title: Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study.
abstract: BACKGROUND
  The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined.
  
  
  METHODS
  Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed.
  
  
  RESULTS
  Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001).
  
  
  CONCLUSIONS
  Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.
authors.affiliation: Department of Cardiac Surgery, Tor Vergata University, Rome, Italy. zeitani@hotmail.com
authors.forename: J
authors.initials: J
authors.lastname: Zeitani
authors.forename: A
authors.initials: A
authors.lastname: Penta de Peppo
authors.forename: M
authors.initials: M
authors.lastname: Moscarelli
authors.forename: L
authors.initials: L
authors.lastname: Guerrieri Wolf
authors.forename: A
authors.initials: A
authors.lastname: Scafuri
authors.forename: P
authors.initials: P
authors.lastname: Nardi
authors.forename: F
authors.initials: F
authors.lastname: Nanni
authors.forename: E
authors.initials: E
authors.lastname: Di Marzio
authors.forename: P
authors.initials: P
authors.lastname: De Vico
authors.forename: L
authors.initials: L
authors.lastname: Chiariello
mesh_terms: D000368:Aged; D001696:Biomechanical Phenomena; D001864:Bone Wires; D006348:Cardiac Surgical Procedures; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009765:Obesity / Q000453:epidemiology; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000453:epidemiology; D012307:Risk Factors; D013249:Sternum / Q000033:anatomy & histology / Q000601:surgery*; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D013530:Surgical Wound Infection / Q000453:epidemiology; D014143:Traction; D014945:Wound Healing