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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Primary Sternal Closure with Titanium Plate Fixation - Plastic Surgery Effecting a Paradigm Shift
DAVID H. SONG, MD, Valluvan Jeevanandam, MD, Jai Raman, M.D.,F.R.A.C.S,Ph.D.
UNIVERSITY OF CHICAGO, CHICAGO, IL, USA.

Purpose: Sternal instability has been linked to increased rates of post-operative mediastinitis, which poses an especially significant threat to high-risk patients. Clinical and biomechanical studies have shown the superiority of rigid plate fixation over wire circlage in healing of sternotomies and reducing post-operative complications. Cardiac surgeons, however, have traditionally been trained to close sterna via wire circlage and have been reluctant to change to newer, more effective techniques of rigid osteosynthesis. Collaborative efforts between Plastic and Cardiac Surgeons have effectively caused a paradigm shift in the closure techniques of high-risk patients at our institution. We present our 6 year experience representing both the largest experience to date and the foundation for the paradigm shift that is currently ongoing in cardiac surgery.
Methods: Between July, 2000 and October 2006, 750 high-risk patients underwent primary internal fixation of the sternum with the FDA approved SternaLock® system (W. Lorenz, Jacksonville FL). High-risk was defined as patients with 3 or more of established risk factors in the literature:

Pre-operative Risk Factors Intra-operative risk factors
Diabetes mellitusOff mid-line sternotomies
COPDOsteoporosis
Renal FailureLong cardio-pulmonary bypass runs (>2 hours)
Obesity (BMI >30)Transverse sternal fractures
Chronic Steroid Use
Concurrent infection
Immuno-suppression
Redo Sternotomy

Results: Demographic data are: mean age 71 (47 - 89), 488 male (65%), 262 female (35%). Most common risk factor was Redo Sternotomy (40%). Successful sternal closure was defined by physical exam devoid of instability, pain, wound healing complications and radiographs showing unchanged location of hardware for a minimum of 12 weeks. Failure of ORIF was seen in 18 patients (2.4%), 4 of the 18 developed mediastinitis (0.5%). No deaths were directly related to the rigid fixation technique.
Conclusions: The benefits of rigid plate osteosynthesis have caused paradigm shifts away from wire fixation for all surgical specialties. Cardiac surgeons are the only surgeons who continue to fix bone with wire-circlage. Ironically, cardiac surgeons perform the most common osteotomy (sternotomy) worldwide yet as a group, have not adopted the state-of-the art techniques of osteosynthesis. Based on our early success in a high-risk population with a historically high rate of complications, cardiac surgeons have now embraced the concept of rigid plate fixation. This report highlights the fact that rigid plate fixation can dramatically reduce sternal wound infection in high-risk patients. While it may not eliminate sternal dehiscence completely, it can provide a way to ensure secure closure in a variety of patients that are at increased risk of wound infections and poor healing and thus has been the basis for an ongoing paradigm shift in cardiac surgery.
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