Sternal reconstruction with titanium plates in complicated sternal dehiscence

Objective: Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. The use of titanium plates is a promising approach for sternal reconstruction. Methods: Titanium plate fixation was used in 15 patients (67 +/- 5.9 years, 171 +/- 8.2 cm, 93.6 +/- 14.9 kg, body mass index 32 +/- 5 kg/m(2)) with unstable thorax after failed attempts of sternal closure and patients in whom failure of conventional rewiring would be expected due to one or more serious risk factors (e.g. multiple fractures or loss of sternum, excessive overweight). In six patients, one of whom had an infection, the Synthes(TM) Titanium Sternal Fixation System was used as transverse plate fixation (series 1). In nine other patients, longitudinal titanium plating of the sternum was performed with 2.4 mm Synthes locking reconstruction plates, which were cross-connected by wires (series 2). In six of these patients the cross-connection was reinforced by additional short transverse plates. In series 2, sternal instability was complicated by multiple fragments of sternum (n = 8) and/or infection (n = 3). In case of infection, initial debridement was performed with consecutive antibiotic and topical negative pressure therapy (median 13 days). Clinical examination was done 3-12 months postoperatively. Results: Mean operation time was 133 +/- 21 min (series 1) and 110 +/- 12 min (series 2). Transverse plating required more extensive mobilization of pectoral muscle. All patients had an uneventful early postoperative course and were extubated 5.1 +/- 5.9 h (median 4 h) after surgery. Postoperatively, all patients had a stable thorax, but in the tong-term three patients from series 1 complained of plate-related pain during breathing, with the subsequent need of plate removal. One multi morbid patient from series 1 died on the 31st postoperative day. The cause of death was not related to the sternal plate refixation. Conclusion: Titanium plate fixation is an effective method to stabilize complicated sternal dehiscence. The longitudinal plating technique is easier to apply and seems to be associated with fewer complications. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.