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Singh et al. Sternal fixation in a diabetic patient

with a titanium plate. One patient died following multi- 2. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes
organ failure secondary to mediastinitis that was present DR, Mack MJ, Ståhle E, Feldman TE, van den Brand M, Bass
prior to plating with 2 requiring wound revisions due to EJ, Van Dyck N, Leadley K, Dawkins KD, Mohr FW; SYNTAX
aseptic wound dehiscence confined to the soft tissue. Investigators. Percutaneous coronary intervention versus coronary-
artery bypass grafting for severe coronary artery disease. N Engl J
Another patient contracted tuberculosis and warranted Med 2009;360:961-72.
an extended in-hospital stay. They concluded that rigid 3. Taggart DP. Bilateral internal mammary artery grafting: are BIMA
plate sternal fixation was a good option particularly for better? Heart 2002;88:7-9.
patients who require aggressive sternal resection. 4. Taggart DP, Aratari C, Wong P, Paul EA, Wright JE. Applicability of
intermittent global ischemia for repeat coronary artery operations. J
The titanium plates also cost more than the other Thorac Cardiovasc Surg 1996;112:501-7.
traditional methods of management including irrigation 5. Yi G, Shine B, Rehman SM, Altman DG, Taggart DP. Effect of
bilateral internal mammary artery grafts on long-term survival: a
debridement and rewiring. However, considering meta-analysis approach. Circulation 2014;130:539-45.
its effectiveness, the shortened postoperative stay, 6. Nasso G, Coppola R, Bonifazi R, Piancone F, Bozzetti G, Speziale G.
improved outcomes and reduced readmission rates Arterial revascularization in primary coronary artery bypass grafting:
may reap its benefits. direct comparison of 4 strategies--results of the Stand-in-Y Mammary
Study. J Thorac Cardiovasc Surg 2009;137:1093-100.
Given the improvements in cardiac surgical techniques, 7. Grossi EA, Esposito R, Harris LJ, Crooke GA, Galloway AC, Colvin
sternal non-union remains an uncommon complication, SB, Culliford AT, Baumann FG, Yao K, Spencer FC. Sternal wound
albeit with significant morbidity. A larger multicentre infections and use of internal mammary artery grafts. J Thorac
Cardiovasc Surg 1991;102:342-6; discussion 346-7.
trial may be warranted to verify its benefits over other 8. De Paulis R, de Notaris S, Scaffa R, Nardella S, Zeitani J, Del Giudice
modalities. C, De Peppo AP, Tomai F, Chiariello L. The effect of bilateral internal
thoracic artery harvesting on superficial and deep sternal infection: The
In conclusion, sternal fixation is a viable method to role of skeletonization. J Thorac Cardiovasc Surg 2005;129:536-43.
treat sternal malunion. Larger studies are needed to 9. Ogawa S, Okawa Y, Sawada K, Goto Y, Yamamoto M, Koyama Y,
highlight its benefits compared to conventional therapy. Baba H, Suzuki T. Continuous postoperative insulin infusion reduces
deep sternal wound infection in patients with diabetes undergoing
DECLARATIONS coronary artery bypass grafting using bilateral internal mammary
artery grafts: a propensity-matched analysis. Eur J Cardiothorac Surg
2016;49:420-6.
Authors’ contributions 10. Hirotani T, Kameda T, Kumamoto T, Shirota S, Yamano M. Effects
Writing: S.S.A. Singh of coronary artery bypass grafting using internal mammary arteries for
Reviewing, editing, supervision: M. Capoccia, K. diabetic patients. J Am Coll Cardiol 1999;34:532-8.
Deep, N. Al-Attar 11. Jeong DS, Sung K, Lee YT, Ahn JH, Carriere KC, Kim WS, Park PW.
Pure bilateral internal thoracic artery grafting in diabetic patients with
triple-vessel disease. Ann Thorac Surg 2015;100:2190-7.
Financial support and sponsorship 12. Schimmer C, Reents W, Elert O. Primary closure of median
None. sternotomy: a survey of all German surgical heart centers and a
review of the literature concerning sternal closure technique. Thorac
Cardiovasc Surg 2006;54:408-13.
Conflicts of interest 13. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne
There are no conflicts of interest. JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME,
Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR,
Patient consent Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD.
Verbal and written consent was obtained at time of 2011 ACCF/AHA guideline for coronary artery bypass graft surgery:
a report of the american college of cardiology foundation/american
surgery. heart association task force on practice guidelines. Circulation
2011;124:e652-735.
Ethics approval 14. Hendrickson SC, Koger KE, Morea CJ, Aponte RL, Smith PK, Levin
Ethical approval was not needed as this was an FDA LS. Sternal plating for the treatment of sternal nonunion. Ann Thorac
and CE-mark approved device that had been used for Surg 1996;62:512-8.
treatment of sternal non-union (FDA 510 k number: 15. Bennett-Guerrero E, Phillips-Bute B, Waweru PM, Gaca JG, Spann
JC, Milano CA. Pilot study of sternal plating for primary closure of the
K093 772). sternum in cardiac surgical patients. Innovations (Phila) 2011;6:382-8.
16. Vos RJ, Jongbloed L, Sonker U, Kloppenburg GTL. Titanium plate
REFERENCES fixation versus conventional closure for sternal dehiscence after
cardiac surgery. Thorac Cardiovasc Surg 2017;65:338-42.
1. Tavilla G, van Son JA, Verhagen AF, Lacquet LK. Modified 17. Kim WK, Kim JB, Kim GS, Jung SH, Choo SJ, Chung CH, Lee
Robicsek technique for complicated sternal closure. Ann Thorac Surg JW. Titanium plate fixation for sternal dehiscence in major cardiac
1991;52:1179-80. surgery. Korean J Thorac Cardiovasc Surg 2013;46:279-84.

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