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A New Method of Sternal Approximation
HOW TO DO IT
A New Method of Sternal Approximation Joseph J. Timmes, M.D., Sidney Wolvek, Marco Fernando, M.D., Maurice Bas, M.D., and Joyce Rocko, M.D. ABSTRACT After sternotomy for a cardiac operation in adults, closure of the sternum is accomplished with five or six wire sutures with twisting of the wire ends. This method may not achieve rigid fixation of the sternum, and the bulky twisted wires may cause skin pain or actual perforation. We have developed a new method of approximating the split sides of the sternum using a new instrument, the Wolvek approximator. With this method rigid fixation is obtained and the ends of the wires are fixed by a small crimped metal plate. This method has been used clinically with success.
C
losure of the sternum after median sternotomy for a cardiac procedure has been accomplished by use of interrupted wire sutures in adults or Tevdek sutures in children. The use of nylon bands for sternal closure, as advocated by LeVeen and Piccone [l], has been found unacceptable by Sanfelippo and Danielson [Z] because of the increased risk of wound complications, wound dehiscence, and major infections. T h e standard closure of the sternum after sternotomy is by means of five or more sutures of monofilament surgical steel passed through the sternum approximately 1 cm. on each side. The suture wires are then crossed and pulled manually in opposite directions. T h e surgeon next twists the wires five to seven times and cuts off the surplus wire. The twisted ends of the suture, which are then approximately 14 mm. long, are bent down so that From the Department of Surgery, College of Medicine and Dentistry of New Jersey at Newark, and Jersey City Medical Center, Jersey City, N.J. Accepted for publication Sept. 19, 1972. Address reprint requests to Dr. Timmes, Jersey City Medical Center, 24 Baldwin Ave., Jersey City, N.J. 07304.
544
THE ANNALS OF THORACIC SURGERY
HOW TO DO IT:
Sternal Approximation
FIG. 1. A comparison of two methods of approximation of the sternum.
they lie as flat as possible over the sternum (Fig. 1). This method has withstood the test of time; however, it does have some inherent disadvantages. It is difficult to maintain constant tension manually in order to obtain rigid fixation of the sternum. Motion between the two sides of the sternal split causes postoperative pain. Also, the twisted ends may penetrate the skin, thus opening a possible avenue of infection. On several occasions we have been required to remove the twisted wire sutures, and this experience engendered a search for a better method of obtaining rigid wire fixation of the sternum without bulky twisted wire ends. For the past six months we have been using the Wolvek approximator" (Fig. 2) and have found closure with this instrument to be superior. In this scheme, the routine wire sutures are placed through the sternum. T h e wires are then passed through a small steel plate that measures 5 x 3.9 X 2.4 nim. T h e ends of the wire are held in the approximator by a nonslipping cam arrangement, and, by rotary motion of the hand magnified by a rack and
FIG. 2. Component parts of Wolvek sternal approximator. 'Pilling Co., Delaware Dr., Fort Washington, Pa. 19054.
TIMMES E T AL.
pinion, controlled tension is applied to close the sternum. T h e suture lock plate is then crimped and the excess wire cut away without any twisting. T h e plate lies flat over the sternotomy so that there is no danger of periosteal or skin breakthrough. Tensile strength testing of the approximator suture lock in the laboratory showed no failure below 50 pounds, whereas the twisted locks showed slippage at an average of 25 pounds of tension and complete failure at an average of 28 pounds of tension. This method has now been used in 9 patients. Four had myocardial revascularization procedures using saphenous vein bypass. One patient had myocardial revascularization using the left internal mammary artery. In 1 patient a valve replacement was performed; in another instance tetralogy of Fallot was repaired in an adult: 1 patient had repair of a laceration of the right atrium; and the ninth patient had resection of a tumor of the trachea. In these 9 patients rigid fixation of the sternum was accomplished, and it was our clinical opinion that they had less postoperative pain with this new method. There were no complications in any of these patients related to the sternal closure. Bone healing was apparently normal in those who have been observed for some months. Three of these patients had undergone operation less than two months prior to the time this manuscript was submitted, and it was too early to determine the rate of bone healing.
References 1. LeVeen, H. L., and Piccone, V. A.
Nylon-band chest closure. Arch. Surg. 96:36, 1968. 2. Sanfelippo, P. M., and Danielson, G. K. Nylon bands for closure of median sternotomy incisions. Ann. Thorac. Surg. 13:404, 1972.
546
THE ANNALS OF THORACIC SURGERY
A New Method of Sternal Approximation Joseph J. Timmes, M.D., Sidney Wolvek, Marco Fernando, M.D., Maurice Bas, M.D., and Joyce Rocko, M.D. ABSTRACT After sternotomy for a cardiac operation in adults, closure of the sternum is accomplished with five or six wire sutures with twisting of the wire ends. This method may not achieve rigid fixation of the sternum, and the bulky twisted wires may cause skin pain or actual perforation. We have developed a new method of approximating the split sides of the sternum using a new instrument, the Wolvek approximator. With this method rigid fixation is obtained and the ends of the wires are fixed by a small crimped metal plate. This method has been used clinically with success.
C
losure of the sternum after median sternotomy for a cardiac procedure has been accomplished by use of interrupted wire sutures in adults or Tevdek sutures in children. The use of nylon bands for sternal closure, as advocated by LeVeen and Piccone [l], has been found unacceptable by Sanfelippo and Danielson [Z] because of the increased risk of wound complications, wound dehiscence, and major infections. T h e standard closure of the sternum after sternotomy is by means of five or more sutures of monofilament surgical steel passed through the sternum approximately 1 cm. on each side. The suture wires are then crossed and pulled manually in opposite directions. T h e surgeon next twists the wires five to seven times and cuts off the surplus wire. The twisted ends of the suture, which are then approximately 14 mm. long, are bent down so that From the Department of Surgery, College of Medicine and Dentistry of New Jersey at Newark, and Jersey City Medical Center, Jersey City, N.J. Accepted for publication Sept. 19, 1972. Address reprint requests to Dr. Timmes, Jersey City Medical Center, 24 Baldwin Ave., Jersey City, N.J. 07304.
544
THE ANNALS OF THORACIC SURGERY
HOW TO DO IT:
Sternal Approximation
FIG. 1. A comparison of two methods of approximation of the sternum.
they lie as flat as possible over the sternum (Fig. 1). This method has withstood the test of time; however, it does have some inherent disadvantages. It is difficult to maintain constant tension manually in order to obtain rigid fixation of the sternum. Motion between the two sides of the sternal split causes postoperative pain. Also, the twisted ends may penetrate the skin, thus opening a possible avenue of infection. On several occasions we have been required to remove the twisted wire sutures, and this experience engendered a search for a better method of obtaining rigid wire fixation of the sternum without bulky twisted wire ends. For the past six months we have been using the Wolvek approximator" (Fig. 2) and have found closure with this instrument to be superior. In this scheme, the routine wire sutures are placed through the sternum. T h e wires are then passed through a small steel plate that measures 5 x 3.9 X 2.4 nim. T h e ends of the wire are held in the approximator by a nonslipping cam arrangement, and, by rotary motion of the hand magnified by a rack and
FIG. 2. Component parts of Wolvek sternal approximator. 'Pilling Co., Delaware Dr., Fort Washington, Pa. 19054.
TIMMES E T AL.
pinion, controlled tension is applied to close the sternum. T h e suture lock plate is then crimped and the excess wire cut away without any twisting. T h e plate lies flat over the sternotomy so that there is no danger of periosteal or skin breakthrough. Tensile strength testing of the approximator suture lock in the laboratory showed no failure below 50 pounds, whereas the twisted locks showed slippage at an average of 25 pounds of tension and complete failure at an average of 28 pounds of tension. This method has now been used in 9 patients. Four had myocardial revascularization procedures using saphenous vein bypass. One patient had myocardial revascularization using the left internal mammary artery. In 1 patient a valve replacement was performed; in another instance tetralogy of Fallot was repaired in an adult: 1 patient had repair of a laceration of the right atrium; and the ninth patient had resection of a tumor of the trachea. In these 9 patients rigid fixation of the sternum was accomplished, and it was our clinical opinion that they had less postoperative pain with this new method. There were no complications in any of these patients related to the sternal closure. Bone healing was apparently normal in those who have been observed for some months. Three of these patients had undergone operation less than two months prior to the time this manuscript was submitted, and it was too early to determine the rate of bone healing.
References 1. LeVeen, H. L., and Piccone, V. A.
Nylon-band chest closure. Arch. Surg. 96:36, 1968. 2. Sanfelippo, P. M., and Danielson, G. K. Nylon bands for closure of median sternotomy incisions. Ann. Thorac. Surg. 13:404, 1972.
546
THE ANNALS OF THORACIC SURGERY