Dhanapathy Vikash, Jones Mark, Stroebel Andrie, He Cheng
School of Medicine, Griffith University, Gold Coast, Qld, Australia; Department of Cardiothoracic Surgery, Princess Alexandra Hospital, Brisbane, Qld, Australia.
Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld, Australia.
Heart Lung Circ. 2025 Aug;34(8):856-862. doi: 10.1016/j.hlc.2025.03.013. Epub 2025 Jun 30.
Despite increasing evidence demonstrating the merits of rigid plate fixation over wire cerclage for sternotomy closure, wire cerclage remains the predominant standard of care, largely because of the substantial cost of plating systems and the perceived lack of difference to outcomes.
This study aimed to compare the incidence of sternal complications between patients receiving rigid plate fixation vs wire cerclage and thereby assess the cost vs benefit of said sternal closure methods.
A retrospective cohort analysis was performed on patients who underwent open cardiac surgery at a single Australian tertiary centre between January 2019 and January 2023. Data were obtained from the Queensland Cardiac Outcomes Registry. The rate of readmissions for sternal complications were compared between those receiving wire cerclage sternal closure vs rigid plate fixation. Index admissions of each cohort were compared to assess secondary outcomes of hospital length of stay, intensive care unit length of stay, and admission costs, using marginal treatment effects analysis to adjust for differences in the two patient groups. Costs associated with each method of sternal closure were assessed, including those pertaining to readmissions.
A total of 941 patients underwent sternotomy closure with wire cerclage and 67 patients received rigid plate fixation. Patients in the plate fixation group were at higher risk of sternal complications because of a higher body mass index (33 vs 29, p<0.001), bilateral internal mammary artery graft use (22.4% vs 6.9%, p<0.001), and rate of diabetes (37.7% vs 22.2%, p=0.007). Comparing index admissions, the use of rigid plate fixation was associated with a trend towards reduced hospital length of stay (12 vs 14 days) and intensive care unit length of stay (33 vs 45 hours), with similar total admission costs. There were 37 readmissions for sternal wound complications in the study period, all of which occurred in the wire cerclage group (incidence rate 3.9% vs 0%, p=0.17). Majority of readmissions were attributed to deep sternal wound infection (n=21). Each readmission was associated with an average hospital length of stay of 17 days and admission cost of $42,326 Australian dollars. Over the study period, the total cost of readmissions for sternal complications was $1,661,414 Australian dollars.
The use of rigid plate fixation compared with wire cerclage for sternotomy closure was associated with a strong trend towards reduced sternal wound complications, such that the higher initial costs of rigid plate fixation were offset by the substantial costs of said complications. Thus, an argument is made for considering rigid plate fixation as a first-line method of sternotomy closure, regardless of risk profile.
尽管越来越多的证据表明，在胸骨切开术闭合中，刚性钢板固定比钢丝环扎术更具优势，但钢丝环扎术仍然是主要的护理标准，这主要是因为钢板固定系统成本高昂，且人们认为其与治疗效果并无差异。
本研究旨在比较接受刚性钢板固定与钢丝环扎术的患者胸骨并发症的发生率，从而评估上述胸骨闭合方法的成本效益。
对2019年1月至2023年1月期间在澳大利亚一家三级医疗中心接受心脏直视手术的患者进行回顾性队列分析。数据来自昆士兰心脏结局登记处。比较接受钢丝环扎术胸骨闭合与刚性钢板固定的患者因胸骨并发症再次入院的发生率。使用边际治疗效果分析对两组患者的差异进行调整，比较每个队列的首次入院情况，以评估住院时间、重症监护病房住院时间和入院成本等次要结局。评估了与每种胸骨闭合方法相关的成本，包括与再次入院相关的成本。
共有941例患者采用钢丝环扎术进行胸骨切开术闭合，67例患者接受刚性钢板固定。钢板固定组患者因体重指数较高（33 vs 29，p<0.001）、双侧胸廓内动脉搭桥术的使用（22.4% vs 6.9%，p<0.001）和糖尿病发生率（37.7% vs 22.2%，p=0.007），发生胸骨并发症的风险更高。比较首次入院情况，使用刚性钢板固定有缩短住院时间（12天 vs 14天）和重症监护病房住院时间（33小时 vs 45小时）的趋势，且总入院成本相似。在研究期间，有37例因胸骨伤口并发症再次入院，均发生在钢丝环扎术组（发生率3.9% vs 0%，p=0.17）。大多数再次入院归因于深部胸骨伤口感染（n=21）。每次再次入院平均住院时间为17天，入院成本为42326澳元。在研究期间，胸骨并发症再次入院的总成本为1661414澳元。
与钢丝环扎术相比，使用刚性钢板固定进行胸骨切开术闭合有明显降低胸骨伤口并发症的趋势，以至于刚性钢板固定较高的初始成本被这些并发症的高昂成本所抵消。因此，无论风险状况如何，都有理由将刚性钢板固定视为胸骨切开术闭合的一线方法。
