Taken for Granted: An Analysis of Sternal Closure Techniques

Median sternotomy remains the most common incision in cardiac surgery, but sternal closure differs drastically between surgeons and institutions. Because sternal wound infections carry an incidence between 0.2% and 6%, with mortality approaching 40%, meticulous sternal closure is imperative to reduce the surgical contribution to infection. Reconnecting the central thoracic support point is not a simple feat considering the sternum experiences physiologic, multidimensional shearing with respiration and movement. Although technique varies (ie, simple-interrupted, figure-of-8, Robicsek technique), sternal wires remain the predominant substrate for closure due to surgeon familiarity, ease of use, cost, speed, and low complication rate. Alternatives to wires (ie, plating, metal bands, polymer bands [ie, ZIPFIX, DePuy Synthes], suture tape (ie, FiberTape, Arthrex, Inc), talons, pins, and bone cement) have failed to gain widespread adoption despite studies indicating superiority in stability, pain, postoperative complications, and mortality. Types of sternal closure depend on patient, surgeon, and operative factors, and a tailored approach may improve surgical outcomes. This review provides a comprehensive discussion about the importance of adequate sternal closure as well as a comparison of technique and technology in efficacy, cost, safety, and reoperative difficulty.