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Eur J Cardiothorac Surg 1999;15:365-369
© 1999 Elsevier Science NL

A biomechanical study of median sternotomy closure techniques1

A.R. Cashaa, L. Yangb, P.H. Kaya, M. Salehb, G.J. Cooperc

a Department of Cardiothoracic Surgery, Leeds General Infirmary, Leeds LS1 3EX, UK
b Department of Biomechanics, Clinical Sciences Building, Northern General Hospital, Sheffield S5 7AU, UK
c Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield S5 7AU, UK

Received 20 September 1998; received in revised form 30 November 1998; accepted 22 December 1998.

Corresponding author. Tel.: +44-1482-875-875; fax: +44-1482-623-257.


   Abstract
Top
 Abstract
Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
Objective: Sternal dehiscence is a complication of median sternotomy incisions with high mortality and morbidity. Different techniques of sternal closure have been described. Rigid fixation of the sternum results in earlier union. We measured the rigidity of sternotomy fixation using a mechanical model in order to differentiate different techniques of sternal closure using their biomechanical characteristics. Methods: We measured the force-displacement curves of six different fixation techniques using a metal sternal model using a computerized materials-testing machine. We tested straight wires (the most commonly used surgical technique), figure-of-8 wires, `repair' technique (used when a wire breaks), Ethibond, Sterna-band and a `multitwist' closure described for the first time. Results: At 20 kg force, twisted wires used for sternotomy closures start to untwist. The most rigid closure was a multitwist closure that displaced only 0.37 mm at a force of 20 kg. Straight wires displaced 0.78 mm, figure-of-8 wires 1.20 mm, Sterna-band 1.37 mm, repair wires 5.08 mm, Ethibond 9.37 mm. The single factor Anova test for the rigidity of the different closures had P-values <0.0001. Conclusions: We applied a mathematical model to calculate chest wall forces during coughing, in order to determine the force placed upon a sternotomy closure. We conclude that severe coughing may cause wires to untwist. We discuss potential applications of different wire closures based on their characteristics.

Key Words: Sternotomy • Wires • Biomechanics


   Introduction
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
Median sternotomy has been used extensively by cardiothoracic surgeons since 1957 for access to the heart, because it provides an excellent mediastinal exposure [1] [2], is relatively pain free and heals well.

Although sternal separation or dehiscence is a rare complication of median sternotomy (0.5–2.5%) [3], it carries a mortality rate of between 10 and 40% [4]. Sternal instability, wound infection, osteomyelitis and dehiscence [5] are related. The most important factor in preventing sternal dehiscence and mediastinitis is a stable sternal approximation [6]. Dehiscence often occurs within the first two weeks postoperatively [7], before bone healing is significant.

Over 40 different techniques have been described for sternal closure, claiming to reduce wound infection rates and even mortality [5]. However, most reports of sternotomy closure are either anecdotal or based on small series. All techniques claim to maximize sternal stability, however it is difficult to differentiate between the merits of various techniques scientifically.

Application of bioengineering techniques allows analysis of the properties of bone fixation devices in a scientific manner. The aim of our study was to assess and quantify the rigidity of sternotomy fixation using a mechanical model, since it has been shown that fixation techniques which ensure a secure, rigid fixation of the sternum result in earlier union with primary osseous healing (osteosynthesis) [8].


   Material and methods
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
We investigated six different fixation techniques ( Fig. 1 ), using Ethicon no. 5 stainless steel wire (Ethicon, UK), Ethibond no. 5 suture (Ethicon, UK) and Sternaband (Stony Brook Surgical Innovations, Stony Brook, NY). A steel jig was used as the sternal model. All the holes in the steel jig were radiused and polished in order to decrease any stresses on the wires. All wiring was pretensioned to 10 Newton by a computer-controlled materials-testing machine (Autograph ASG-10KN, Shimadzu, Japan), calibrated and certified to the industry standard NAMAS. The two halves of the jig were separated at velocity of 2 mm per min and force and displacement data were recorded every quarter-second using a data capture card (Amplicon PC 20G, Amplicon, UK).



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  		Fig. 1. (a–f) Diagrams of the different closure techniques tested.

 
Force-displacement curves were produced for each type of closure ( Fig. 2 ). When a force is applied to a wire, it undergoes deformation and stretches in a reversible manner, as illustrated in Fig. 3 . This is called the elastic phase. As a force on a twisted wire continues to be progressively increased, it reaches a point where untwisting occurs. This untwisting is irreversible, although the wire is still in the elastic phase. For stainless steel wire no. 5 untwisting occurred at 20–22 kg. We therefore measured the displacement of the wire at 20 kg as the point at which the closure starts to deform. The less the displacement of the wire, the more rigid the closure. As the wire is loaded further, it untwists and stretches until the wire reaches the yield point at which stage the wire becomes plastic and irreversibly stretched. For practical purposes, the yield point is identical to the maximum load recorded on the force-displacement curve since the tension in the wire drops prior to reaching the point of rupture.



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  		Fig. 2. (a–f) Typical force displacement curves for each type of closure.

 


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  		Fig. 3. Typical stress-strain curve [2].

 
The type of wire closures we tested included figure-of-8, `straight', Ethibond, `repair', Sternaband and `Multitwist'. The `Multitwist' closure starts with two `straight' wires, whose adjacent ends on each side of the sternum are tensioned and twisted together, and the two resultant double-strands are twisted together. We used two `straight', two Ethibond and two `repair' closures in our comparative tests versus one figure-of-8, one Sternaband and one `Multitwist'. The reason for this is that in essence, figure-of-8 and `Multitwist' closures have two strands of wire across the sternum as opposed to one with `straight'.


   Statistical analysis
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
Single factor analysis of variance and paired t-tests with a hypothesized difference of zero were used to determine if significant statistical differences existed between groups (Table 1). A P-value of less than 0.05 was used to indicate if a significant difference occurred between measurements. The paired t-test analyses are shown in Table 2.


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  		Table 1. Physical characteristics of different closure techniques

 

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  		Table 2. The results of the paired t-test analyses

 

   Results
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
The values obtained are shown in Table 1. All results were highly reproducible indicating that the physical properties of each group of wires tested (tensile strength, diameter, material composition and fixation technique) were for all intents identical. Ten experiments were performed for each closure technique. From the force-displacement curves we calculated the rigidity (defined as the displacement with a load of 20 kg – the `untwisting point') and the strength (defined as the maximum force reached before failure of the closure occurs). Measurements are reported as mean±the standard deviation of the mean. Failure occurred at the base of the twisted wire portion or at the base of the Ethibond knot or adjacent to the Sternaband `buckle'.

The single factor Anova tests for both rigidity and strength had P-values <0.0001. The paired t-tests showed significant statistical differences (P<0.0001) between all fixation methods tested in the rigidity group apart from the figure-of-8 versus Sternaband (P=0.33). The paired t-tests also showed significant statistical differences (P<0.0001) between all fixation methods tested in the strength group apart from the figure-of-8 versus straight (P=0.06). The most rigid closure (multitwist) shows highly significant (P=0.003) differences as compared with the rigidity of other closures.


   Comment
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 
We applied a mathematical model to calculate chest wall forces during coughing in order to determine the force placed upon a sternotomy closure. We assumed that the chest was a cylinder and that the forces acting during coughing along the circular portion of the cylinder would be radially directed. The force across a sternotomy closure can be calculated [9] as:

where T is the resultant force required to keep the sternum closed, r is the radius, l is the length of the cylinder, P is the distending pressure (difference between internal and external pressures).

The radius of a chest is approximately 15 cm. At functional residual capacity (FRC) the thoracic cavity from the apices to the dome of the diaphragm is approximately 25 cm high. Before an individual coughs he inhales 1.5 litres, and the height of the thoracic cavity increases. The intrapleural/intraalveolar pressures can reach 300 mmHg (40 kPa) during coughing [10]. The compressive phase of coughing lasts about 200 ms. However, pressures may rise again during a cough if the glottis closes again in a staccato cough. Substituting these values into the equation:

This figure is more likely to be reached in subjects with a large chest cage and a strong cough. If six wires had been inserted into the sternum, as is common practice, then there would be a force of about 25 kg across each individual wire. Since a perpendicular wire untwists at about 22.5 kg [11], then it would be theoretically possible that failure of the closure could occur during a bout of coughing as is documented in the literature [6] [12]. Any closure that has most resistance to displacement at any given force, i.e. that is the most rigid, is the safest closure under these conditions. The magnitude of the forces involved show that it is rigidity rather than maximum strength that is the important differentiating feature.

Although the material used in four of the different closures was identical stainless steel no. 5, the force-displacement curves obtained were different. The greatest similarity was between figure-of-8 and straight wire closures. The rigidity of figure-of-8 wires was similar to that of two straight wires. This shows that figure-of-8 wires (with the component wires angled at 45°) can be tightened to produce an almost comparably rigid closure as straight wires. The multitwist closure is the most rigid of all the closures tested. The rigidity of the multitwist closure is due to the fact that it has four wires in its twisted portion rather than two.

`Repair' closure refers to the common practice to insert a small piece of wire to bridge the gap when a wire breaks. However, our study reveals that the repair closure has very little rigidity. This closure is markedly inferior and should be considered as essentially non-load bearing in the company of other straight wires in a closure. The use of more than one such repair in such a closure should be discouraged, since the load on coughing would be distributed amongst the other wires in effect loading them more, increasing the risk of untwisting and cutting-through.

Ethibond no. 5 suture has a force-displacement graph that is linear, which means that it is the least rigid closure (paired t-tests, P=0.0002).

Sternaband closure is slightly more rigid than straight wires if one had to compare six straight wires versus six Sternabands. Upon a force being applied to a Sternaband, the clasp initially compacts and then rotates through 90° to an upright position, before failing, in over 90% of cases, by fracturing at the junction of the clasp with the band. Rigidity in a Sternaband closure is very dependent on adequate pre-tensioning of the device during application.

In clinical practice, dehiscence can occur by wire fracture or wire cutting through bone [13] or both [14]. This study has only analyzed the problem of wire fracture. A rigid closure may theoretically be disadvantageous in the presence of osteoporotic bone as it may be more likely to cut through. This is because an elastic material would theoretically transfer some energy into its own reversible deformation. With osteoporotic bone, stability may be increased by increasing the area of bone/wire contact, such as the use of parasternal wires [6] or lateral reinforcement [13] , which produces `collars' at the sternochondral junctions, thus spreading the load. We are currently investigating a bone sternal model so as to simulate in vivo conditions.

However, some clinical inferences can be drawn. We think that the multitwist closure is particularly useful in fractured bleeding sternums where the force imparted by the lateral-most part of the closure can help stop the bleeding. We think that Ethibond sternal closure should be limited to individuals unable to generate powerful coughs, with small sized chests as in the paediatric population, and those at high risk of dehiscence because of osteoporosis as in elderly patients. The Sternaband, in view of its flat ribbon shape, would be expected to be more resistant to cutting-through as compared with wires.

In conclusion, our mathematical model for chest wall forces shows that during maximum coughing, a force of 150 kg is placed upon a sternotomy closure. Since twisted steel wires untwist at 20–22 kg, then, in a chest closed with six `straight' wires, we also conclude that there is a risk that severe coughing may cause wires to untwist. To put this in perspective, orthopaedic devices are expected to have a safety margin of two, i.e. they are expected to withstand two times the maximum force to which they can be subjected to. We suggest closing the sternum with a minimum of eight straight, four multitwist or four figure-of-8 wires. There is clinical evidence [15] that beefing up the sternal closure by increasing the number of wires is the answer to the problem of sternal dehiscence.


   Footnotes
 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998. Back


   Appendix A. Conference discussion
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
References
 
Dr D Loisance (Creteil, France): Could you elaborate on your bone model?

Mr Casha: We are using a sheep bone model. We are using a machine which cycles between loads, and we leave the model for initially 2 h in order to find out how much it cuts through. And we have already compared Ethibond with straight wire in this regard.

Dr Loisance: And could you put in your mathematical model a parameter, which is very important in surgery, which is the case in applying the technique?

Mr Casha: Well, it is obviously an important part of the closure. I'm not sure if it can be put in terms of specific mathematical constant.

Dr A. Haverich (Hannover, Germany): The results shown are very nice. Also, I think the methods are very adequate. However, the experimental model that you set up with the steel bars may not actually reflect what there is in reality. So, I like the idea that you switched to the bone model, like all the orthopaedic surgeons do in testing new implantable or repair devices, because it probably gives more physiologic data to that.

Mr Casha: Initially we used a steel model to study the factors specific to the wires. Later we switched to the bone model as this simulates clinical practice more closely. The results of the steel model helped us interpret the results from the bone model experiments.

Dr H. Van Swieten (Nieuwegein, The Netherlands): I don't agree with your model, as already mentioned, and I don't agree with your conclusion. And I hope that you will be next year in Glasgow with a presentation with your bone model. I think your conclusion will be the total reverse of what you find now, because the combination of bone and steel wires can be very unfavourable for the rigidity of the closure technique. In my experience, when you use Ethibond, you use a suture with very little lower rigidity but it won't tear as easily through the bone. And I think many surgeons have the experience that in case of a refixation of a steel wire closed sternum, you don't find that the sternal wires are broken, but that the bone is totally broken.

Mr Casha: We have some initial data about comparison between Ethibond and stainless steel wire in bone. We were actually quite surprised when we found that the Ethibond cuts through the bone equally as quickly. There was no statistically significant difference.

Dr Van Swieten: Okay. I would like to see that experience next year.


   References
Top
 Abstract
 Introduction
Material and methods
Statistical analysis
Results
Comment
Appendix A. Conference...
 References
 

  1. Sirivelia S., Zikria E.A., Ford W.B., Samadani S.R., Miller W.H., Sullivan M.E. Improved technique for closure of median sternotomy incision. J Thorac Cardiovasc Surg 1987;94:591-595.[Abstract]
  2. Cheng W., Cameron D.E., Warden K.E., Fonger J.D., Gott V.L. Biomechanical study of sternal closure techniques. Ann Thorac Surg 1993;55:737-740.[Abstract]
  3. Del Campo C., Heimbecker R.O. Repair of refractory sternal dehiscence: a new technique. J Thorac Cardiovasc Surg 1982;83(6):937-938.[Medline]
  4. Tavilla G., van Son J.A.M., Verhagen A.F., Lacquet L.K. Modified Robicsek technique for complicated sternal closure. Ann Thorac Surg 1991;52:1179-1180.[Abstract]
  5. Goldman G., Nestel R., Snir E., Vidne B. Effective technique of sternum closure in high-risk patients. Arch Surg 1988;123:386-387.[Abstract/Free Full Text]
  6. Di Marco R.F., Lee M.W., Bekoe S., Grant K.J., Woelfel G., Pellegrini R.V. Interlocking figure-of-8 closure of the sternum. Ann Thorac Surg 1989;47:927-929.[Abstract]
  7. Wilkinson G.A.L., Clarke D.B. Median sternotomy dehiscence: a modified wire suture closure technique. Eur J Cardio-Thorac Surg 1988;2:287-290.[Abstract]
  8. Sargent L.A., Seyfer A.E., Hollinger J., Hinson R.M., Graeber G.M. The healing sternum: a comparison of osseous healing with wire versus rigid fixation. Ann Thorac Surg 1991;52:490-494.[Abstract]
  9. Timoshenko S. Strength of materials. Princeton: Van Nostrand, 1972: 117–121.
  10. Murray JF, Nadel JA. Textbook of respiratory Medicine, Vol. 1, 2nd edn. London: Saunders, 1994: 531–532.
  11. Stoney W.S., Alford W.C., Burrus G.R., Frist R.A., Thomas C.S. Median sternotomy dehiscence. Ann Thorac Surg 1978;26:421-426.[Abstract]
  12. Hicks G.L., Haake W., Stewart S.S., DeWeese J.A. The nuts and bolts of sternal dehiscence. Ann Thorac Surg 1983;36:364-365.[Abstract]
  13. Robicsek F., Daugherty H.K., Cook J.W. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg 1977;73:267-268.[Abstract]
  14. Santos G., Cook W.A., Frater R.W.M. Reclosure of sternotomy disruption produced by hiccups. Chest 1974;66(2):189-190.[Abstract/Free Full Text]
  15. Opie J.C., Stoney W.S. Avoidance of sternal non-union (Reply). Ann Thorac Surg 1997;64:888-889.[Free Full Text]



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