Zeitani J, Penta de Peppo A, Moscarelli M, Guerrieri Wolf L, Scafuri A, Nardi P, Nanni F, Di Marzio E, De Vico P, Chiariello L
Department of Cardiac Surgery, Tor Vergata University, Rome, Italy.
J Thorac Cardiovasc Surg. 2006 Jul;132(1):38-42. doi: 10.1016/j.jtcvs.2006.03.015.
The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined.
Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed.
Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001).
Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.
胸骨大小及意外的旁正中胸骨切开术对胸骨闭合部位稳定性的影响尚不明确。
前瞻性收集171例连续接受正中胸骨切开术心脏手术患者的数据。术中测量胸骨尺寸包括胸骨柄、第三和第五肋间的厚度和宽度；旁正中胸骨切开术定义为在三个水平中的任何一个水平，胸骨一侧的宽度等于整个宽度的75%或更多。胸部用简单的胸骨周围钢丝闭合，并在术后3个月检查是否有深部伤口感染和/或不稳定。将胸骨因素及一些患者/手术相关因素纳入多变量分析模型，以确定影响稳定性的因素。对6个正中或旁正中胸骨切开术后重新固定钢丝的胸骨模型进行机电牵引试验，并分析分离数据。
12例（7%）患者检测到胸部不稳定，2例（1.2%）有伤口感染。患者体重（P = 0.03）、左心室功能不全（P = 0.04）、胸骨厚度（以体重为指标，P = 0.03）和旁正中胸骨切开术（P = 0.0001）是术后不稳定的危险因素；旁正中胸骨切开术是唯一的独立预测因素（P = 0.001）。机电试验显示，旁正中胸骨切开术后重新固定钢丝的两半胸骨的侧向移位比正中胸骨切开术后更多（P = 0.002）；因此，旁正中胸骨切开术后骨折点的负荷较低（220±20 N对545±25 N，P = 0.001）。
意外的旁正中胸骨切开术强烈影响术后胸部伤口稳定性，且独立于胸骨大小，需要迅速加强胸部闭合。
