Sternal Talon, a novel repair for sternal dehiscence.

Sternal dehiscence is a recognised complication after median sternotomy, occurring in 0.5-5% of cases with or without infection. A 72-year-old man presenting with collapse and ventricular tachycardia was investigated for a possible acute cardiac event 2 years after coronary artery bypass grafting for ischemic heart disease. Work-up chest X-ray showed displacement of all sternal wires, and computed tomography (CT) performed to investigate further showed sternal dehiscence with right ventricle wall herniation through the defect and sternal wire breakdown. A decision was made after discussion with the patient to repair the defect using 3 Sternal Talon devices and 2 sternal wires. The patient made an uncomplicated recovery, and the outpatient clinic review after discharge home showed satisfactory and stable sternal union. We report a case of non-infected sternal dehiscence managed successfully with the Sternal Talon without long-term complications.

A 72-year-old man was brought in by ambulance following collapse after tying his shoe. The electrocardiogram showed ventricular tachycardia. The patient had undergone an uncomplicated coronary bypass grafting 2 years prior to admission and had been asymptomatic with no limitations of daily living. This prompted us to investigate the patient for a possible acute cardiac event, and a repeat coronary angiogram was performed. Investigation showed no significant occlusion to coronary vessels including grafted vessels. Echocardiography showed good left ventricular (LV) function with ejection fraction (EF) at > 55% with no valvular pathology. The superficial surgical wound healed without complications.

Admission chest X-ray showed displacement of all sternal wires. This was clinically supported with an unstable sternum with no superficial wound complications. Computed tomography (CT) of thorax with intravenous (IV) contrast was performed to investigate further.

Both images show sternal dehiscence with right ventricle wall herniation through the defect and sternal wire breakdown (Figs. 1, 2).

Fig. 1

3D reconstruction showing sternal dehiscence

Fig. 2

Non-contrast CT image

Ventricular tachycardia resolved with oral amiodarone and bisoprolol. The patient was then referred for cardiothoracic service for repair of the sternal defect.

CT findings were confirmed during surgery, and the right ventricle was mobilised away from the sternal edge and reduced into the mediastinum. The sternum was repaired with 3 Sternal Talons and 2 sternal wires. Open implants were placed in either side of the sternum after accurate approximation of depth and width. All 3 implants were then closed and locked using a screwdriver. Superficial facia and skin were closed in layers after haemostasis was achieved.

The patient was discharged home on day 7 after surgery with no acute complications. Pain was managed well with tapering doses of opioid analgesia with no requirements for long-term analgesia. The patient was reviewed in the outpatient clinic one month after the procedure. The review included clinical examination and chest X-ray with findings that support good sternum union and stability. The patient was reviewed again after 4 months, with no long-term complications.

Discussion

Median sternotomy for open cardiac procedure is a bone splitting procedure that can be complicated by poor healing, resulting in sternal dehiscence at an incidence of 0.5-5% with or without infection [1, 2]. Higher risk group are those with obesity, osteoporosis, chronic obstructive pulmonary disease, diabetes mellitus and patients on long-term immunosuppressive drugs [1]. Surgical technique also contributes in particular to off midline sternotomy [1] and poor closure technique. Sternal dehiscence may further complicate the post-operative period with superficial wound infections, mediastinitis, pain, and cardiac and pulmonary function compromise [3].

Repair of sternal dehiscence is guided by radiological and intra-operative findings. In the present case, Robicsek sternal closure was unsuitable due to significant loss of bone. However, the Sternal Talon with wires provided good bony opposition and rigid fixation. Recent publications have supported the safe use of this novel sternal closure technique, and our patient had successful repair with no reported no long-term complications.

A male and female Sternal Talon component is placed intercostally on either side of split vertical sternal segments following width and depth measurements. Both components are reduced and locked in place to achieve accurate and secure reduction. Long-term removal can be achieved by unlocking the screw after exposure and dissection.

In conclusion, we have reported a case of non-infected sternal dehiscence managed successfully with the Sternal Talon without long-term complications.