Different Sternal Closure Techniques After J-shaped Ministernotomy
Eduard Charchyan, Denis Breshenkov, Yuriy Belov
Petrovsky National Research Centre of Surgery, Moscow, Russian Federation
BACKGROUND: Aim of our study to compare the results of three different sternal closure techniques after J-shaped ministernotomy (J-MS) through 4th intercostal space (ICS).
METHODS: A total of 881 patients undergoing thoracic aorta surgery from 2013 to 2020 at our centre. MI aortic root repair was performed of 198 (22.4%) patients through J-shaped ministernotomy. Of them, we included 80 patients (40.4%) with thoracic aorta repair through J-MS through 4th ICS (14 patients (17,5%) with sternal steel wires (SW), 44 patients (55%) with sternal ZipFix (ZF) and 22 patients (27,5%) with thermoreactive nitinol clips (NC)). Sternum healing was evaluated using CT scan after the procedure, at 1-years and 2 years after. Endpoints were operative parameters, rate of postoperative bleeding, major adverse postoperative (osteosynthesis-related) complications, pain intensity (according to visual analogue scale (VAS) and use of analgesics. RESULTS: Detailed results are presented in Table 1. Using of NC reduces time of sternal closure (groups SW/ZF/NC: 18.5 (14.5-20.8) min vs. 24 (20-32) min vs. 11.5 (10-15.8) min, p = <0.001, p1-2 = 0.082, p1-3 = 0.013, p2-3 <0.001). Also, NC technique had tendency to reduce postoperative pain insensitivity according VAS at 5 postoperative day (groups SW/ZF/NC: 1.57 ± 0.938 vs. 1.39 ± 0.628 vs. 1.32 ± 0.568, p = 0.096, p1-2 = 0.665, p1-3 = 0.521, p2-3 = 0.915) and need for the postoperative use of opioid analgesics (SW/ZF/NC: 3 (21.4) vs. 3 (7.3) vs. 0 (0), p = 0.066, p1-2 = 0.316, p1-3 = 0.065, p2-3 = 0.401; V Cramer = 0.184; OR (95% CI) = 0.169; 0.00913-3.14). This tendency can be explained by the need for traction of the sternum by an assistant when performing hemostasis after suturing, whereas when using external NC, such manipulation is not required. No significant difference in the incidence of major postoperative complications was observed in the early and midterm postoperative period. CONCLUSIONS: Sternal closure using NC has certain advantages over alternative methods associated with technical difficulty, rapidity of sternal closure and a tendency to reduce pain intensity. 
| N (%), mean SD | Group SW (n = 14) | Group ZF (n = 44) | Group NC (n = 22) | p |
| Sternal closure time, min | 18,5(14,5-20,8) | 24(20-32) | 11,5(10-15,8) | P < 0,001P1-2= 0,082P1-3 = 0,013P2-3 < 0,001 |
| Superficial wound infection | 0(0) | 2(4,9) | 1(4,5) | 0,709 |
| Deep wound infection | 1(7,1) | 1(2,4) | 3(13,6) | 0,231 |
| Re-exploration for bleeding | 0(0) | 0(0) | 1(4,8) | 0,287 |
| Pain intensity (VAS) at 5th POD, point | 1,57±0,938 | 1,39±0,628 | 1,32±0,568 | P = 0,096P1-2= 0,665P1-3 = 0,521P2-3 = 0,915 |
| Use of opioid analgesics | 3(21,4) | 3(7,3) | 0(0) | P = 0,066P1-2= 0,316P1-3 = 0,065P2-3 = 0,401 |
| Late sternal healing by CT | 14(100) | 43(97,7) | 22(100) | 1,000 |
| Blood loss, ml | 734±150 | 721±164 | 680±254 | P1-2= 0.7932 P1-3 = 0.4256P2-3 = 0.4309 |