What are the best techniques for performing rigid plate fixation in a high-risk cardiac surgery patient to prevent sternal wound complications?

Rigid Plate Fixation for High-Risk Cardiac Surgery Patients

Rigid plate fixation is the preferred technique for sternotomy closure in high-risk cardiac surgery patients, as it provides superior sternal healing, fewer complications, and improved patient outcomes compared to traditional wire cerclage. 1

Primary Fixation Technique

Use rigid titanium plate fixation as the primary closure method in high-risk patients rather than standard wire cerclage. 1, 2 The technique involves:

• Securing rigid plates with bi-cortical screws after the cardiac surgical procedure is complete and hemostasis is achieved 2
• Applying plates longitudinally along the sternum to provide anterior-posterior stability 3
• For maximum stability in morbidly obese or osteoporotic patients, combine rigid plate fixation with wire cerclage to achieve 360-degree stabilization 4

The combined technique addresses the limitation that rigid plate fixation alone lacks posterior stability, which can be problematic in patients with severe osteoporosis or extreme obesity. 4

High-Risk Patient Identification

Apply rigid plate fixation when patients have three or more of the following risk factors: 2

• Chronic obstructive pulmonary disease (COPD)
• Re-operative cardiac surgery
• Renal failure
• Diabetes mellitus
• Chronic steroid use
• Morbid obesity
• Concurrent infection
• Acquired or iatrogenic immunosuppression 2

Intraoperative indications include: 2

• Off-midline sternotomy
• Osteoporotic bone quality
• Prolonged cardiopulmonary bypass runs (>2 hours)
• Transverse sternal fractures 2

Clinical Outcomes Supporting Rigid Fixation

The evidence strongly favors rigid plate fixation over wire cerclage:

• Zero cases of mediastinitis with rigid plate fixation versus 14.8% with wire closure in matched high-risk populations 2
• Significantly reduced deep wound infection rates (0.63% vs. 3.45%) 3
• Lower 30-day mortality (1.57% vs. 5.96%) 3
• Shorter hospital length of stay (median 7 vs. 8 days for postoperative stay; 8.2 vs. 11.7 days overall) 5, 3
• Superior sternal healing at 3 months post-surgery on CT imaging 3
• Significantly lower pain scores and better upper-extremity function 1, 3
• Improved quality-of-life scores with no difference in total 90-day cost 1

Infection Prevention Bundle

Implement a comprehensive care bundle alongside rigid fixation to minimize surgical site infections: 1

• Administer topical intranasal therapies to eradicate staphylococcal colonization preoperatively 1
• Give weight-based cephalosporin infusion within 60 minutes before incision 1
• Redose antibiotics for procedures exceeding 4 hours 1
• Follow strict skin preparation and depilation protocols 1
• Change dressings every 48 hours postoperatively 1
• Remove sterile dressings within 48 hours and implement daily incision washing with chlorhexidine 1

Critical Antibiotic Management

Discontinue prophylactic antibiotics at 48 hours maximum after surgery completion. 1 Prolonged prophylaxis beyond this timeframe does not reduce infection rates and promotes antibiotic resistance. 1 This is a common pitfall—extending antibiotics beyond 48 hours without documented infection provides no benefit and causes harm. 1

Technical Considerations for Internal Mammary Artery Harvest

When harvesting internal mammary artery grafts in high-risk patients, use the skeletonization technique rather than pedicled harvest to reduce the risk of sternal wound complications. 6 This is particularly important in patients who will receive rigid plate fixation, as it preserves sternal blood supply and reduces devascularization. 6

Timing of Rigid Fixation Application

Apply rigid plate fixation as primary closure at the time of initial sternotomy closure in high-risk patients. 2, 3 The benefit is most pronounced when used preventively rather than waiting for complications to develop. 2 Early postoperative complications (≤30 days) are virtually eliminated with primary plating, though late complications (>30 days) may still occur in patients with extreme obesity or severe osteoporosis. 5

Management of Active Infection

Rigid plate fixation can be successfully used even in the setting of active sternal infection or open wounds. 7 A single-center study showed no statistically significant difference in subsequent infection rates between patients plated in clean versus infected settings (14% vs. 16%, respectively). 7 All but one patient achieved a healed and stable sternum regardless of infection status at the time of plating. 7

Common Pitfalls to Avoid

• Do not rely solely on wire cerclage in high-risk patients—the evidence overwhelmingly supports rigid fixation for preventing mediastinitis and improving outcomes 1, 2, 3
• Do not extend antibiotic prophylaxis beyond 48 hours without documented infection—this promotes resistance without benefit 1
• Do not use rigid plates alone in morbidly obese or severely osteoporotic patients—add wire cerclage for 360-degree stability 4
• Do not delay rigid fixation until complications develop—primary prevention is more effective than treatment 2, 5