk-score calculator yielded scores ranging from 2 to 22. Among the 46 patients, 21 were categorized as minimal risk, 12 as low risk, 9 as intermediate risk, and 4 as high risk. According to the recommendations by Cauley et al,⁷ only 13 of these patients should have received prophylactic plating. In contrast, the MUST score system classified 1 patient as low risk, 21 as intermediate risk, 17 as high risk, and 7 as very high risk.⁸ Based on this scoring system, 24 patients should have undergone primary plating. Only 10 patients were consistently recommended for SRPF by both risk scores (Fig. 1).

Fig. 1.

This histogram shows the recommended closure methods based on DSWI risk (yellow) and malunion risk (blue, MUST score). Standard wire cerclage is suggested for low-risk patients, SRPF or bands for intermediate risk, and SRPF for high-risk patients.

DISCUSSION

The definition of high risk for sternal wound dehiscence remains ambiguous, with no consistent criteria established in the literature. Although relative indications such as obesity, COPD, and diabetes may raise concerns about potential postoperative complications, they do not provide a clear basis for preventative action. This study aimed to identify a preoperative risk-score calculator to assist with prophylactic SRPF decisions. However, our findings highlight the limitations of 2 promising available risk calculators, the DSWI risk score⁷ and the MUST score.⁸

We chose these calculators because of their specificity for failed wiring outcomes, particularly for DSWI and malunion (nonunion). It is important to clarify that nonunion, which means no union between the sternal halves, is a more appropriate term than malunion, which implies union, albeit abnormal. Regardless, these tools recommend enhanced closure techniques for patients with intermediate- to high-risk scores. Our analysis found that the MUST score, though imperfect, more reliably identified candidates for prophylactic plating compared with the DSWI model. We believe that the enhanced reliability of the MUST score likely stems from its more nuanced approach to risk factors, including distinctions between insulin-dependent and noninsulin-dependent diabetes mellitus, incorporation of COPD as a risk factor, and consideration of former smokers as being at higher risk regardless of quit time. Notably, only 10 of 46 patients in our study were consistently identified as candidates for prophylactic plating by both scoring systems, highlighting a significant discrepancy in clinical decision-making guides for sternal closure.

The difficulty in defining “high risk” is underscored by the inconsistent criteria established across various studies. Song et al² defined high risk as having 3 or more established risk factors, including COPD, reoperative surgery, renal failure, diabetes, chronic steroid use, morbid obesity, concurrent infection, and immunosuppression. In contrast, Sharma et al¹⁰ considered patients to be at high risk with just 1 risk factor, such as age 65+ years, diabetes, bilateral internal mammary artery harvest, reoperations, eccentric sternotomy, obesity, or COPD. In Japan, primary SRPF is indicated for patients with 1 or multiple risk factors, including a BMI greater than 30 kg/m², insulin-dependent diabetes, steroid use, or CABG using BITA.¹¹ The Veterans Affairs Medical Center in Birmingham, Alabama, provides primary sternal plating for patients with 1 or more risk factors, including a BMI greater than 30 kg/m², employment as a manual laborer, osteoporosis, or intraoperative transverse sternal fracture. Additional risk factors less frequently considered include the use of ACE inhibitors and adrenergic drugs for respiratory problems.¹² This variability in risk factor definitions highlights the need for a more standardized approach to identify high-risk patients for sternal wound complications.

Our findings suggest that current risk calculators may overlook less common, yet critical comorbidities and risk factors, potentially reducing their predictive accuracy. Unaccounted-for factors include OSA, respiratory diseases other than COPD, GERD, fall risk factors, compliance with respiratory medications and/or antacids, use of ACE inhibitors, and compliance with sternal precautions.

OSA was present in nearly 55% of the patients in our cohort, but it was not accounted for by either calculator. Although OSA is often associated with obesity, a well-known risk factor, it may introduce additional variables that impair wound healing. Intermittent hypoxia seen with OSA interferes with oxygen-dependent processes of tissue repair.¹³ A recent systematic review study found that patients with OSA had a higher risk of wound dehiscence following open surgery, compared with laparoscopic surgery. Although there are many potential confounding variables in the studies included in the review, it is fair to suggest that OSA has some influence on the pathophysiology of wound healing in some wound types.¹³ The high prevalence of OSA in our study group demands further attention, as several patients with confirmed OSA did not meet the BMI threshold of 35 required to accrue points on the MUST score, highlighting a potential blind spot in current risk stratification methods. Furthermore, the effect of continuous positive airway pressure (CPAP) therapy on sternal healing is a critical area of research. Specifically, investigation is needed to understand how CPAP-induced variations in intrathoracic pressure and reduction in hypoxia may influence wound healing mechanisms.

Respiratory diseases other than COPD, such as chronic bronchitis or persistent cough, merit attention. More than 40% of patients reported exacerbation of chest pain with cough in the postoperative period, not all of whom had an official COPD diagnosis. This suggests that COPD should not be considered the sole respiratory risk factor for sternal wound complications but rather any condition associated with chronic coughing.

Almost one-third of our patients were prescribed ACE inhibitors (eg, lisinopril) for blood pressure management, and approximately 40% were taking antacid medication for acid reflux management, and/or some form of adrenergic inhaler for the treatment of asthma or COPD symptoms. These prevalences are potentially significant, as ACE inhibitor–induced cough may affect 35% of patients,¹⁴ and acid reflux–related cough is seen in approximately 40% of GERD patients.¹⁵ Additionally, poor inhaler compliance can exacerbate chronic cough. These factors are critical for sternal wound healing, as persistent coughing may significantly increase intrathoracic pressure and exert repeated mechanical stress on the healing sternum, potentially compromising surgical outcomes.¹⁶ Future studies should assess ACE inhibitors, inhalers, and GERD medications as potential risk factors for sternal wound dehiscence, given their prevalence and plausible links to impaired healing.

Furthermore, neither calculator considered fall risk factors, such as joint pain, neuropathy, alcohol abuse, seizure disorders, narcolepsy, and tremor, which all interfere with balance and could potentially impact sternal stability and healing. Interestingly, many patients categorized as low risk could pinpoint the exact moment they first experienced sternal clicking or severe pain, suggesting a potential role for mechanical trauma in seemingly low-risk patients. Seizure disorders and narcolepsy warrant special consideration. In our cohort, 2 patients had a history of seizure disorder, and 1 had poorly managed narcolepsy. One patient experienced a seizure 10 months post cardiac surgery, whereas the other reported a syncopal event with loss of consciousness and a subsequent fall 4 months postoperatively. These conditions significantly elevate fall risk and may be considered absolute indicators for SRPF.

Sternal precautions following median sternotomy typically include restrictions on arm movements, weight lifting, and weight bearing, as well as recommendations to avoid reaching backward.¹⁷ We observed poor compliance with postsurgical weight restrictions in nearly 35% of patients, noting early engagement in physical labor at work or home (eg, landscaping, garage work, home repair, cooking, lifting children). This observation aligns with the suggestion by Hirose⁶ that SRPF may be reasonable for patients wishing to return to work early or those with physically demanding occupations, as well as the Veterans Affairs Medical Center in Birmingham, Alabama, guidelines for plating.¹² We propose expanding this recommendation to include highly independent individuals who regularly perform manual housework, as they may also benefit from the enhanced stability and potentially faster recovery offered by SRPF. Overall, these findings raise questions about whether patient behavior and compliance with restrictions might play a more significant role in dehiscence risk, especially in patients considered to be “low risk,” than previously recognized health factors. Future research should investigate the potential protective effects of patient education on sternal dehiscence prevention among patients with a low to intermediate risk of dehiscence who do not qualify for prophylactic SRPF.

We propose a modification to the MUST score, which demonstrated greater predictive performance compared with the DSWI model. We suggest the nonunion risk score as a modified assessment tool to guide prophylactic plating decisions. In the original MUST score, only 7 (15.2% of our cohort) patients accumulated points for intraoperative factors; this, however, cannot be assessed preoperatively and therefore limits the model’s ability to prospectively identify patients who may benefit from primary plating. To address this, we replaced intraoperative factors with preoperatively identifiable variables: the presence of OSA, chronic cough or respiratory disease, dependence on the upper body for mobility or increased fall risk, and a history of seizure disorder (Table 3). With these revised criteria, 38 out of 46 (82.6%) patients were identified as candidates for primary plating. Although promising, this modified scoring system will require rigorous external validation before it can be recommended for clinical use.

Table 3.

Modified Nonunion Risk Score

BMI, kg/m2

>35 (4)

25–35 (1)

Sex

Male (1)

Diabetes

Noninsulin-dependent (1)

Insulin-dependent (2)

Smoking

Current (2)

Former (1)

COPD (1)

Age > 60 y (2)

OSA (2)

Cough/respiratory disease (2)

Dependence on the upper body for mobility or fall risk factors (1)

Seizure disorder (5)

7+: Recommendation for SRPF

Adapted from the MUST score by removing intraoperative factors and incorporating additional risk variables: OSA, cough or respiratory disease, upper body dependence for mobility or fall risk, and seizure disorder

LIMITATIONS

Our study has important limitations. The absence of a control group limits our ability to distinguish the relative influence of patient behaviors versus clinical risk factors on dehiscence. Because our cohort consisted solely of patients with symptomatic sternal nonunion, the findings may not generalize to the broader population undergoing primary sternal wire cerclage. Moreover, we were unable to incorporate certain risk factors reported in the literature, such as computed tomography–derived sternal thickness-to-body weight ratio and inferior sternal width,¹⁸ which may enhance future predictive models. The single-center, single-surgeon design also raises the possibility of selection bias, and the comorbidity profile of our patients may not reflect that of the broader cardiac surgical population. Finally, although data collection followed standardized protocols with independent verification, reliance on retrospective chart review introduces potential bias. These factors underscore the need for external validation before widespread application of our proposed risk score.

CONCLUSIONS

This study highlighted the persistent ambiguity in defining “high risk” for sternal wound dehiscence and the challenges cardiothoracic surgeons face in determining when to involve plastic surgery for prophylactic SRPF. Although both the DSWI and MUST scores offer valuable guidance, our analysis found the MUST score to be more effective in identifying appropriate candidates—likely due to its more detailed consideration of comorbidities. However, both tools overlook key risk factors that were prevalent and clinically significant in our cohort, including OSA, respiratory diseases other than COPD associated with chronic cough, upper body dependence for mobility, fall risk, and poor compliance with postoperative precautions. These findings suggest that current scoring systems may underestimate risk in certain patients, particularly those labeled as “low risk” who nonetheless experience mechanical trauma or resume activity prematurely. To address this gap, we proposed a new nonunion risk score, incorporating OSA, chronic cough or respiratory disease, upper body dependence, fall risk, and seizure disorder. Future studies should validate this revised score and assess the potential protective role of patient education in preventing sternal complications.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ETHICAL APPROVAL

This study was conducted in compliance with all applicable regulations and guidelines governing human and animal rights.