Indian Journal of Thoracic and Cardiovascular Surgery (July–August 2020) 36(4):388–396

https://doi.org/10.1007/s12055-019-00880-5

ORIGINAL ARTICLE

Sternal reconstruction after post-sternotomy

dehiscence and mediastinitis
Andrea Dell’Amore 1 & Stefano Congiu 1 & Alessio Campisi 1 & Sara Mazzarra 1 & Silvia Zanoni 1 & Domenica Giunta 1

Received: 8 August 2019 / Revised: 19 September 2019 / Accepted: 22 September 2019 / Published online: 2 January 2020
# Indian Association of Cardiovascular-Thoracic Surgeons 2020

Abstract
Purpose Post-sternotomy dehiscence and mediastinitis remains a serious complication in cardiothoracic surgery. The aim of this
work is to report our experience over a period of 8 years in the surgical treatment and risk factor analyses of post-sternotomy
dehiscence and mediastinitis.
Methods All patients treated for post-sternotomy dehiscence at our Thoracic Surgery Unit in the last 8 years were retrospectively
collected. We identified 237 patients with post-sternotomy dehiscence/mediastinitis. Forty-two patients had simple fractures of
the metal steel wires, 61 had an asymmetric sternotomy with multiple sternal fractures, 113 had a symmetric sternotomy with
multiple sternal fractures, 14 had a failed Robicsek procedure, and 7 had sternal dehiscence with mediastinal abscess.
Results Different surgical techniques and materials were used to repair the sternum. In 21 patients, the first revision failed and a
second reoperation was required. At multivariate analyses, we have identified risk factors for revision failure and in-hospital
mortality. Mortality rate was significantly higher in patients who underwent more than one surgical revision (8% vs 19%,
p < 0.001).
Conclusions Patients with sternal dehiscence are very fragile due to multiple preoperative comorbidities as reflected by postop-
erative morbidity and risk factors for in-hospital mortality. A correct evaluation of the characteristics of sternal dehiscence is
important to guide the most appropriate repair strategy. Patients who need repeated sternal revisions had a higher mortality.
Further randomized studies are needed to evaluate different techniques and medical devices to define the gold standard procedure
to reduce significantly sternal wound complications in high-risk patients as defined by well-known risk factors.

Keywords Sternotomy . Sternal dehiscence . Mediastinitis . Sternal reconstruction . Sternal wound complications . Allogenic
bone graft . Titanium bars

Introduction diabetes, osteoporosis, renal failure, peripheral vascular disease,

Median sternotomy is the favorite surgical access in cardiac
surgery [1]. The sternotomy represents a simple and fast surgi-
cal access that guarantees an excellent visibility to the main
mediastinal structures, in particular the heart and the large ves-
sels and both pleural cavities. Unfortunately, the sternotomy is
burdened by a high morbidity dependent on various risk factors
including older age, obesity, chronic obstructive pulmonary
disease, New York Hospital Association class IV status, surgi-
cal priority, low ejection fraction (EF), chronic steroid use,
bilateral mammary artery harvesting, surgical re-exploration,
long extracorporeal time, asymmetrical sternotomy, intra-
aortic balloon pump, extracorporeal membrane oxygenation
support, prolonged ventilation, sepsis, respiratory failure, and
tracheostomy, just to mention the most significant. These fac-
tors could be of technical nature, related to patients or secondary
to various postoperative problems [2, 3]. The importance of this
problem is underlined by a flourishing literature on this field [1,
4]. Nevertheless, there is no technique or material considered
the standard to guarantee a stable closure and a low incidence of
complications after sternotomy.

* Andrea Dell’Amore
dellamore76@libero.it Aim of the study

1
Department of Cardio-Thoracic Surgery, S. Orsola Malpighi The aim of this work is to report our 8 years of experience in the
University Hospital, Via Massarenti 9, Bologna, BO, Italy surgical treatment of post-sternotomy dehiscence and
Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396 389

mediastinitis. Our primary endpoint was to identify risk factors surgery with BIMA was performed in 71 patients (30%), and
for reconstruction failure, and our secondary endpoint was to saphenous vein grafts plus LIMA were performed in 88 patients
standardize the surgical technique in reference to the type of (37%). Sixty-three patients underwent other cardiac procedures
sternal dehiscence. (27%), and 15 patients had general thoracic operations (6.3%).
On-pump surgery was performed in 203 patients (87%); among
these, 49 patients (21%) had an extracorporeal time of more
than 180 min. Twenty-one patients had a postoperative intra-
Methods
aortic balloon pump (IABP) (8.9%), and seven cases had a
postoperative peripheral venoarterial extracorporeal membrane
All patients referred to our Thoracic Surgery Unit from different
oxygenation (ECMO) (3%). Re-sternotomy for bleeding was
cardiothoracic surgery departments with post-sternotomy de-
performed in 44 patients (19%). Sixty-three patients received
hiscence between May 2010 and August 2018 were included
prolonged mechanical ventilation (ventilation time > 48 h), and
in the study. The data were collected retrospectively from an
9 (3.4%) underwent cardiac resuscitation with external cardiac
institutional data set.
compression. Twenty-six patients (11%) were re-intubated in
During an 8-year time frame, we collected 237 cases (158
the postoperative period, and 13 had tracheostomy (5.6%). The
males and 79 females). The mean age was 73 years ± 27.3 years
intensive care unit (ICU) stay was prolonged for more than 72 h
(range 39–89), and the preoperative risk factor profile is sum-
in 105 patients (44%). Pulmonary complications, such as pneu-
marized in (Table 1). More than one risk factor were reported in
monia and atelectasis, were reported in 31 patients (13%), and
209 patients (88%). The majority of the patients underwent
renal failure with necessity of hemodialysis was reported in 9
sternotomy as surgical access for cardiac surgery procedure.
patients (4%). Two patients survived to a septic shock (1%),
Coronary artery bypass grafting (CABG) with the left internal
and 1 patient had endocarditis (0.4%).
mammary artery (LIMA) plus saphenous vein grafts (SVGs)
Fourteen patients underwent a Robicsek sternal closure [5]
was performed in 88 patients (37%), CABG with the bilateral
at the time of the first operation because they were judged to
internal mammary artery (BIMA) grafting in 71 patients (30%),
be at a high risk of sternal dehiscence (6%). All these patients
and valvular surgery in 63 patients (27%). Other procedures,
underwent CABG (6 cases with LIMA+SVG and BIMA in 8
such as anterior mediastinal mass removal and pericardial pa-
cases). Five were obese (body mass index (BMI) > 30 kg/m2),
thology, were performed in 15 patients (6.3%). Extracorporeal
11 were diabetic, 4 had severe chronic obstructive pulmonary
circulation was used in 203 patients (87%). The intraoperative
disease (COPD), and three were severely osteoporotic. Two
and postoperative variables and complications after the first
patients received an asymmetrical sternotomy. All of these
operation are summarized in (Table 2). Coronary artery bypass
patients had more than one risk factor.
Table 1 Preoperative risk factor profile The mean interval time between sternotomy and the clinical
assessment of dehiscence was 11.7 days ± 7.9 days (range 3–
Variables Number (%), total no. of patients = 237 49).
The skin was intact at the time of dehiscence diagnosis in 67
Current smokers 127 (53)
patients (28%), and the remaining patients had at least one small
Diabetes 101 (43)
cutaneous fistula.
Hypertension 198 (84)
The cultures from the wound were positive in 183 patients
Hypercholesterolemia 139 (59)
(77%). The pathogens were gram positive in 61% of the cases,
Peripheral vascular disease 77 (31)
gram negative in 22%, anaerobic in 14%, and fungal in 3% of
Obesity (BMI > 30 kg/m2) 46 (19)
the patients. Forty-seven percent of the positive patients had
Low BMI < 16 kg/m2 22 (9)
more than one pathogen.
Chronic renal failure 51 (22)
We classified the sternal dehiscence as simple fractures of the
NYHA class ≥ III 22 (9)
metal steel wires (42 patients; 18%), an asymmetric sternotomy
EF < 35 39 (17)
with multiple sternal fractures (61 patients; 26%), a symmetric
Treated for COPD 48 (20) sternotomy with multiple sternal fractures (113 patients; 48%),
Osteoporosis 8 (3.4) failed Robicsek procedure (14 patients; 6%), and sternal dehis-
Older age (> 80 years old) 87 (37) cence with mediastinal abscess (7 patients; 3%).
Preoperative IABP 11 (5)
Immunosuppressed state 5 (2) Statistical analysis
Urgent operative status 48 (20)

BMI body mass index, NHYA New York Heart Association, EF ejection
The statistical analysis was performed with SPSS, version 21
fraction, COPD chronic obstructive pulmonary disease, IABP intra-aortic (IBM-SPSS Inc., Armonk, NY, USA). All data were collected
balloon pump retrospectively from hospital data record.
390 Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396

Table 2 Intraoperative and

postoperative variables and Variables Number (%), total no. of patients = 237
complications at the time of the
first sternotomy Intraoperative data
CABG (SVG+LIMA) 88 (37)
CABG (BIMA) 71 (30)
Other cardiac surgery 63 (27)
Other non-cardiac surgery 15 (6.3)
On-pump surgery 203 (87)
ECC time > 180 min 49 (21)
Robicsek closure 14 (6)
Postoperative variables
Postoperative IABP 21 (8.9)
Postoperative ECMO 7 (3)
Surgical re-exploration 44 (19)
Prolonged mechanical ventilation (> 48 h) 63 (27)
Cardiac arrest with external massage 9 (3.4)
AMI 16 (7)
Re-intubation 26 (11)
Tracheotomy 13 (5.5)
Acute renal failure with hemodialysis 9 (4)
Pulmonary complications 31 (13)
Supraventricular arrhythmia 98 (41)
Bowel ischemia 1 (0.4)
Major stroke 3 (1.3)
TIA 14 (6)
Pulmonary embolism 7 (3)
Septic shock 2 (1)
Endocarditis 1 (0.4)

CABG coronary artery bypass graft, SVG saphenous vein graft, LIMA left internal mammary artery, BIMA
bilateral internal mammary artery, ECC extracorporeal circulation, IABP intra-aortic balloon pump, ECMO
extracorporeal membrane oxygenator, AMI acute myocardial infarction, TIA transient ischemic attack

Data were reported as a mean ± standard deviation (SD)
and range or with number and percentage.
Continuous variables were compared using unpaired
Student’s t test, and categorical variables were compared using
the chi-square test. A multivariate logistic regression model
was performed to identify independent risk factors for in-
hospital mortality and sternal revision failure. Variables that
showed a p value < 0.1 at univariate analysis were entered in
the regression models. Results were reported as odds ratios
(ORs) with 95% confidence interval and corresponding p val-
ue. A p value ≤ 0.05 was considered statistically significant.
Results
We used a vacuum-assisted closure (VAC) therapy in 207
patients (87%) before the sternal resynthesis attempt. The
mean time of VAC therapy was 16.3 days ± 12.4 days (range
7–32). The medical therapy with antibiotics was guided by
antibiogram in patients with positive wound cultures or a large
spectrum therapy in patients with negative cultures, and 171
patients received a combination of at least two different mol-
ecules (72%). The mean preoperative duration of medical
therapy was 19.6 days ± 15.9 days (range 3–41). The mean
duration of postoperative medical therapy was 23 days ±
9.5 days (range 14–49).
Sternal resynthesis techniques
Simple sternal rewiring with stainless steel was performed in
12 patients (5%), a hemi-Robicsek procedure [6] was per-
formed in 76 patients (32%), and a standard Robicsek proce-
dure [5] was performed in 85 patients (36%) (Fig. 1a).
Titanium plates/bars and screws (Titanium Sternal Fixation
System; DePuy Synthes, West Chester, PA, USA) [7] were
used in 47 patients (20%). In most of the cases, the titanium
bars were fixed to the patient’s ribs bilaterally using titanium
screws. We applied at least three screws to both ends of each
plate, taking care to avoid the cartilaginous part of the ribs.
When the sternal bone is still well represented, especially in
Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396
Fig. 1 Different surgical techniques and materials for sternal
reconstruction. a CT scan showing the standard Robicsek technique. b
Chest X-ray showing the titanium H-shaped plate, bars, and screws for
sternal stabilization. c Sternal fixation with plastic bands. d Sternal
the manubrium, an H-shaped titanium plate was used
(Fig. 1b). Nitinol thermoclips (Nitinol clips; Praesidia,
Bologna, Italy) [8] were used in 6 patients (2.5%).
Electrocautery was used to create a tunnel through the inter-
costal spaces to set the clips, paying attention to avoid the
portion of fractured sternum. When the two parts of the ster-
num are put together using Backhaus forceps, the distance
between intercostal spaces was measured and the clip size
was chosen (clip size range, 2.25 cm to 4 cm). The clips were
then cooled with ice and set on a special forceps. Cooling
(5 °C) makes the clips very malleable and easy to fit into the
intercostal space. When the clips were correctly in place,
warm water was applied to give rigidity to them. We used at
least 4 clips per patient, generally on the second, third, fifth,
and seventh intercostal spaces. Plastic sternal bands (ZipFix;
DePuy Synthes, West Chester, PA, USA) [9] were used in 11
patients (4.6%). Even in this case, using the electrocautery,
tunnels through the intercostal spaces were created, paying
attention to avoid the area of the fractured sternum. Then,
the plastic bands were passed through the parasternal holes
facilitated by the blunt-tipped needle mounted at their ends.
When all the bands were in place, they were finger tightened
391
allograft transplantation, in which the bone graft is fixed with titanium
bars and screws to the ribs. e Tibia bone allograft as sternal substitute
fixed with titanium bars and screws to the ribs. f Sternal reconstruction
with titanium mesh fixed with titanium bars and screws to the ribs
initially, and then using a dedicated instrument, they were tied
until the complete re-approximation of the sternal edges was
achieved (Fig. 1c). In all cases, the reconstruction was covered
with a pectoralis major muscle flap. The major pectoralis mus-
cles were carefully isolated, and the muscle fibers were cut
along the sternal attachments. The major pectoralis muscle
was separated from the minor pectoralis muscle and the infe-
rior costal arches, taking care to avoid damage of the
thoracoacromial artery branch. The pedicle should be in view
while transecting the lateral muscle attachments. After com-
plete mobilization of the muscle bilaterally and a careful he-
mostasis, the pectoralis major muscles were rotated medially
to cover the bone allograft implantation and the manubrium.
The pectoralis muscles were sutured using heavy absorbable
interrupted stitches. The right and left chest cavities were
drained, and then subcutaneous and cutaneous layers were
sutured.
The overall in-hospital mortality was 9.7% (23/237 pa-
tients). The causes of death were cardiac complications in 8
patients; sepsis in 5; respiratory failure in 3; pulmonary em-
bolism, major stroke, and multi-organ failure in 2 patients
each; and bowel ischemia in 1 patient.
392 Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396

The mean ICU stay was 13.6 days ± 18.7 days (range 1–76, replacement plus coronary artery bypass (LIMA on the left
interquartile range (IQR) 7.7–19.8), and the mean ventilation anterior descending artery, SVG on the right coronary artery),
time was 31.2 h ± 42.7 h (range 4–312, IQR: 27.3–53.4). Four BIMA coronary artery bypass revascularization, and triple-
patients received tracheostomy (2%). The mean hospital stay vessel CABG with LIMA and SVGs as the primary proce-
was 35.8 days ± 22.3 days (range 6–108, IQR 13.9–41.7). The dure. The in-hospital mortality of patients who underwent a
overall morbidity was 75% (177 patients). The first sternal single sternal revision (216/237 patients) was 8% (18/216 pa-
resynthesis failed in 21 patients (9%). A hemi-Robicsek pro- tients) versus 19% (4/21 patients) of patients who underwent
cedure was used in 8 of these patients (38%), simple rewiring two surgical revisions (21/237 patients) (p < 0.001). No pa-
in 7 patients (33%), a standard Robicsek procedure in 3 pa- tient required a third revision.
tients (14%), Nitinol thermoclips in 2 patients (10%), and At the multivariate logistic risk factor analysis for failure of
titanium bars and screws in 1 patient (5%). the first revision, factors identified were re-exploration at the
The mean interval time between the first sternal revision time of the first surgery (OR 7.3), asymmetrical sternotomy
and the second dehiscence was 6.3 days ± 4.2 days (range 1– with multiple sternal fractures (OR 6.9), prolonged mechani-
16). cal ventilation (OR 3.8), BMI > 30 kg/m2 (OR 2.7), COPD
In 13 patients, the wound cultures were still positive, and 8 (OR 2.4), diabetes (OR 1.8), and mediastinal abscess (OR 1.5)
cases had the same microbial contamination. VAC therapy (Table 3).
was reapplied in 9 patients for a mean time of 5.1 days ± 3 days At the multivariate logistic risk factor analysis for in-
(range 2–9). All of these patients were re-operated after a hospital mortality, significant factors were second revision
mean time of 8.3 days ± 4.4 days (range 2–17). (OR 10.5), re-exploration at the time of first operation (OR
Fourteen patients underwent sternal reconstruction with ti- 5.0), older age (OR 3.4), left ventricular EF < 35% (OR 3.0),
tanium plates and screws. Three patients underwent sternal cardiac arrest in ICU (OR 3.3), and mediastinal abscess (OR
replacement with a bone allograft (two sternal allografts and 2.8) (Table 4).
one tibial segment) fixed to the chest cage with titanium bars
and screws as previously described [10] (Fig. 1d, e). Three
patients underwent a standard Robicsek closure. One patient
underwent sternal replacement with titanium mesh fixed with Discussion
steel wires and titanium bars and screws (MDF Medica S.r.l.,
Italy) (Fig. 1f). Pectoralis major muscle flap coverage was Sternal wound complications occur in 1% to 10% of patients
used when possible. Latissimus dorsi muscle flap was used undergoing sternotomy [2]. Moreover, true mediastinitis with
in two patients. The latissimus dorsi muscle flap was prepared substernal abscess is a life-threatening condition with a high
by placing the patient in lateral decubitus position before ster- in-hospital mortality rate of up to 47% [3]. Sternotomy com-
nal repair. After a lateral skin incision at the level of the 7th plications remain a significant source of morbidity, the hospi-
intercostal space, the anterior border of the muscle is incised talization greatly prolongs, and long-term antibiotics and mul-
first, then the lateral border of the latissimus dorsi is retracted tiple operative procedures are required; thus, the cost of hos-
and the thoracodorsal neurovascular bundle is visualized and pitalization increases exponentially [11].
carefully preserved. The tendon of the muscle is divided. The During the years, many efforts have been made to identify
muscle was tailored to fit with the wound to be filled. The flap risk factors for sternal dehiscence or infection and to under-
was temporally placed in the axillary cavities, and by placing stand which closure technique is better to prevent these com-
the patient in the supine decubitus, the muscle flap was rotated plications [1, 3, 11]. Several preoperative, intraoperative, and
to cover the reconstructed sternum. Omental transposition into
Table 3 Multivariate logistic regression analysis for failure of the first
the anterior mediastinum was used in two patients with signs sternal revision
of mediastinitis (two patients who had mediastinitis at the time
of the first revision and failure of the first attempt). After upper Variable Odds ratio 95% CI p value
laparotomy, the omentum was separated from the transverse
Surgical re-exploration 7.3 4.4–17.3 < 0.001
colon and the greater curvature of the stomach by ligating the
Asymmetrical sternotomy with MSF 6.9 4.0–13.2 < 0.001
gastroepiploic vessels. The right gastroepiploic vascular ped-
Prolonged mechanical ventilation 3.8 2.7–5.6 < 0.001
icle is identified and dissected, mobilizing the omentum, and it
BMI > 30 kg/m2 2.7 1.7–4.6 < 0.001
is rotated into the anterior mediastinum before repair of the
Treatment for COPD 2.4 1.8–3.4 < 0.001
sternum.
Diabetes 1.8 1.1–3.2 0.02
Four of these patients died in the postoperative period
Mediastinal abscess 1.5 1.0–2.3 0.04
(three of cardiac failure and one of a major stroke) (postoper-
ative mortality 4/21; 19%). They had undergone the Bentall MSF multiple sternal fractures, BMI body mass index, COPD chronic
procedure for type A aortic dissection, aortic and mitral obstructive pulmonary disease
Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396
Table 4 Multivariate logistic analysis risk factors for in-hospital
mortality
Variable Odds ratio 95% CI p value
Second revision 10.5 7.1–22.3 < 0.001
Surgical re-exploration 5.0 3.9–7.3 < 0.001
Older age (> 80 years old) 3.4 2.3–5.0 < 0.001
EF < 35% 3.4 2.7–5.2 < 0.001
Cardiac arrest in ICU 3.3 2.3–4.4 < 0.001
Mediastinal abscess 2.8 2.0–3.7 < 0.001
EF ejection fraction, ICU intensive care unit
postoperative risk factors for sternal complications are well
known and supported by a large amount of previous studies
[2]. Our selected population of patients presented many of
these risk factors (Tables 1 and 2); moreover, 88% of the
patients had a combination of more than one of them. Some
of these factors are not corrigible, so the best way to avoid
sternal problems is to prevent them with a meticulous surgical
technique during sternal opening and closure [3, 11]. Till date,
we are still waiting for a demonstrated gold standard tech-
nique for sternal closure. Wire cerclage using stainless steel
has been the most widely used technique for sternal approxi-
mation since 1957 because it is a simple, very fast, not expen-
sive technique, usually with short healing time and reproduc-
ible to anywhere and by anyone [4]. We still use simple steel
wire cerclage after sternal dehiscence mainly due to previous
steel wire breakage. This complication is, generally, a techni-
cal problem of excessive twisting and tightness of steel wire at
the time of closure. Typically, this dehiscence occurs early in
the postoperative period, and generally, the sternal bone is not
compromised nor the skin and subcutaneous tissues. In our
experience, 18% of the sternal dehiscence was due to simple
steel wire fractures. In the 84% of these patients, the skin was
intact and the wound sterile. The first appearance of this kind
of dehiscence is between the 4th and 6th postoperative days
and is confirmed by chest X-ray in which it is simple to iden-
tify the broken steel wires. Generally, it is not a complete
dehiscence, but the patient complains of thoracic pain due to
movement and friction of the sternal edges, and this may be
responsible for superficial breathing with a risk of pulmonary
infection and atelectasis. If the diastasis is not treated prompt-
ly, it could worsen with subsequent complete dehiscence and
infection of the wound. In such a case, simple application of
new steel wire cerclage is an accepted technique. Different
alternative techniques of sternal closure using steel wires or
polyester heavy sutures are reported in the literature [1, 4–6,
12]. The number of wires that should be used and how to
distribute them along the sternum have been discussed in the
literature [4, 13–15]. Biomechanic studies have tried to clarify
these aspects to guide surgeons to use a technique that is as
effective as possible [15]. Unfortunately, when the sternal
393
bone is very friable or presents fractures of its sternal edge
or when the sternotomy has been performed asymmetrically,
the simple steel wire cerclage is not applicable. Robicsek was
first studied and introduced in the clinical practice as an effec-
tive method to prevent or treat sternal dehiscence in these
situations. This technique is still extensively used as a first
choice all over the world in many surgical departments. It
consists of creating bilateral and longitudinal parasternal run-
ning steel wires, with alternating sutures passed anteriorly and
posteriorly to the costal cartilages for the whole length of the
sternum [5]. We find this technique very useful, and we ap-
plied it extensively in patients with sternal fractures or pro-
phylactically in high-risk patients who underwent cardiac sur-
gery. Obesity (BMI > 30 kg/m2), diabetes, chronic obstructive
pulmonary disease, BIMA grafting, and steroid use were for
us the main indications for prophylactic Robicsek closure. In
our experience, we performed 85 Robicsek procedures with
only three failures. The main disadvantage of this technique is
that it produces a constrictive weave which impairs the collat-
eral blood supply of the sternum; thus, a preexisting ischemia
can get worse, resulting in bone necrosis and further sternal
fragmentation [16]. Indeed, in our experience, the most chal-
lenging case to treat is the sternal dehiscence after Robicsek
procedure, because the sternal bone frequently is unusable and
the infection rate of the surrounding tissue is very high. In this
case, it is necessary to completely remove the necrotic infected
sternal bone fragments and the steel wires. At the end of this
debridement, no more sternum remains and complex repair
techniques are mandatory. In our experience, we used, with
good results, the implantation of allograft bone segments fixed
to the ribs with titanium bars and screws [16, 17].
Alternatively, a titanium mesh supported by titanium bars
and screws fixed to the ribs could be used [16]. Kalab et al.
[18] reported their experience using allogenic bone graft for
massive post-sternotomy defects with optimal early and long-
term results. Similar results were reported as small series or
case reports by other groups [18–20]. In our experience, the
main indication for bone allograft implantation is a massive
fragmentation of the sternal edges, when there is no more
sternal bone available for stabilization, generally after a pre-
vious Robicsek closure, with an active infected surgical site
[16–18]. Indeed, the sternal allograft is very resistant to infec-
tion and it has the possibility to be integrated in the host
skeleton. Kalab et al. [18] performed scintigraphy examina-
tion during follow-up in 5 patients who underwent sternal
allograft transplant, documenting high healing activity of the
grafts and particularly of the crushed spongy bone.
In less complicated cases when the sternal bone is fractured
but sufficiently represented to avoid excessive ischemic com-
promise, a modified Robicsek technique could be useful.
Sharma et al. [6] reported in 2004 a significantly lower inci-
dence of sternal wound complications in patients treated with
the modified Robicsek technique.
394
In our experience, the hemi-Robicsek procedure is a much
used procedure, but with high failure rate, in particular when
the sternal edges are fragmented and asymmetric, and in light
of our experience in these patients, this technique should be
avoided.
Different materials have been introduced over the years for
chest wall reconstruction. Titanium is one of the more prom-
ising, because it is highly biocompatible with low density,
resistant to corrosion, ductile, diamagnetic, and compatible
with magnetic resonance imaging [21].
Titanium is as resistant as steel but 40% lighter; it weighs
60% more than aluminum but with double strength.
Moreover, it is an inert material resistant to microbial
colonization.
Allen et al. [22] published a randomized trial comparing
wire cerclage with titanium plate sternal closure. The authors
demonstrated that titanium closure resulted in significantly
better sternal healing and lower complication rates, even after
6 months from surgery. Other randomized studies comparing
titanium plate/bars with steel wire closure have been pub-
lished in the literature with similar results [13, 23]. We used
titanium bars, plates, and screws extensively in sternal dehis-
cence with fractured sternum, with excellent outcomes in the
last 5 years. We reported only one failure in a patient with a
failed Robicsek procedure.
Recently, satisfactory results using other materials such as
plastic bands or Nitinol thermoreactive clips have been report-
ed in the literature [8, 9]. We have a limited experience in
these, and we implanted plastic bands in 11 patients and
Nitinol clips in 6 patients. Plastic bands are simple to use
and guarantee a very safe closure even after a failed
Robicsek procedure in our experience. We reported no failures
using plastic bands. Instead, our experience with thermoclips
is inconsistent. We had two failures on seven patients, due to
further fractures of the sternal edges at the level of clip im-
plantation. Probably, for these devices, a good quality of the
sternal edge is important to guarantee optimal results.
Obviously, the experience is limited and it is impossible to
gain conclusions.
The sternal wound should always be considered contami-
nated when the skin is open or in the presence of fistulae.
Indeed, in the majority of the patients with sternal dehiscence,
the cultures from the wound are positive for microbial con-
tamination and, generally, with more than one pathogen [24].
Before surgical revision, the application of VAC therapy
has become a standard procedure in many centers [25]. We
routinely used VAC therapy in our patients. Only in early
dehiscence with intact skin and without signs of mediastinitis
on computed tomography we go straight for surgical revision.
VAC therapy is very effective to reduce microbial contamina-
tion, remove excessive fluids, decrease wound edema, im-
prove the vascularization of the surrounding tissues, improve
wound healing and granulation tissue formation, reduce pain,
Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396
and improve respiratory dynamics, stabilizing the sternum and
avoiding paradoxical movement of the chest wall before ster-
nal fixation [25]. The sponge should be changed every 48 h
and sent for microbial cultures. Ideally, the best time to operate
the patient is after three consecutive negative sponge cultures.
Those results are difficult to achieve even with maximal anti-
biotic therapy. In our experience, only 67% of the patients
were re-operated with a complete negative sponge culture.
In colonized patients, we perform a more extensive debride-
ment of all necrotic or poorly vascularized tissues and we try
to use inert or biological materials such as titanium or bone
allograft. We always cover the reconstruction with a muscular
flap, and the first choice is the pectoralis major muscle when
usable. Omental transposition into the anterior mediastinum
has become our first choice in case of evident mediastinitis
[26]. We reported two failures after reconstruction for sternal
dehiscence with mediastinitis due to recurrence of the medi-
astinal abscess. Probably, in these cases, if we had used omen-
tal transposition at the time of the first revision, the final result
may have been better.
In our analysis, we identified several risk factors for repair
failure, in particular surgical re-exploration, asymmetrical
sternotomy with multiple sternal fractures, prolonged mechan-
ical ventilation, BMI > 30 kg/m2, diabetes, COPD, and true
mediastinitis with mediastinal abscess. All of these are well-
known risk factors for sternal dehiscence after cardiac surgery.
We underscore that these factors should be considered care-
fully at the time of the first revision, because the failure rate in
these patients could be very high. All the efforts should be
spent on using the most effective preoperative care, surgical
technique/materials, and postoperative care to avoid failure of
the sternal reconstruction. Indeed, the failure of sternal recon-
struction and the recurrence of the mediastinal infection are
responsible for worse outcomes with higher in-hospital mor-
tality. Gummert et al. [27] in a large series showed that the
mortality rate increases exponentially with the number of sur-
gical re-exploration from 9% after one revision to 41% after
more than two revisions. In our experience, in-hospital mor-
tality of patients who underwent a single sternal revision was
8% versus 19% of patients who underwent two surgical revi-
sions (p < 0.001) and that second revision is a risk factor for
in-hospital mortality (OR 5.0). As shown by the preoperative
characteristics and risk factors of patients with sternal dehis-
cence, the repeated surgical trauma, the needs of long-term use
of antibiotics with their related side effects, and the respiratory
impairment secondary to prolonged lodging and chest wall
instability are poorly tolerated events in such fragile patients.
Other risk factors for in-hospital mortality are surgical re-ex-
ploration, low left ventricle ejection fraction (LVEF), a car-
diac arrest in the ICU, the older age, and true mediastinitis.
Some of these factors are difficult to control such as age and
low LVEF. Others, on the contrary, could be prevented with
careful hemostasis during the first operation, with awareness
Indian J Thorac Cardiovasc Surg (July–August 2020) 36(4):388–396
of asepsis in the theater and ICU, and by using a meticulous
surgical technique even during sternotomy and sternal closure
[11].
Limitation of the study
The retrospective design and the absence of a control group
are the main limitations of this study. Moreover, this is a much
selected population of patients with sternal complications al-
ready present when they were referred to our department. This
makes it impossible to evaluate possible preventive strategies
at the time of the first intervention. Therefore, we cannot an-
alyze the incidence of sternal complications based on the over-
all surgical activities performed over the years, because we
lack activity data from other centers and, for the same reasons,
we lack follow-up data because the patients were entrusted to
the referral center after our discharge and it reflects our selec-
tion bias.
Conclusion
The patients with sternal dehiscence are very fragile due to
multiple preoperative comorbidities as reflected by postoper-
ative morbidity and risk factors for in-hospital mortality. The
preoperative, intraoperative, and postoperative risk factors for
sternal dehiscence and mediastinitis are well known in the
literature and further confirmed in our experience. A correct
evaluation of the characteristics of sternal dehiscence is very
important to guide the most appropriate repair strategy.
Different techniques and materials have been introduced over
the years; thus, a cardiothoracic surgeon should be familiar
with most of them to handle different scenarios. Patients
who need repeated sternal revision have a very high mortality,
so all the efforts should be spent on achieving a stable and
effective reconstruction at the first time. With all the knowl-
edge of the risk factors for sternal dehiscence and the possible
technical mistakes that increase the risk for sternal dehiscence
and infection, attention to details may be the gold standard to
avoid sternal wound complications.
Authors’ contribution Conception and design: ADA and DG
Administrative support: SZ and SM
Provision of study materials: SC and AC
Collection and assembly of data: SM, SC, and SZ
Data analysis and interpretation: ADA and DG
Manuscript writing: all Authors
Final approval of the manuscript: all authors
Funding We declare no external financial support.
Compliance with ethical standards This retrospective mul-
ticenter study was approved by the Institutional Review Board of S.
395
Orsola Malpighi University Hospital in Bologna, and the study has been
performed in accordance with the ethical standards as laid down in the
1964 Declaration of Helsinki and its later amendments or comparable
ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Conflict of interest The authors declare that they have no conflict of
interest.
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