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Letters to the Editor |
University of Würzburg, Department of Cardiac and Thoracic Surgery, Oberdürrbacherstraße 6, 97080 Würzburg, Germany
Received 21 July 2008; accepted 22 July 2008.
* Corresponding author. Tel.: +49 931 2010; fax: +49 931 201 33 009.
Key Words: Sternal closure techniques • Standard wire closure • Robicsek technique • Modified Robicsek technique
We would like to thank Khaled Al-Ebrahim for his comments [1] on our paper regarding our results of the Robicsek sternal closure technique in elderly patients [2]. Nowadays, there are many sternal closure techniques available, but the routine use of a defined advanced sternal closure technique in the growing group of patients expected to have postoperative healing problems is still a matter of debate. Especially, if a more complex technique seems theoretically to be superior, it is not always able to achieve the requirements under ‘real-life’ conditions for everybody.
Careful attention to haemostasis and meticulous surgical technique remain the mainstays of prevention of sternal dehiscence and must include precise sternal alignment and stable closure. All techniques claim to maximise sternal stability, but it is difficult to differentiate between the merits of various techniques. Depending on the amount of movement and tension placed on the point of contact, the bone will often fracture before the period of healing is complete. Especially if the sternum is unusually narrow or osteoporotic, or if it has been mishandled with sternum retractor, the wire sutures may easily cut through the bone with simultaneous transverse fragmentation and longitudinal separation [3].
I agree with your arguments that the Robicsek technique has its advantages (it stabilises the sternum if it is fragile or broken, or if subsequent instability develops, it prevents the wires cutting through the bone, it changes the point of contact from metal-to-bone to metal-to-metal), but it also has some disadvantages (it produces a constrictive weave that can disrupt the collateral blood supply of the sternum and effective approximation of the top and bottom of a gaping sternum cannot be obtained).
The technique described by Robicsek was modified by Sharma et al. [5] who placed a line of continuous wire suture on either side of the sternum and tied both lines cranially and caudally and Al-Ebrahim et al. [4] who utilise single longitudinal wire on each side with only sternal punctures at the lower and upper parts of the sternum surrounded by the conventional transverse or figure of eight wires. These techniques have an added advantage over conventional Robicsek's closure in that the blood supply of the sternum is not ‘strangulated’ by the ring formed by encircling wires around the costal cartilages by anterior and posterior longitudinal wires.
The essential point of this issue is the prevention of sternal dehiscence and subsequent infection in the growing group of patients expected to have postoperative healing problems. In order to achieve more evidence in this matter we will publish in the near future the results of a prospective randomised multicentre trial comparing the Robicsek technique versus the conventional trans/peristernal technique (with >6 cerclages) not in a special subgroup but in all high risk patients (n = 815 patients; all with one or more inclusion criteria: diabetes mellitus, peripheral vascular disease, obesity, osteoporosis, old age, immunosuppressed state, preoperative renal failure, chronic lung disease). Obviously, it would have been of interest to involve your advanced technique as a third arm of this trial.
References
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