Optimal Sternal Wound Stabilization
Rigid plate fixation should be used for sternal closure instead of traditional wire cerclage, as it provides superior sternal healing, fewer complications, and improved patient outcomes without additional cost. 1
Primary Stabilization Method
Rigid sternal fixation is the preferred technique for sternotomy closure, particularly in high-risk patients. 1 Two multicenter randomized clinical trials demonstrated that rigid plate fixation resulted in:
- Significantly better sternal healing compared to wire cerclage 1
- Fewer sternal complications at 6 months post-surgery 1
- Significantly less pain and better upper-extremity function 1
- Improved quality-of-life scores with no difference in total 90-day cost 1
- Decreased mediastinitis rates 1
High-Risk Patients Requiring Rigid Fixation
Rigid sternal fixation should be especially considered in patients with: 1
- High body mass index 1
- Previous chest wall radiation 1
- Severe chronic obstructive pulmonary disease 1
- Steroid use 1
Limitations of Wire Cerclage
Traditional wire cerclage achieves approximation and compression but does not eliminate side-to-side movement, failing to provide true rigid fixation. 1 While wire cerclage has been historically used due to perceived low complication rates and low cost, the evidence demonstrates that rigid plate fixation is superior without incurring additional expenses. 1
Infection Prevention Bundle
To reduce surgical site infections during sternal wound management, implement the following care bundle: 1
- Topical intranasal therapies to eradicate staphylococcal colonization 1
- Weight-based cephalosporin infusion fewer than 60 minutes before skin incision 1
- Redosing antibiotics for cases longer than 4 hours 1
- Skin preparation and depilation protocols using clipping (not shaving) close to surgery time 1
- Dressing changes every 48 hours postoperatively 1
- Daily incision washing with chlorhexidine after sterile dressing removal within 48 hours 1, 2
Critical Antibiotic Timing
Prophylactic antibiotics should be continued for 48 hours maximum after completion of cardiac surgery. 1 Prolonged prophylaxis beyond this timeframe does not reduce infection rates and promotes antibiotic resistance. 2
Management of Established Sternal Wound Infections
When sternal wound infection occurs despite preventive measures, the management approach depends on infection severity: 3, 4
Initial Surgical Management
- One-stage surgical debridement with closed drainage using Redon drains is effective for most sternal wound infections 4
- The extent of debridement is the key determinant of successful treatment 5
- Radical debridement must be performed before any primary coverage with flaps 5
Advanced Reconstruction Options
For severe cases requiring extensive debridement: 6, 5
- Latissimus dorsi muscle flaps are the gold standard for deep sternal wound infections with open, unstable thorax 5
- Transverse plate fixation can provide thoracic stabilization after extensive bone loss 6
- Dynamic wound closure using elastic systems can achieve gradual approximation after debridement 7
Common Pitfalls to Avoid
- Do not use uniform timelines across all patients—closure method, bone quality, and individual risk factors significantly impact healing 8
- Do not attempt conservative management for protruding wires near the skin surface, as progression to infection is highly likely 2
- Do not extend antibiotic prophylaxis beyond 48 hours without documented infection 2
- Do not perform immediate operative repair of crush injuries due to indistinct injury borders 9