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Traumatic fracture of nitinol thermoreactive sternal clips

Jack Broadhurst, Narain Moorjani and Sunil Ohri

Interact CardioVasc Thorac Surg 2010;10:465-466; originally published online Dec 9,
DOI: 10.1510/icvts.2009.218867

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Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association
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New Ideas
Interactive CardioVascular and Thoracic Surgery 10 (2010) 465–466

Case report - Cardiac general

Progress Report
Traumatic fracture of nitinol thermoreactive sternal clips

Work in
Jack Broadhurst, Narain Moorjani*, Sunil Ohri
Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, SO16 6YD, UK

Received 11 August 2009; received in revised form 10 November 2009; accepted 17 November 2009


Median sternotomy can be associated with significant morbidity, including non-union, dehiscence and mediastinitis. The use of flexible
thermoreactive sternal clips has been introduced recently as an alternative method of sternal closure and is advocated in patients at
increased risk of sternal breakdown. It is associated with a decreased incidence of sternal complications as well as allowing faster sternal
closure and easy removal on resternotomy. This report describes the case of a fractured thermoreactive clip following trauma, resulting in

sternal dehiscence necessitating sternal rewiring.

䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Thermoreactive sternal clips; Sternal closure

Proposal for Bail-

out Procedure
1. Introduction with chronic stable angina. Cardiac catheterisation dem-
onstrated severe three-vessel coronary artery disease. He
Complications of median sternotomy include non-union,
underwent coronary artery bypass grafting surgery, includ-

dehiscence, mediastinitis, superficial wound infection and

ing the use of the left internal mammary artery. In view of
fistula w1x. Following cardiac surgery, sternal wound com-
his age, comorbidities and markedly osteoporotic sternum
plications occur in ;2–5% of patients w2x. There are mul-
observed intraoperatively, the sternum was closed using
tiple risk factors for these complications including obesity,
nitinol thermoclips. Interrupted stainless steel wires were

diabetes, renal impairment, chronic obstructive pulmonary

initially placed in the manubrium and a single wire placed
disease, steroids, advanced age, osteoporosis, smoking and
harvesting bilateral internal mammary arteries w3, 4x. Rou- inferiorly just above the level of the xiphoid process to
tine closure of median sternotomy in adults usually involves achieve sternal approximation. Electrocautery was then

5–9 interrupted stainless steel wires used to achieve osse- used to create a passage through the 3rd, 4th and 5th
ous apposition of the two hemisternums. The pressure point intercostal spaces immediately adjacent to the sternal
of contact during the closure is determined by the diameter edge, taking care not to injure the remaining right internal
of the wire. If bony apposition is not exact or if there is mammary artery. Backaus forceps were placed into the
excessive movement, such as in patients with lower respi- spaces to determine the size of each clip (ranging between

Best Evidence
ratory tract infections or chronic obstructive pulmonary 20 mm and 40 mm). The clips were placed in ice-cooled

disease, it is possible for the stainless steel wires to water to achieve temperatures -9 8C until they become
‘cheesewire’ through the bone resulting in sternal dehis- malleable. Following mounting on special insertion forceps,
cence w5, 6x. Sternal closure using thermoclips, however, the clips were placed in the intercostal spaces. Once in
distributes the pressure over a wider area as the clips have situ, the clips then warm up to body temperature becoming Nomenclature
a greater diameter at the point of contact w7x. Furthermore, more rigid and conforming to the curve of the intercostal
their thermoreactive properties allow the clips to be slight- spaces. The patient’s initial postoperative recovery was
ly loose at insertion to allow accurate positioning followed uneventful. On the 7th postoperative day, he sustained a
by auto-tightening induced by body temperature, ensuring fall and landed on the metallic edge of his bed, sustaining
good osseous apposition. This report describes the use of direct trauma to the sternum. Clinical examination and

thermoreactive clips in a high-risk patient and a complica- chest radiograph (Fig. 1) confirmed sternal disruption with

tion of its use. fracture of the inferior thermoclip. In view of this, he

underwent reoperation where multiple fractures of the
2. Case report
sternum were observed with all four steel wires cut through
An 83-year-old man with a history of chronic obstructive the sternum. The inferior thermoclip (Fig. 2) was fractured

pulmonary disease and chronic renal impairment, presented with the middle clip dislodged but the superior clip still in

situ. In view of the multiple sternal fractures, the sternum

*Corresponding author. Tel.: q44-(0)2380-794938; fax: q44-(0)2380-
794256. was reunited with steel wires in a figure-of-eight configu-
E-mail address: (N. Moorjani). ration. The patient was discharged two weeks after the
Case Report

䊚 2010 Published by European Association for Cardio-Thoracic Surgery

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466 J. Broadhurst et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 465–466

encircle the sternum, unlike sternal wires, and they possess

a greater degree of flexibility, they allow a 10–15% defor-
mation in shape during vigorous coughing w4x. At body
temperature, the rigidity of the thermoclips means that
when exposed to a high energy impact above a certain
tensile force, the clips may fracture. These forces are,
however, rarely exerted on the sternum and in our experi-
ence when applied, they also result in fracture of the
sternal wires and sternal bone itself. Nitinol also has many
physical advantages over stainless steel, in that it is more
stable, less corrosive and more biocompatible. Further-
more, unlike stainless steel wires, the nitinol thermoreac-
tive clips do not integrate into bone and being non-
ferromagnetic are safe to use in magnetic resonance imag-
ing w7x.
Although these thermoreactive clips can be used in most
situations, they were not used in this patient at the second
operation as the sternum had multiple fractures. In this
situation, there was no rigid foundation for the thermoclips
Fig. 1. Chest radiograph demonstrating the dislodged thermoclip (A) and the
fractured inferior thermoclip (B).
to bind.
In summary, the use of thermoreactive nitinol clips is an
effective technique for sternal closure but this case report
demonstrates that when high impact forces are applied to
the sternum, the thermoclips can fracture. One of the
sternal clips, however, was still able to remain intact even
when all the sternal wires and the sternal bone were
fractured in several places.


w1x Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting:
Fig. 2. Intact superior thermoclip (a) and fractured inferior thermoclip (b). the Society of Thoracic Surgeon National Database experience. Ann
Thorac Surg 1994;57:9–12.
w2x Losanoff JE, Jones JW, Richman BW. Primary closure of median ster-
second procedure with no further complications and notomy: techniques and principles. Cardiovasc Surg 2002;10:102–110.
remains well at six months follow-up. w3x The Parisian Mediastinitis Study Group. Risk factors for deep sternal
wound infection after sternotomy: a prospective multicenter study. J
Thorac Cardiovasc Surg 1996;111:1200–1207.
3. Discussion w4x Negri A, Manfredi J, Terrini A, Rodella G, Bisleri G, El Quarra S,
Muneretto C. Prospective evaluation of a new sternal closure method
Sternal dehiscence following median sternotomy can have with thermoreactive clips. Eur J Cardiothorac Surg 2002;22:571–575.
a major impact on health service resources and patient w5x Casha AR, Yang L, Kay PH, Saleh M, Cooper GJ. A biomechanical study
survival w1, 3x. Nitinol thermoreactive clips have been of median sternotomy closure techniques. Eur J Cardiothorac Surg
shown to reduce the incidence of sternal complications w4, w6x Losanoff JE, Collier AD, Wagner-Mann CC, Richman BW, Huff H, Hsieh
7, 8x. Nitinol sternal clips (Nickel Titanium Naval Ordinance F, Diaz-Arias A, Jones JW. Biomechanical comparison of median ster-
Laboratory, Praesidia, Bologna, Italy) are characterized by notomy closures. Ann Thorac Surg 2004;77:203–209.
shape memory and superelasticity. They become malleable w7x Centofanti P, La Torre M, Barbato L, Verzini A, Patanè F, di Summa M.
at -9 8C and then by thermoelastic martensitic transfor- Sternal closure using semirigid fixation with thermoreactive clips. Ann
Thorac Surg 2002;74:943–945.
mation return to their original shape when warmed to body w8x Reiss N, Schuett U, Kemper M, Bairaktaris A, Koerfer R. New method
temperatures, thereby able to apply compressive forces for sternal closure after vacuum-assisted therapy in deep sternal
on the two hemisternums w7x. As the clips do not fully infections after cardiac surgery. Ann Thorac Surg 2007;83:2246–2247.

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Traumatic fracture of nitinol thermoreactive sternal clips
Jack Broadhurst, Narain Moorjani and Sunil Ohri
Interact CardioVasc Thorac Surg 2010;10:465-466; originally published online Dec 9,
DOI: 10.1510/icvts.2009.218867
This information is current as of April 6, 2010

Updated Information including high-resolution figures, can be found at:

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Coronary disease
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