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Eur J Cardiothorac Surg 2003;23:435
© 2003 Elsevier Science NL

Letter to the Editor

Median sternotomy closure

Julian E. Losanoff, Bruce W. Richman, James W. Jones*

Department of Surgery, M580 Health Sciences Center, University of Missouri–Columbia School of Medicine, One Hospital Drive, Columbia, MO 65212, USA

Received 5 September 2002; accepted 2 December 2002.

* Corresponding author. Tel.: +1-573-882-4158; fax: +1-573-884-4585
e-mail: jonesjw{at}health.missouri.edu

Key Words: Median sternotomy • Wound closure • Wound infection

We read with interest the recent article by Risnes et al. on sternal wound closure [1]. The study prospectively analyzes 300 patients undergoing open heart surgery. Half the patients had their skin wound closed with zippers and half with intracutaneous suture. No statistically significant difference in the sternal wound infection rates between the groups was noted [1].

Risnes et al.’s study considered 21 sternotomy infection risk factors [1], but their analysis may not be complete. The report does not cite two recent reviews listing over 60 risk factors, including but not restricted to those they noted [2,3]. Other investigators have published conclusions that marked obesity and larger breast sizes predispose toward postoperative skin separation and thus to sternotomy wound infection; retention sutures, breast support, reduction mammoplasty, and submammary skin incisions [2–4] have been proposed as alternatives to modified skin approximation [1] to prevent these infections.

Risnes et al.’s study was not designed to explore their patients’ preoperative bacteriology status. Intranasal pathogen carriage has been recently reported as a major risk factor for surgical site infections after median sternotomy [5]. Because the study cannot consider all the risk factors reported in large groups of sternotomy patients [2–5] it cannot provide us with a validated concept of the most significant risk factors or the most effective prevention guidelines.

Risnes et al. do not list details of the particular type of sternotomy closure used in their series. They suggest that neither sternal osteoporosis nor suboptimal sternal closure were important factors in the group's sternal infection incidence. The recent literature suggests that closure stability can be improved by increasing the number of sternotomy wires; a stabler mechanical fixation of the sternotomy reduces the incidence of infectious complications [2,3].

The strongest insight in Risnes et al.’s study reflects the cosmetic perspective of sternotomy wound closure. Future studies evaluating all possible risk factors’ cross-potentiations will help to reduce the incidence of life-threatening sternotomy infections.

References

  1. Risnes I., Abdelnoor M., Lundblad R., Baksaas S.T., Svennevig J.L. Sternal wound closure in patients undergoing open-heart surgery: a prospective randomized study comparing intracutaneous and zipper techniques. Eur J Cardiothorac Surg 2002;22:271-277.[Abstract/Free Full Text]
  2. Losanoff J.E., Jones J.W., Richman B.W. Primary closure of median sternotomy: techniques and principles. Cardiovasc Surg 2002;10:102-110.[CrossRef][Medline]
  3. Losanoff J.E., Richman B.W., Jones J.W. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21:831-839.[Abstract/Free Full Text]
  4. Baucia J.A., Sobrinho A.F., Barbero-Marcial M. Submammary incision for median sternotomy (in Portuguese). Arq Bras Cardiol 1993;60:335-338.[Medline]
  5. Cimochowsky G.E., Harostock M.D., Brown R., Bernardi M., Alonzo N., Coyle K. Intranasal mupirocin reduces sternal wound infection after open-heart surgery in diabetics and nondiabetics. Ann Thorac Surg 2001;71:1572-1578.[Abstract/Free Full Text]




This Article
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