Rigid fixation for the prevention and treatment of sternal complications

Most surgical specialties working with bone have transitioned from wire fixation to more stable plate and screw fixation. Rigid plate fixation results in more rapid bony healing with decreased rates of nonunion, malunion, and infection. Despite sternotomies being the most frequently performed osteotomy, cerclage wire fixation remains the standard technique of closure. This study reviews our 5-year experience with rigid fixation at the University of California Davis Medical Center.

A retrospective review of patients who underwent rigid sternal fixation between January 2006 and December 2012 at UC Davis Medical Center was performed. Demographic factors, indications for surgery, and risk factors for postoperative complications including mediastinitis and nonunion were reviewed. The type of fixation system was recorded. Outcomes assessed included dehiscence, deep and superficial infections, sternal instability, and need for reoperation.

Fifty-seven rigid sternal fixations were performed (M/F, 37:20; average age, 54 years; range, 16-79 years). Indications for operation included prophylaxis against mediastinitis (61.4%), sternal nonunion (24.6%), sternal fractures (7.0%), and pectus deformities (7.0%). Of the rigid fixation systems used, 87.3% used SternaLock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip. Thirty-five patients were plated for prophylaxis against mediastinitis. In the prophylactic group, the average number of risk factors per patient was 3.92, indicating very high-risk patients. Fourteen patients were plated for sternal nonunion. The average number of risk factors in the nonunion group was 1.57. Other less common indications for rigid sternal stabilization included sternal fracture (4 patients) and pectus deformity (4 patients). Eight patients had a pectoralis flaps performed at the time of their sternal fixation, 7 for soft tissue coverage of plates and 1 for coverage of a contaminated wound bed. All patients went on to heal their sternums without evidence of mediastinitis.

Rigid sternal fixation is a natural extension of principles learned from bone stabilization in other parts of the body. It can be used for rigid bony fixation of osteotomies performed after median sternotomy as well as in sternal reconstructions for traumatic fractures, nonunions, and pectus deformities. Rigid sternal fixation can be used safely and effectively in the prophylaxis against the development of mediastinitis in addition to the treatment of sternal nonunion or malunion in high-risk patients.