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Sternal wound closure in the current era: the need of a tailored approach

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Abstract

Objective

Median sternotomy remains the most common access to perform cardiac surgery procedures. However, the experience of the operating surgeon remains a crucial factor during sternal closure to avoid potential complications related to poor sternal healing, such as mediastinitis. Considering the lack of major randomized controlled trials and the heterogeneity of the current literature, this narrative review aims to summarize the different techniques and approaches to sternal closure with the aim to investigate their reflections into clinical outcomes and to inform the choice on the most effective closure method after median sternotomy.

Methods

A literature search through PubMed, Embase, EBSCO, Cochrane database of systematic reviews, and Web of Science from its inception up to April 2019 using the following search keywords in various combinations: sternal, sternotomy, mediastinitis, deep sternal wound infection, cardiac surgery, closure.

Results

Single wire fixation methods, at present, seems the most useful method to perform sternal closure in routine patients, although patients with a fragile sternum might benefit more from a figure-of-eight technique. In high-risk patients (e.g. chronic pulmonary disease, obesity, bilateral internal mammary artery harvesting, diabetes, off-midline sternotomy), rigid plate fixation is currently the most effective method, if available; alternatively, weave techniques could be used.

Conclusion

The choice among the sternal closure techniques should be mainly inspired and tailored on the patient’s characteristics, and correct judgement and experience play a pivotal role. A decisional algorithm has been proposed as an attempt to overcome the absence of specific guidelines and to guide the operative approach. This operative approach might be used also in non-cardiac procedure in which median sternotomy is required, such as in case of thoracic surgery.

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Author notes

  1. Massimo Chello and Cristiano Spadaccio equally contributed to the work.

Authors and Affiliations

  1. Department of Cardiovascular Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 200, 00128, Rome, Italy

    Antonio Nenna, Umberto Satriano, Ciro Mastroianni, Mario Lusini & Massimo Chello

  2. Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France

    Francesco Nappi

  3. Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK

    Jennifer Dougal & Cristiano Spadaccio

  4. Dermatology, University of Rome “La Sapienza”, Rome, Italy

    Camilla Chello

Authors
  1. Antonio Nenna
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  2. Francesco Nappi
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  3. Jennifer Dougal
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  4. Umberto Satriano
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  5. Camilla Chello
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  6. Ciro Mastroianni
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  7. Mario Lusini
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  8. Massimo Chello
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  9. Cristiano Spadaccio
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Correspondence to Antonio Nenna.

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Nenna, A., Nappi, F., Dougal, J. et al. Sternal wound closure in the current era: the need of a tailored approach. Gen Thorac Cardiovasc Surg 67, 907–916 (2019). https://doi.org/10.1007/s11748-019-01204-5

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