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Closing the chest

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The median or midline sternotomy was first studied and shown to be effective in goats in 1897. It was another 50 years before Dr Ormand Julian at Rush Presbyterian Medical Center popularized it. The sternotomy is the most commonly performed bone-breaking procedure or osteotomy in world today. At that stage, bone was lashed together with heavy suture or twine - and the technique was called cerclage.

As I mentioned in the previous blog, wire closure is not effective in eliminating micro-movement and is associated with inadequate bony approximation on biomechanical studies. Persistent movement between the bony fragments predisposes to delayed healing, inadequate healing, pain or infection. Some of these are intertwined. Sternal wound infections are a big deal - and a major cause of morbidity and mortality after heart surgery. Frequently, the bony fragments of the sternum are involved in the infection. This may result in loss of bone and structural integrity of the chest wall.

in the mid-1990s Dr Larry Gottlieb, an innovative plastic surgeon at the University of Chicago showed that one could salvage sternal fragments and get them to heal, after sternal wound infections, with the use of modified plates and screws (used to fix broken jaws!). He then suggested prophylactic use of plates and screws in patients who were at increased risk of sternal dehiscence and/or infection.

The first experience with custom made sternal plates was reported by Dr David Song, another skillful plastic surgeon at the University of Chicago and myself in 2003. This paper showed dramatic reduction in sternal wound problems in a high risk population if the sternum was plated prophylactically. Over the next 10 years, we worked with Biomet (which is now Zimmer Biomet) and other companies to come up with plates and screws that could be used easily on the sternum by simple cardiac surgeons!

The first randomized study to show benefits of plate fixation of the sternum was published in 2013, after I presented the data at the Western Thoracic Surgery meeting. Since then, another study published in 2018 by Allen et al has shown better wound outcomes and less pain in plated patients.

Despite growing evidence, the adoption of this simple technology in chest closure has taken time. The trend is favoring increased utilization of these fixation techniques in the chest.

The benefits are better healing, less pain and decreased bony complications.

Lets talk about rib fixation next time.

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