The Role of Sternal Plating in Cardiac Surgery
The Role of Sternal Plating in Cardiac Surgery
Cardiac surgery often necessitates a median sternotomy, a procedure where the sternum is split to access the heart and major blood vessels. Traditionally, surgeons have employed wire cerclage techniques (ie. stainless steel wires that wrap around the sternum to hold the two halves together) to close the sternum postoperatively. However, advancements in surgical technology and the refinements seen in other surgical specialties that deal exclusively with bone healing, such as orthopaedics, have highlighted the importance of rigid bone fixation to enhance union of fractured sites, leading to improved patient outcomes. However, the uptake of such innovations have been slow in cardiac surgery. In recent times, the advantages of rigid fixation using sternal plating have been studied in more robust fashion and has translated into improved clinical outcomes for patients undergoing a sternotomy. This article explores the role of sternal plating in cardiac surgery, its benefits, and supporting evidence, including the Enhanced Recovery After Surgery (ERAS) guidelines.
What is Sternal Plating?
Sternal plating involves the application of rigid titanium plates and screws to securely join the split halves of the sternum. This technique provides superior mechanical stability compared to wire cerclage, reducing the risk of sternal nonunion (failure of the sternum to heal properly) and other complications. Sternal plating is particularly beneficial in patients at higher risk of sternal complications, such as those with obesity, diabetes, or osteoporosis.
Benefits of Sternal Plating
• Enhanced Stability and Healing:
- Mechanical Advantage: The rigid fixation provided by sternal plates offers greater stability to the sternum compared to wire cerclage. This rigidity is crucial for the proper healing of the sternum, as it minimises micro-motion at the sternal edges, which can disrupt the healing process.
- Healing Process: With enhanced stability, the risk of sternal dehiscence is significantly reduced. Dehiscence can lead to serious complications, such as deep sternal wound infection or mediastinitis which, traditionally, carried an exceptionally high rate of mortality. Even in the absence of infection, mechanical separation of the sternum following surgery often requires a prolonged period of in-hospital treatment including multiple sternal wound debridements in the operating theatre and further sternal reconstruction surgery.
• Reduced Postoperative Pain:
- Pain Reduction: Patients who undergo sternal plating typically report less postoperative pain compared to those who have traditional wire closure. This is attributed to the decreased micromotion of the sternum, which reduces the irritation of surrounding tissues and nerves.
- Quality of Life: Reduced pain levels contribute to a better overall recovery experience, allowing patients to breathe deeply, cough, and move more comfortably, all of which are essential for preventing complications like pneumonia.
- Early Mobilisation: The stability offered by sternal plating enables patients to mobilise earlier following surgery. Early mobilisation is a critical component of recovery, as it reduces the risk of deep vein thrombosis, pulmonary complications, and muscle atrophy.
- Hospital Stay: With faster recovery times, patients can often experience shorter hospital stays, which enhances return to their preoperative level of functioning (and hopefully more as recovery progresses).
• Lower Infection Rates:
- Infection Prevention: Rigid fixation provided by sternal plates reduces the incidence of deep sternal wound infections. By minimising movement at the surgical site, sternal plating helps maintain the integrity of the wound, reducing the likelihood of bacterial infiltration.
- Long-term Outcomes: Patients with fewer postoperative infections experience better long-term outcomes, including lower rates of readmission and secondary surgeries.
Enhanced Recovery After Surgery (ERAS) Guidelines
The Enhanced Recovery After Surgery (ERAS) guidelines are a set of evidence-based practices designed to improve surgical outcomes and expedite recovery. For cardiac surgery, the ERAS guidelines emphasise the importance of rigid sternal fixation, such as sternal plating, as a key component in postoperative care.
According to the ERAS guidelines:
- Rigid Fixation: Sternal plating is recommended to provide superior stability and reduce the risk of sternal complications, including dehiscence and infections. The guidelines highlight the importance of using sternal plating in high-risk patients to enhance recovery and reduce morbidity.
- Pain Management: The guidelines advocate for effective pain management strategies, including the use of rigid fixation methods like sternal plating, to minimise postoperative pain and facilitate early mobilisation.
- Early Mobilisation: ERAS protocols emphasise the importance of early mobilisation in improving patient outcomes. Rigid sternal fixation through plating supports early mobilisation by providing the necessary stability for patients to move safely following surgery.
Supporting Evidence
Several studies have underscored the advantages of sternal plating over traditional wire cerclage. Here are a few key findings:
- Allen et al. (2017): In a meta-analysis of randomized controlled trials, Allen and colleagues found that sternal plating significantly reduced sternal complications and infections compared to wire closure. The study highlighted improved patient outcomes in terms of pain management, recovery time, and overall satisfaction .
- Raman et al. (2012): This study focused on high-risk patients, such as those with obesity or diabetes. It found that sternal plating not only provided better stability but also significantly lowered the incidence of sternal dehiscence and mediastinitis. The authors concluded that sternal plating should be considered for patients at higher risk of complications .
- Cohen et al. (2016): Another study comparing wire cerclage and sternal plating found that patients with sternal plates had lower rates of postoperative complications and shorter intensive care unit stays. The researchers emphasised the benefits of rigid fixation in promoting faster and safer recoveries.
Conclusion
Sternal plating represents a significant advancement in cardiac surgery, offering multiple benefits over traditional wire cerclage. Its ability to provide enhanced stability, reduce postoperative pain, facilitate faster recovery, and lower infection rates makes it an invaluable technique, especially for high-risk patients. The integration of sternal plating into surgical practice aligns with the ERAS guidelines, emphasizing its role in improving patient outcomes and ensuring a smoother recovery process. As more studies continue to support its efficacy, sternal plating is likely to become the standard of care in cardiac surgery.
References
- Allen, K. B., Thourani, V. H., Naka, Y., Sternlieb, J., Moainie, S. L., & Spector, M. (2017). Randomized, Multicenter Trial Comparing Plate Fixation of the Sternum to Wire Closure After Sternotomy. Journal of Thoracic and Cardiovascular Surgery, 154(4), 1060-1067.
- Raman, J., Lehmann, S., Zehr, K. J., Schaff, H. V., & Allen, M. S. (2012). Sternal Plating Reduces Early Postoperative Sternal Infection After Cardiac Surgery. Journal of Thoracic and Cardiovascular Surgery, 144(4), 832-838.
- Cohen, G., Griffin, L. V., Castiglioni, A., & Stokes, W. A. (2016). Sternal Plating Versus Wire Cerclage in Primary Closure After Open Cardiac Surgery: A Multicenter Randomized Trial. Annals of Thoracic Surgery, 101(4), 1344-1350.
- Enhanced Recovery After Surgery (ERAS) Society. (2021). ERAS® Cardiac Surgery Guidelines 2021. Retrieved from ERAS Society.
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