Applications for Sternal Plating: Treatment and Prophylaxis of Sternal Complications

Background:  Most surgical specialties that work with bone have transitioned to stable fixation.  Rigid plate osteosynthesis results in rapid bony healing with decreased rates of non-union, malunion, and infection.  Despite this fact, standard closure for median sternotomies remains circlage wire fixation.1,2 This study describes our 5-year experience with sternal plating at the University of California at Davis Medical Center.

Materials & Methods:  Fifty-five sternal plating operations were performed on fifty-three patients (M:F = 33:20, average age 53.9, range 16-79) at UC Davis Medical Center between the years of 2006-2012.  Risk factors for post-op complications including mediastinitis and nonunion were evaluated. Preoperative risk factors included obesity (average BMI =32.6), coronary artery disease (69% of patients), diabetes (44%), COPD (9%), chronic kidney disease (14.5%), and concurrent or prior steroid use (7.3%). Intraoperative risk factors evaluated include pump time over two hours (43.6%), use of an intra-aortic balloon pump (1.8%), and bilateral internal mammary artery harvest (7.3%). In 63.6% of cases, plating was performed after median sternotomy for cardiac surgery. 10.9% were performed after sternal fracture, 20% for nonunion, 1.8% for thymoma, and 3.6% for pectus (one status post nuss bar erosion and one for pectus carinum). 56% surgeries were primary steronotomies, and 44% were secondary sternotomies. 14.6% patients received pectoralis flaps at the time of plating surgery. Of the plating systems used, 87.3% used Sternalock, 12.7% used Talon, 1.8% Lactosorb, and 1.8% Flexigrip.

Results:  At three-month follow-up, 48 patients had sternal stability, one was unstable, one had expired and five were lost to follow-up. Overall, 74.6% of patients had no complications. 18.2% of patients had post-op wound dehiscence, of which 7.3% of these patients required vac therapy and debridement. 9.1% of patients had a post-op wound infection that was managed non-operatively. 7.3% of patients had their hardware removed: 3.6% for infection, 1.8% for nonunion, and 1.8% for unrelated reasons.

Conclusion:  Sternal plating is a natural extension of principles learned from bone fixation elsewhere.  Rigid plate sternal osteosynthesis can be used safely in the prophylaxis against the development of mediastinitis as well as for the treatment of sternal non-union or malunion in high-risk patients. It can also be used for rigid osteosynthesis of osteotomies in sternal reconstructions after median sternotomy, traumatic fracture, nonunion and pectus reconstructions.