Alternatives to Metal Sternum Closure
Rigid plate fixation is the most effective alternative to traditional wire cerclage for sternum closure, offering significantly better sternal healing, fewer complications, less pain, and improved quality of life with no additional cost compared to wire cerclage. 1
Rigid Fixation Systems
Rigid fixation systems provide superior stability compared to traditional wire cerclage by eliminating side-to-side movement of the sternum, which wire cerclage fails to prevent. These systems include:
1. Titanium Plate Systems
- Custom H-plates: Provide significantly greater stiffness and less lateral displacement than wire fixation 2
- X-shaped plates: When used in combination (three X-shaped plates plus one box-shaped plate), they effectively resist sternal separation 3
- Straight plates: Less effective than custom H-plates but still provide improved stability 2
2. Ultra-High Molecular Weight Polyethylene (UHMWP) Sutures
- Avoid the "cheese-cut" effect seen with metal wires
- Eliminate artifacts on X-ray imaging
- May reduce sternal damage compared to metal wires 4
3. Composite Fixation Techniques
- Combination of titanium fixation plates with circumferential stainless steel wires
- Particularly useful for complicated sternal closures
- Provides both stability and buttressing effect 5
Clinical Benefits of Rigid Fixation
Multicenter randomized clinical trials have demonstrated that rigid plate fixation provides:
- Significantly better sternal healing at 6 months post-surgery
- Fewer sternal complications
- Less pain
- Better upper-extremity function
- Improved quality-of-life scores
- No difference in total 90-day cost compared to wire cerclage 1
Patient Selection for Rigid Fixation
Rigid sternal fixation should be especially considered in high-risk patients:
- High body mass index
- Previous chest wall radiation
- Severe chronic obstructive pulmonary disorder
- Steroid use
- Complicated sternal wound infections or dehiscence 1, 6
Alternative Sternotomy Approaches
1. Lower Hemisternotomy
- Preserves the manubrium intact
- 6-8 cm vertical skin incision in the midline
- Sternotomy extends into the right second intercostal space
- Closure typically with 4 simple wires or sternal plates 1
2. Minimally Invasive Approaches
- Minithoracotomy approach as an alternative to full sternotomy
- Particularly useful for mitral valve procedures
- Requires specialized retractors and instruments 1
3. Hybrid Approaches
- Combining transcatheter and surgical techniques
- Can avoid sternotomy entirely in some cases
- Particularly useful in high-risk surgical candidates 1
Management of Complicated Sternal Closures
For cases of sternal instability, infection, or dehiscence:
- Transverse plate fixation systems offer a safe alternative to traditional re-wiring 6
- Composite plate and wire fixation achieves sternal closure, stability, and uncomplicated wound healing in difficult cases 5
Pitfalls and Caveats
Cost considerations: While initial costs may be higher for rigid fixation systems, total 90-day costs show no significant difference due to fewer complications 1
Technical expertise: Proper placement of plates is critical for effectiveness - studies show that configuration and placement significantly impact stability 3
Patient-specific factors: Not all patients may benefit equally from rigid fixation; assessment of risk factors for sternal complications should guide selection
Imaging considerations: Metal plates may create artifacts on future imaging studies, which should be considered for patients likely to need frequent chest imaging
By implementing these alternative approaches to metal sternum closure, particularly rigid fixation systems in high-risk patients, surgeons can significantly improve outcomes related to sternal healing, reduce complications, and enhance patient quality of life.