Comparison between two sternum closing techniques by median sternotomy during open cardiac surgery
Median sternotomy is the most frequently used incision in patients of open cardiac surgery. Following open cardiac surgery by median sternotomy, sternum is closed by surgical steel wires as whole layer. Potential post-operative sternal instability definition is dehiscence of both sternal parts due to cutting of sternal cortical layers by sternum closing wires with inappropriate movements of patient. This may result in conditions ranging from increased postoperative pain, sternal wound infection and mediastinitis associated with higher morbidity and mortality, prolonged hospital stay and increased treatment cost.(1-4)
Sternal bands used in our study are reported to prevent cutting of sternal cortex as tension on sternum is applied on larger and more balanced area, unlike to conventional sternal steel wires.(4-6) The aim of this study to compare two different sternal band closing methods combined by conventional sternal closing method and to report the results.
Pre-operative demographics were not statistically significantly different between two groups (Table 1). Surgery type of operated patients is shown on Table 2.
Mean pain index was 6.00 (min 1 – max 48 ) and 4.00 (min 1 – max 63) in Group A and Group B, respectively. Statistically significant difference was found between two groups in respect of pain index (p = 0.011).
Complete closing of sternum following median sternotomy during open cardiac surgery, is a critical point in prevention of postoperative complications due to sternotomy. These complications include mainly dehiscence as well as a broad range of conditions such as pain, superficial wound infection and mediastinitis. Currently several sternal closing methods were described to prevent these complications.(4) Therefore, in our study we compared two different sternal bands used for sternal closing.
In patients with sternotomy, sternal dehiscence is the most frequent complication and the rate is 0.3% to 5%. This is a mechanical problem associated with certain factors such as lack of attention of patient to protect the sternum post-operatively, COPD, obesity, osteoporosis, use of bilateral mammarian arteries, renal insufficiency, administration of steroids and re-operation.(4) The incidence of sternal wound infection is 0.4-5% and it is closely associated with dehiscence.(10)
Closing of sternum is an important factor for sternal dehiscence. During sternal closing done by conventional approach using steel wires 5/0, bone cortex erosion, fracture and consequently sternal dehiscence can occur due to compression of steel wires. Sternal dehiscence may lead to respiratory dysfunction, infection, increased pain and re-exploration.(16) Use of sternal band, especially retrosternal application at intercostal space 3 and 4 to transversely surrounding whole sternum, is the most important mechanism to reduce development of sternal dehiscence with its 6 times larger surface than steel wires and thus providing equal loading on sternum. In our study, sternal dehiscence and sternal wound infection were not detected in both groups.
Postoperative pain is an acute pain gradually reducing by tissue healing accompanied also by inflammatory process.(6) Indeed, acute pain is a complex sensation besides its simple perceptional character. Difference in pain perception may be due to central process, fear, anxiety, depression and previous experience on pain perception. Certain patients may not describe the pain due to their higher pain tolerance or their introvert pain handling methods. Difference in pain perception of patients may be also due to post-operative analgesic administration methods. However, 30% of surgery patients don’t require postoperative analgesics.(7) In a prospective clinical study, localization, distribution and severity of postoperative pain were evaluated in consecutive 200 patients with cardiac surgery by median sternotomy.(8) Investigators determined the highest pain intensity on day 1 and lowest intensity on day 3. Although pain distribution was not different during post-operative period, there was difference in its localization.(9,15) Another factor affecting the pain severity is the age of patient. Young patients reported more severe pain than patients over 60 years.(8,11)
Previous studies comparing sternal band and conventional sternal closing also showed that usage of sternal band was associated with decreased pain and this was explained by reduced development of sternal dehiscence. However, in our study, we determined a difference between different methods of sternal bands in respect of pain development. When two groups of our study were compared, there was significant reduction in post-operative pain development in Group B compared to Group A. At this point, we consider that reduced compression of band method on a smaller bone cortex area only at intercostal space 3 in Group B compared to band method of Group A, could explain lower pain.
However, we think that the limited number of studies on pain in cardiac surgery and multifactorial nature of pain are limitations of our study. Although our study is prospective and including low number of patients, we conclude that larger studies will provide more guidance by including psychological and anatomic-physical parameters such as difference in physical load on bone structure by the material utilized.
Please cite this article as: Kara K.A., Erk Z., Koçyiğit A., Gülmen Ş., Öcal A., Okutan H. Comparison between two sternum closing techniques by median sternotomy during open cardiac surgery EJCM 2017; 05 (3): 44-49. Doi: 10.15511/ejcm.17.00344.
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