A Retrospective Application of Deep Sternal Wound Dehiscence and Malunion Risk Scores on Sternal Nonunion Patients

More than 750,000 median sternotomies are performed annually in the United States, with wire cerclage as the standard closure technique. However, cerclage may not ensure optimal stability in high-risk patients, leading to complications such as dehiscence, mediastinitis, and nonunion. Sternal rigid plate fixation offers improved outcomes but remains underused, in part, due to a lack of clear indications. Recent risk models quantify the risk of sternal dehiscence, but have not been validated to guide closure decisions. We evaluated 2 risk calculators to guide prophylactic plating decisions and identified overlooked risk factors.

A retrospective chart review was conducted on patients referred to a single plastic surgeon for symptomatic sternal nonunion between 2017 and 2024. Demographics, comorbidities, and surgical outcomes were collected, and 2 risk-score calculators for deep sternal wound infection and malunion were assessed.

Forty-six patients with symptomatic sternal nonunion were identified. Comorbidities were prevalent, including diabetes (56.52%), obstructive sleep apnea and gastroesophageal reflux disease (54.25% each), and chronic kidney disease (36.9%). Postdischarge, 43.48% reported coughing-related sternal pain, and 34.78% reported poor compliance with sternal precautions. The deep sternal wound infection calculator recommended plating for 13 patients, whereas the malunion risk score recommended it for 24 patients, with only 10 patients recommended for plating by both systems.

Current risk calculators may overlook critical patient factors, limiting their predictive accuracy for sternal complications. These findings highlight the need for more comprehensive risk assessment tools to improve patient selection for prophylactic sternal rigid plate fixation and optimize sternal closure techniques.