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Eur J Cardiothorac Surg 2006;29:920-924
© 2006 Elsevier Science NL

The outcome of sternal wire removal on persistent anterior chest wall pain after median sternotomy

Martin Agge Nørgaard * , Torben Colberg Andersen, Michael Jarner Lavrsen, Sven Borgeskov

Department of Cardio-thoracic Surgery, RT 2152, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark

Received 24 November 2005; received in revised form 5 February 2006; accepted 7 February 2006.

* Corresponding author. Tel.: +45 3545215; fax: +45 35452182. (Email: martin.n{at}dadlnet.dk).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Objective: To evaluate the effect of wire removal on a consecutive series of patients with persistent anterior chest wall pain after median sternotomy. Methods: Ninety-five patients receiving sternal wire removal during the period January 1994–October 2001 were included in a follow-up study. Preoperative data, data from the primary operation, the postoperative course, and the sternal wire removal were collected from patient histories. The patients were attempted contacted by telephone, and interviewed about the outcome of the wire removal. Results: Wire removals were performed 2.7 ± 3.3 (SD) years (40 days–20 years) after the primary procedure. Wire removal appeared to occur more frequently in patients with allergies, patients receiving valve-related procedures, and patients that had been reoperated for surgical complications within the first month after the primary operation. In 79 patients, the pain was unrelated to skin affection or infection. Full follow-up was available for 71 patients. For 24 patients only partial follow-up was possible since the patients were dead (n = 19) or unreachable (n = 5). Of the patients followed up, 86% reported complete or partial relief of symptoms, while 11% reported no change in symptoms, and 3% reported worsening of symptoms after wire removal. In patients (n = 23) where symptoms appeared to be related to specific wires, only these were removed, and this approach produced as good results as for patients where all wires were removed. Conclusions: The surgical results were generally good. Sternal wire removal should be offered to patients with persistent anterior chest wall pain after sternotomy, when other serious postoperative complications have been excluded.

Key Words: Sternal • Wire • Removal • Persistent • Chest • Pain


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Persistent anterior chest wall pain after sternotomy and wire closure constitutes a well-recognized pain syndrome, previously reported to occur in as many as 28% of patients after median sternotomy [1]. The largest series of wire removal for persistent anterior chest wall pain, previously reported in the literature, included 18 patients [2].

Poststernotomy chest pain should be investigated to rule out serious pathology, such as infection, myocardial ischemia, and sternal or costo-sternal cartilage instability. In the absence of these obvious causes, persistent anterior chest wall pain may be attributed to the sternal wire sutures, either by direct sternal or periostial irritation [3]. Other reasons such as scar-entrapped sensory nerve fibers [2,4] and hypersensitivity reaction to metals in the wires, especially nickel, have been described [5–9].

The relief of pain and allergic symptoms after sternal wire removal has previously been reported [2,3,6,7], but the long-term outcome from a large group of patients receiving this procedure has not previously been described.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
This study was a retrospective and follow-up investigation of patients who underwent sternal wire removal over a 7-year period (January 1994–October 2001).

Patients were identified from our institution's database. Ninety-five patients who had wires removed due to pain likely to be caused by the sternal wires were included in the study. Thirteen of these patients further more had wire-related infection.

Patients, who had sternal rewiring performed due to pseudoarthrosis, and patients having wires removed during reoperation for cardiac or vascular causes, were not included.

2.1 Ethics
The study was approved by the Ethical Committee for Copenhagen and Frederiksberg, including telephone interviews and obtaining verbal consent, as well as contacting patients by mail.

2.2 Statistics
Data were analyzed using Statistica 6.0® (StatSoft® Inc., Tulsa, OK, USA).

Continuous data were reported as mean and standard deviation.

Comparison between groups was performed using chi-square tests.

Survival data were analyzed using Kaplan–Meier statistics.

2.3 Surgical procedure for sternal wiring
Sternal wiring was performed using single wire loops. Two or three wires were inserted in the sternal manubrium, and the sternal corpus was either wired using peristernal wires through the intercostals spaces, or through the costochondral joints, depending on the surgeon's preference. A minimum of five wires was always inserted.

2.4 Patient selection for wire removal
Our algorithm, for patients referred with persistent poststernotomy chest pain, has been to exclude serious pathology, such as infection, myocardial ischemia, and sternal or costo-sternal cartilage instability. When appropriate investigations have returned negative results, we have opted for wire removal.

When patients were assessed for wire removal, it was decided whether to remove all or only selected wires. Our policy has been to remove selected wires only if there was a very convincing relation between symptoms and specific wires. Otherwise we have opted for removal of all wires.

2.5 Surgical procedure for wire removal
Under general anesthesia the patients underwent incision or resection of all or part of the sternotomy scar, dissection and extraction of all or the selected wires. In case of infection, the infected area was debrided. All incisions were primarily sutured without drainage.

The patients typically left hospital on the first postoperative day.

At follow-up, information was collected from the patient records and operating reports regarding:

• Patient's age, gender, height, weight, comorbidity (diabetes, COPD, allergies)
• Date and type of primary operation
• Postoperative complications (pericardial collection, infection, and sternal instability)
• Date and type (all wires or selected wires) of sternal wire removal

All patients alive were attempted contacted by telephone for a short interview. Patients unreachable by telephone were contacted through mail, and asked to call one of the investigators.

At the telephone interview the patients were informed about the purpose of the study and verbal consent was obtained.

The patients were then questioned about the outcome of the wire removal, and the outcome was classified as:

Group A: No symptoms remaining
Group B: Improvement, some symptoms persist
Group C: Equal to before wire removal
Group D: Worse than before wire removal
Group E: Cannot answer the question

Furthermore, information not accessible or unclear in the patient histories was obtained or clarified during the interview, and it was assured that the patients had not undergone further sternal surgery since wire removal.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
For 71 patients the necessary follow-up information could be obtained by telephone interview (n = 70) or from the patient's history (n = 1), resulting in a follow-up rate of 93% for patients still alive, and 75% over all. Twenty patients had died prior to follow-up. Five patients could not be followed up due to emigration (n = 2), or they were not contactable by telephone or mail (n = 3).

The mean interval from wire removal to follow-up was 3.5 ± 2.2 (SD) years (range: 0.9–8.6 years).

The patients’ preoperative characteristics before the primary procedure are described in Table 1 .


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  		Table 1. The patients’ preoperative characteristics before the primary procedure
 
No patient indicated allergy towards metals.

The primary operations performed were: revascularization procedures (n = 54), valve repair or replacement (n = 24), combined revascularization and valve procedures (n = 8), and other procedures (n = 9, including five pediatric cardiac procedures, one stab wound, two mediastinal masses, and one vascular procedure).

During the period 1994–2000, the number of sternotomies at our institution varied between 940 and 1425. The number of patients having wire removal at a later stage, as percentage of sternotomies performed the year their primary operation was performed, varied between 0.6 and 1.1%.

Seventeen patients (18%) had undergone reoperations on days 0–27 due to bleeding (n = 8), pericardial collection (n = 5), wound infection/mediastinitis (n = 3), or sternal instability (n = 1). In these patients, wire removal was performed due to pain (n = 10) 167–3453 days after the reoperation, due to infection (n = 6) 78–568 days after the reoperation, and a wire protruding towards the skin (n = 1) 725 days after the reoperation.

Table 2 describes the symptoms leading to sternal wire removal and the outcome as reported by the patients at follow-up.


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  		Table 2. The primary symptoms leading to sternal wire removal (all patients experienced pain before wire removal) and the outcome as reported by the patients at follow-up
 
Table 3 describes the effect of removal of all wires versus removal of selected wires.


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  		Table 3. The effect of removal of all wires versus removal of selected wires
 
The mean interval from primary operation to wire removal was 2.8 ± 3.3 (SD) years (range: 40 days–20.8 years) (Fig. 1 ).


Figure 1
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  		Fig. 1. Number of patients versus time from the primary operation to wire removal (all patients).

 
As described in Table 2, a subgroup of 79 patients had wires removed due to sternal pain without associated symptoms. In this subgroup, wire removal was performed 5 months–20 years after the primary operation. The outcome of wire removal for this subgroup is shown in Fig. 2 describing the fraction of patients with improvement or complete pain relief (group A or B), the fraction with no change or worsening of symptoms (group C or D), and the fraction dead or unreachable (group E).


Figure 2
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  		Fig. 2. Outcome of wire removal versus time from the primary operation to wire removal when pain was the only indication.

 
The survival after wire removal is shown in Fig. 3 .


Figure 3
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  		Fig. 3. Survival after wire removal (all patients).

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
It seems peculiar, that although poststernotomy pain may be one of the most frequently occurring complications to cardiac surgery, it has received little attention in the literature.

Most likely, some patients from every cardiac surgical department will occasionally be investigated for postoperative chest pain, and depending on the investigators approach, referred for surgical intervention.

We do not have information available on demographic distribution or comorbidities of the general patient population operated at our institution during the period where this patient material was operated. However, we believe that the distribution described in Table 1 was equivalent to the general patient population at the time, although the indicated allergy frequency (14%) may be higher than usual. Previous authors have suggested that hypersensitivity towards the wire material, and especially nickel in the wires may cause sternal pain and skin reactions, and that removal of wires may resolve symptoms [5–9]. Our recording of allergies included all types of allergy, not only metal allergy, to which no patients indicated to be allergic.

Valve-related procedures appear to be over represented in this material, compared to the general distribution of procedures during this period. The reason for this is unclear. As previously reported by other investigators [10–12], we expected coronary bypass procedures to be over represented due to the surgical trauma applied to the chest wall during internal mammary artery harvesting. However, this was not the case in our material. This question remains controversial and other investigators [1] were, as we, not able to identify an association between internal mammary artery harvesting and postoperative chest pain.

Eighteen percent of patients in this material had received a reoperation within the first month after the primary procedure. Being much higher than our usual reoperation frequency, reoperations seem to precipitate persistent anterior chest wall pain.

As demonstrated in Tables 2 and 3, our simple algorithm for identifying patients likely to benefit from wire removal, as well as allocation to removal of all versus selected wires, has proven to be reasonably successful. Out of 71 patients available for complete follow-up, 61 (86%) reported complete or partial relief of symptoms after wire removal, 8 (11%) reported no change in symptoms, while 2 (3%) reported worsening of symptoms after wire removal.

For every patient, the surgeon has to decide to remove all or only selected wires. Fifteen patients available for follow-up had only selected wires removed. One (7%) of these reported symptoms equal to before wire removal. Out of 52 patients having all sternal wires removed (and available for follow-up), 8 (15%) reported symptoms equal to before wire removal (nonsignificant at chi-square test; p = 0.38). There was, however, a difference between the groups in the indications for sternal wire removal. Out of the 15 patients available for follow-up and having selected wires removed, pain was the only indication in 10 (67%), while in 48 of the 52 patients (92%) having all wires removed, the only indication was pain. The surgical success in treating pain was 83% (40 of 48) following complete wire removal, and 90% (9 of 10) after selected wires were removed (nonsignificant at chi-square test; p = 0.60). Over all, surgical success with wire removal for pain as the only symptom was achieved in 51 of 61 patients (84%) (including 3 patients having an unknown number of wires removed for pain, with surgical success in 2).

Only 1 out of 10 patients followed up after wire removal for other indications than pain indicated remaining, although improvement of symptoms at follow-up, indicating a surgical success rate of 100% for these indications.

When consenting patients with unexplained sternal pain for sternal wire removal, it thus seems reasonable to quote an overall postoperative long-term rate of freedom from pain of about 65%, improvement but remaining pain in 21%, no change in 14%, and worsening of symptoms in 3%. If a few symptomatic wires can be clearly identified preoperatively, removal of these seems to produce as good results as removal of all wires. For the indications wires protruding towards the skin and infection related to wires, a higher success rate may be quoted, although caution must be exercised due to the smaller numbers in our series. Although our routine has been to use general anesthesia, removal of a few wires can potentially be performed in local anesthesia.

We recommend that patients with remaining symptoms following wire removal undergo further investigations in order to identify the underlying pathology. If no treatable underlying pathology can be uncovered, we recommend referral to a specialized pain clinic.

Most of our patients presented with wire problems within the first 6 years after the primary operation. We were surprised to find that nine patients (9%) presented later, up to 20 years after the primary operation. Seven of these presented with pain, while two had developed infections related to wires 12 and 13 years after the primary operation, respectively. As seen in Fig. 2, the surgical success of removal of sternal wires is unlikely to merely reflect the natural history of early poststernotomy pain (Dressler's Syndrome), as wire removal seems to have been beneficial even several years after the primary operation. Whether there has been a placebo effect of wire removal in some patients remains unknown.

The 5-year survival was >70% for this patient material. We do not have survival statistics available for a matched patient population poststernotomy making a comparison with this patient population possible. However, poststernotomy anterior chest pain leading to wire removal does not seem to be a major risk factor for survival.

When expressing the number of patients having wire removal as a percentage of the number of sternotomies performed the year their primary operation was performed, 0.6–1.1% of sternotomies have resulted in wire removal at some later stage. When comparing this percentage to the incidence of chronic chest pain after sternotomy reported by Kalso et al. [1], we suspect that our patients who received wire removal were only a small fraction of the total number of patients suffering persistent anterior chest wall pain after sternotomy. Most patients are probably managed by their general practitioners, using analgesic therapy.

When considering the surgical results, the small risk, the short hospital stay, and the low cost of wire removal, we find it reasonable to offer this procedure to a larger number of patients.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
Sternal wire removal should be offered to patients with persistent anterior chest pain after sternotomy, when other serious postoperative complications have been excluded. Although a small fraction of patients (3%) may experience worsening of symptoms after wire removal, the surgical results are generally good, with an over all 86% long-term success rate.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

  1. Kalso E, Mennander S, Tasmuth T, Nilsson E. Chronic post-sternotomy pain. Acta Anaesthesiol Scand 2001;45(8):935-939.[CrossRef][Medline]
  2. Eastridge CE, Mahfood SS, Walker WA, Cole Jr. FH. Delayed chest wall pain due to sternal wire sutures. Ann Thorac Surg 1991;51(1):56-59.[Abstract]
  3. Weber LD, Nashel DJ, Peters RW. Persistent chest pain due to sternal wire sutures: a complication of coronary artery bypass surgery. South Med J 1985;78(8):1018-1019.[Medline]
  4. Defalque RJ, Bromley JJ. Poststernotomy neuralgia: a new pain syndrome. Anesth Analg 1989;69(1):81-82.[Abstract/Free Full Text]
  5. Fine PG, Karwande SV. Sternal wire-induced persistent chest pain: a possible hypersensitivity reaction. Ann Thorac Surg 1990;49(1):135-136.[Abstract]
  6. Ancalmo N, Perniciaro C, Ochsner J. Hypersensitivity reaction to sternal wires: a possible cause of persistent postoperative pain. Cardiovasc Surg 1993;1(4):439-441.[Medline]
  7. Takazawa K, Ishikawa N, Miyagawa H, Yamamoto T, Hariya A, Dohi S. Metal allergy to stainless steel wire after coronary artery bypass grafting. J Artif Organs 2003;6(1):71-72.[Medline]
  8. Hayashi K, Kaneko H, Kawachi S, Saida T. Allergic contact dermatitis and osteomyelitis due to sternal stainless steel wire. Contact Dermatitis 1999;41(2):115-116.[Medline]
  9. Gordon PM, Buxton PK, McLaren KM, Aldridge RD. Sensitivity to sternotomy wires may cause postoperative pruritus. Ann Thorac Surg 1996;61(5):1514-1516.[Abstract/Free Full Text]
  10. Rowe MA, King KB. Long-term chest wall discomfort in women after coronary artery bypass grafting. Heart Lung 1998;27(3):184-188.[Medline]
  11. Cohen AJ, Moore P, Jones C, Miner TJ, Carter WR, Zurcher RP, Lupkas R, Edwards FH. Effect of internal mammary harvest on postoperative pain and pulmonary function. Ann Thorac Surg 1993;56(5):1107-1109.[Abstract]
  12. Mailis A, Umana M, Feindel CM. Anterior intercostal nerve damage after coronary artery bypass graft surgery with use of internal thoracic artery graft. Ann Thorac Surg 2000;69(5):1455-1458.[Abstract/Free Full Text]




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