title: Modified closure technique for reducing sternal dehiscence; a clinical and in vitro assessment.
abstract: OBJECTIVE
  Although the incidence of sternal dehiscence is low its mortality can be high. An alternative technique is described (modified closure) which aims to redistribute the dehiscence force into the longer longitudinal axis rather than the shorter transverse axis, thereby maximising the closure strength. Four ethibond sutures, which interlock anteriorly, are used in addition to eight transverse sternal wires. The aim of the study was to assess the modified closure using both an in vitro and a clinical study.
  
  
  METHODS
  (a) In vitro study: A weight and traction pulley system applied a force of 0.1kN to pairs of silicone rubber hemisterna approximated to each other using alternative closure techniques. The dehiscence tendency (DT) was measured as the amount of separation under tension. Using 10 pairs of hemisterna for each closure technique the measured DT for the modified closure (MC) was compare with those for each of five alternative closures (two figure-of-eight and four transverse sutures (2C), 6 (6T), 8 (8T), 10 (10T) and 12 transverse sutures (12T)). (b) Clinical study: The incidence of sternal dehiscence for the first 4 years of a consultants' practice (using 8T) was compared with the second 4 years (using MC).
  
  
  RESULTS
  (a) Measured DT (mean+/-SEM), (MC: 149+/-14; 6T: 256+/-13; 8T: 223+/-9; 10T: 213+/-13; 12T: 203+/-8; 2C: 294+/-15). DT was significantly smaller for MC (p<0.003). (b) The incidence of dehiscence was significantly smaller in the second 4 years (MC) than in the first (8T): 0.2% (1/529) versus 1.6% (13/788); p=0.01
  
  
  CONCLUSIONS
  In vitro and clinical studies suggest that the modified closure technique can reduce the incidence of sternal dehiscence.
authors.affiliation: Department of Cardiothoracic Surgery, Kings College Hospital, Denmark Hill, London SE5 9RS, UK. lindsay.john@kch.nhs.uk
authors.forename: Lindsay C H
authors.initials: LC
authors.lastname: John
mesh_terms: D001696:Biomechanical Phenomena; D001864:Bone Wires; D006801:Humans; D008422:Materials Testing / Q000379:methods; D013249:Sternum / Q000601:surgery*; D013529:Surgical Wound Dehiscence / Q000517:prevention & control*; D013536:Suture Techniques / Q000295:instrumentation*; D013537:Sutures; D013718:Tensile Strength; D013908:Thoracotomy / Q000379:methods; D016896:Treatment Outcome; D016474:Weight-Bearing