Novel Longitudinal Plate-Fixation Technique after Gross Resection of the Sternum

Abstract

Herein, we describe a plate-fixation technique as an alternative method to close a fragile or fractured sternum. A 69-year-old obese woman with diabetes mellitus and chronic obstructive pulmonary disease underwent coronary artery bypass grafting. One week postoperatively, sternal instability was detected, and traditional rewiring was performed. A week later, because of multiple sternal fractures, we performed sternal resection, with use of longitudinally affixed titanium plates and figure-8 steel wires for the anterior chest wall. The procedure was uneventful, and, on short-term follow-up, the anterior chest wall was stable.

This longitudinal plate-fixation technique can be tailored to each patient. We think that the technique is safe, effective, economical, and easy to implement, and it is readily reproducible. To evaluate any associated risks, long-term follow-up in additional patients is warranted.

Multiple sternal fracture is an infrequent sequela of median sternotomy after cardiac surgery; however, its occurrence significantly increases morbidity and mortality rates. Traditional treatment involves aggressive débridement with use of pectoral muscle flaps or transposed omentum. However, this approach can lead to thoracic instability that necessitates prolonged mechanical ventilatory support, extended hospital stays, and increased costs.^1,2 Herein, we report a case of thoracic reconstruction with the use of a novel longitudinal plate-fixation technique after gross resection in a patient with multiple sternal fractures.

Case Summary

In March 2009, a 69-year-old obese woman underwent coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery at our institution. She weighed 115 kg and had insulin-dependent diabetes mellitus and chronic obstructive pulmonary disease (COPD). One week postoperatively, sternal instability was detected. There was no erythema, swelling, or drainage of purulent fluid. The patient underwent sternal débridement and rewiring by means of the Robicsek weave technique.³ She did well initially; however, she had severe chest pain 2 weeks postoperatively, after falling out of bed. After her condition was stabilized, reexploration was performed with aggressive wound débridement, and sternal resection was required because of multiple fractures of the osteoporotic sternum.

Surgical Technique

The major pectoral muscle was elevated bilaterally, from its insertion along the medial aspects of the ribs to the midclavicular line, until it was sufficiently mobile for longitudinal plate placement and later approximation. After sternal débridement, there was a very large but inevitable defect, with a few sternal fragments in the sternal area. These fragments were resected. The only remaining intact segments of sternum were parts of the manubrium (Fig. 1). Titanium plates were affixed with figure-8 wire sutures on 2 symmetrical medial parts of the bony portion of the ribs and proximal remaining area of the manubrium (Fig. 1). The patient's cardiac dimensions were not too large for this procedure: when we brought the plates near to each other, no cardiac compression was observed. There was no need for reapproximation. After this, the left and right sides of the remaining medial part of the ribs and manubrium were approximated with the use of steel surgical wires, and 6 wire sutures were placed very closely around the titanium plates in a figure-8 configuration (Fig. 2). The operation time was 95 minutes.

Fig. 1 Diagram shows that only parts of the manubrium were intact. Titanium plates (left) were affixed 0.5 to 1 cm lateral of the rib extension with figure-8 wire sutures and brought to the middle line. (Artist: Irfan Tasoglu)

Fig. 2 Photograph shows the plated sternum.

The patient was extubated 4 hours postoperatively. After the sternal plate fixation, her condition improved. The postoperative chest pain disappeared shortly after the operation, and she reported only minor discomfort in the long term.

Discussion

In many cases, sternal instability or infection makes complete débridement of the sternum and concomitant pectoral muscle-flap reconstruction necessary.^1,2,4 If complete resection of the sternum is required, reconstruction can become problematic, because muscle flaps might not prevent paradoxical chest-wall movement. In this event, atelectasia might develop due to malfunctions in full inhalation and expiration, which could result in hypoxia or a decreased discharge of carbon dioxide. In this event, patients with underlying lung disease, especially COPD, might have to be placed on prolonged mechanical ventilatory support. Many studies have shown the superiority of rigid plate fixation over wire for aggressive resection of the sternum.^1,4,5 Using plates confers the advantage of thoracic stability, and eventually pulmonary function is less affected. Transverse and longitudinal sternal plates can be used to treat these complications. However, an additional disadvantage of custom-made transverse plates is their limited availability, which increases the cost of surgery. The delay required to unscrew and remove plates could be catastrophic when emergent re-entry into the chest is warranted in intensive care unit situations. Moreover, drilling holes in the ribs might actually cause fractures, and drilling too deeply or using screws that are too long could increase the risk of pneumothorax. In addition, bicortically placed screws may lead to graft damage, because the tips of the screws are in the region of underlying bypasses.^4–6 We prefer to affix the plates with wire rather than with screws, because we think that drilling holes in the ribs unacceptably increases the risk of rib fracture. Our technique leads to none of the typical sequelae, and its use in our patient rendered her sternum stable.

Our longitudinal plate-fixation technique adds to the solutions for treating gross sternal débridement. It can be tailored to each patient. This technique is safe, effective, easily reproducible, and economical. Long-term follow-up in additional patients is warranted, in order to evaluate any associated risks.