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© 2004 European Association of Cardio-Thoracic Surgery
Is the figure-of-eight superior to the simple wire technique for closure of the sternum?
a Department of Cardiothoracic Surgery, Wythenshawe Hospital, South Moor Road, Manchester M23 9LT, UK
* Corresponding author. Address: Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 3BW, UK. Tel.: +44-780-154-8122; fax: +44-161-276-8538 Received November 7, 2003; accepted November 10, 2003
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether the figure-of-eight technique is superior to the simple wire technique for closing of the sternum? Altogether 111 papers were found in Medline of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the figure-of-eight wire technique is not superior to the simple wire technique for closure of the sternum.
Key Words: Evidence-based medicine; Thoracic surgery; Bone wires; Sternum
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
You are assisting with an aortic valve replacement operation in an 85 year old female. She had a long-standing history of chronic obstructive airway disease and diabetes mellitus. The valve was severely calcified. You successfully excise and replace the valve and you are now asked to close the sternum by the consultant. He states that this patient is high risk for sternal dehiscence and thus you should use the figure-of-eight technique to close the sternum. You agree that this patient is high risk and you close the sternum using this technique but you wonder what evidence there is to support the benefit of this technique in high risk patients.
In (patients undergoing cardiac surgery) is closure of the sternotomy using (standard or figure-of-eight sternal wire closure) the most effective in preventing (sternal dehiscence).
Medline 1966–Aug 2003 using the OVID interface (exp sternum/or stern$.mp) and (exp suture techniques/or exp bone wires/or bone wires.mp or wire$.mp) and (exp models,biological/or exp stress, mechanical/or exp surgical wound dehiscence/or dehiscence.mp or exp mediastinitis/or mediastinitis.mp or biomechanic$.mp or sternal union.mp)
One hundred and eleven papers were found from Medline and seven relevant papers were selected as providing the best evidence. [2–8]. These papers are presented in Table 1.
Two types of paper were found in this search. Several clinical papers documented the authors' clinical experience of a particular technique, and the remaining papers looked at biomechanical testing of the various sternal wire techniques using ex vivo sternal models. Three clinical papers are presented here. Casha et al. [5] described their particular technique of trans-sternal multi-twist wire closure, and stated that over 10 years and 2000 cases their sternal complication rate was 0.5%. Murray et al. [7] reported that in 34 high-risk patients and an additional 84 consecutive patients there were no cases of dehiscence or mediastinitis using a figure-of-eight technique. DiMarco et al. [8] reported that in 978 patients who had peristernal figure-of-eight wires used to close the sternum, the major sternal complication rate was 0.9%. However no clinical studies have directly compared one closure technique to another, and thus it is difficult to come to any firm conclusion from the results of these uncontrolled, retrospective cohort studies. In contrast, several well conducted biomechanical studies have been performed. Dasika et al. [2] used a polyurethane foam sternal model to compare six simple wires, seven simple wires and six figure-of-eight wires, all placed peristernally. They found that figure-of-eight wires performed similarly to the standard six simple wires and only adding a 7th simple wire reduced the distraction seen at 400 N of tension. Losanoff et al. [4] directly compared peristernal simple wires with peristernal figure-of-eight wires in a porcine sternal model. They found that the single peristernal wire technique required a higher force to cause failure than the figure-of-eight technique. Casha et al. [5] in 1999 studied five techniques of closure using a steel sternal model. They found that the displacement at 20 kg of tension was smaller for single wires than figure-of-eight and the breaking strain was similar for both techniques. Casha et al. [3] hypothesised that in fact single distraction testing was inferior to repeated cycles of loading which could mimick the clinical phenomenon of sternal cut-through of wires. They used sheep sternums to test a range of techniques and found that trans-sternal figure-of-eight wires performed more poorly than simple wires and peristernal simple wires were considerably superior to either technique in preventing cut-through. It is however important to note that they did not assess peristernal figure-of-eight wires. None of these clinical or biomechanical studies demonstrated any superiority of the figure-of-eight wire technique over simple wiring, and in fact several of the biomechanical studies suggest that the issue of whether the wire is placed trans-sternally or peristernally may be a more important factor in promoting sternal stability.
The figure-of-eight wire technique is not superior to the simple wire technique for closure of the sternum.
ICVTS on-line discussion Author: Prof. John Pepper, London Hospital Royal Brompton, Cardiothoracic Surgery Dept., Sydney Street, London SW3 6NP, UK Date: 16-Dec-2003 Message: Criticism of a particular surgical technique is difficult as it depends so much on the skill of the operator. But sternal closure is so important and so frequently delegated to junior staff that any proposed technique must be simple, easy to teach and easily reproducible. The figure-of-eight is more difficult than a simple suture placed around the sternum and through the manubrium but fails on the test proposed above. Furthermore, in a paper which examined fatigue-testing, by Cooper and colleagues (Casha AR. et al., Eur.J.Cardiothorac.Surg. 2001; 19: 249–253) figure-of-eight sutures were the least satisfactory method of sternal closure. Author: Dr. Sameh Ibrahim Sersar, Assistant Lecturer of Cardiothoracic Surgery, Mansoura University, Department of Cardiothoracic Surgery, Mansoura University, Mansoura, 123 Egypt Date: 11-Jan-2004 Message: To determine the best method of sternal closure, there are certain factors to consider: (i) age above 65 years; (ii) diabetes mellitus; (iii)bilateral internal mammary artery is harvested; (iv) reoperations; (v) eccentric sternotomy; (vi) sternal reclosure for mediastinitis or dehiscence; (vii) obesity (body weight 20% higher than expected); and (viii) chronic obstructive pulmonary airway disease. The surgeon preference and experience also is an important factor as Pepper J. stated in his comment on this article. Sharma et al. found that tension/ wire no. is higher in Rob < PS < PS8 < APTS < PC8 < TS where APTS alternating peristernal and transsternal single wires; PC8 pericostal figure-eight wires; PS peristernal single wires; PS8 peristernal figure-eight wires; Rob Robicsek; TS multiple transsternal single wires [1]. The factors assessing the efficacy of a method of sternal closure are: stiffness, proportional limit load, displacement at first cycle peak, displacement after 10 and 25 cycles, maximum displacement at the end of test, permanent displacement after the first, fifth and tenth cycles; and percent of catastrophic failures before each test's conclusion [2]. References [1]Rajeev Sharma, Deepak Puri, Bishnu P. Panigrahi, and Inderjeet S. Virdi, A modified parasternal wire technique for prevention and treatment of sternal dehiscence, Ann Thorac Surg 2004 77: 210–213. [2]Julian E. Losanoff, Andrea D. Collier, Colette C. Wagner-Mann, Bruce W. Richman, Harold Huff, Fu-hung Hsieh, Alberto Diaz-Arias, and James W. Jones Biomechanical comparison of median sternotomy closures, Ann Thorac Surg 2004 77: 203–209. Author: Mr. Joel Dunning, SpR Cardiothoracic Surgery, Freeman Hospital, Newcastle-upon-Tyne, Freeman Road, Newcastle-upon-Tyne, UK Date: 30-Jan-2004 Message: This topic searched Medline from 1966 to Aug 2003. However one of the advantages of publishing and stating our search strategy in these topics is that the full search can be put into Ovid's update service. This means that if a new paper is published that would have been included in the search strategy it is automatically E-mailed to us. This has occurred for this topic. In Jan 2004 Losanoff et al [1] published another paper in the Annals of Thoracic Surgery that in our opinion is the best published paper on this topic so far. They used Fifty-three fresh adult human cadaveric sternal plates with adjacent ribs, fixed with specially designed spiked stainless steel clamps. They assessed Single peristernal and transsternal, alternating single peristernal and transsternal, figure-eight peristernal, figure-eight pericostal, and Robicsek closures using no. 5 stainless steel wires for a number of biomechanical parameters. They conclude that single peristernal and alternating peristernal/transternal are the best two techniques followed by figure-of-eight peristernal. Trans-sternal single wires and pericostal figure of eight performed most poorly. Reference [1]Losanoff JE, Collier AD, Wagner-Mann CC, Richman BW, Huff H, Hsieh F, Diaz-Arias A, Jones JW. Biomechanical Comparison of Median Sternotomy Closures. Annals of Thoracic Surgery:2004;77:203–9. doi:10.1016/S1569-9293(03)00259-7
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Abstract
1. Introduction
