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About 700,000 patient undergo open heart surgery every year in US. Up to 3% of those patients suffer from poor healing of the breastbone not healing correctly after the surgery.

Only in 1978 Dr. Stoney recognized breast bone non-union as a separate medical condition. The patients experience discomfort or pain after heart or valve surgery. They may also notice feeling of instability, clicking and difficulty participating in sports activities. If the symptoms continue after 3 month, most likely, it is sternal mal-union.

In some patients the discomfort may be related to scar sensitivity. However, if there is deep pain and clicking, it is most commonly related to incorrect healing of sternum, or breastbone.

During heart surgery thoracic surgeon split breast bone, aka sternum, from top to bottom in order to do surgery on heart or heart valves. Many thoracic surgeons still use steel wires, or cords, to put the chest wall together after the surgery. Traditionally cardiac surgeon puts several steel wires across from right to left and back. When patients breeze, the chest wall expands to allow air in. This lateral motion and tension created by breathing muscles after the surgery can loosen wires. If not noticed early, it can lead to mal-union or non-union. Wired breast bone may not be strong enough to tolerate higher level of activity in younger patients, as it allows a little bit of movement between right and left sides.

Surprisingly, many affected patients do not report this condition to their heart surgeons. And when they do, it is not uncommon for heart surgeons to dismiss the concerns of the patient once they made sure that the pain that patient has after the surgery is non-cardiac in nature. The patients usually complain to their primary care providers who have very little to offer besides waiting longer for breastbone to heal or Motrin for pain and swelling. Many patients experience episodes of severe anxiety, and frequent hospital visits with complaints of repeated chest pain. Eventually, once pain was proven to be non- cardiac, the patients get labeled crazy and they end up on variety of psychiatric, anti-anxiety medications, antidepressants, narcotics and other medications or referred to pain management specialists and psychiatrists. At that point some of them get referred to plastic surgeons.

Sternal non-union, or sternal instability, can also happen after car accidents, after industrial injuries when the breast bone was broken and not properly secured.

The most accepted indications for sternal instability repair are chronic pain, clicking, grinding, feeling of chest wall moving incorrectly, limitations of activities of daily living, and changes in breathing pattern.

Before the surgery CT scan of the chest and X ray may be needed to diagnose the problem.

Many cardiothoracic surgeons still treat mal-union with repeated sternal wires. They place multiple figure of eight wires, oblique wires, wrap them around the ribs, etc. Unfortunately, the repair with more aggressive wire placement produces more problems than it solves, because wires can either cut through the breastbone or choke it blood supply. One of the more complicated wire techniques is Robicsek weave. Recent study showed that even with that technique 20% had chronic instability, 10% had chronic pain and 14% needed another operation.

The latest advance in sternal repair is using plates and screws instead of wires. This is based on the same principle that all orthopedic surgeons use when they treat bone fractures.

Treatment of sternal non-union, mal-union, or instability is not very complicated. The wires from the breast bone are removed and the steel or titanium plates are placed. As the result, the breast bones are secured together in proper position much better, they stop moving and rubbing against each other with every breath and now can heal properly, just like any other bone.

In most patients pain and discomfort of the breast bone improves very quickly and once the breast bone heals, patients can return back to the activities they love, like golfing, swimming, biking, etc.

The surgery usually takes a couple of hours depending on complexity, it is done in the hospital under general anesthesia.

If you had open heart or valve surgery in the past, if you had automobile or industrial accident that traumatized your chest wall and you experience breastbone discomfort, pain, clicking, instability, or feeling that your rib cage is not moving the right way after the surgery, call our office for consultation.

Solution to your problem may be simpler and quicker than you might think. If you are scheduled to have valve of heart surgery at one of the participating institutions, please feel free to call us and we gladly work together with your cardiothoracic surgeon to use the latest chest wall stabilization methods possible, so you may return to your favorite activities sooner.

  • Julian O C, Lopez-Belio M, Dye W S, Javid H, Grove W J. The median sternal incision in intracardiac surgery with extracorporeal circulation; a general evaluation of its use in heart surgery. Surgery. 1957;42:753–761.

  • Stoney W S, Alford W C, Jr, Burrus G R, Frist R A, Thomas C S., Jr Median sternotomy dehiscence. Ann Thorac Surg. 1978;26:421–426.

  • Breyer R H, Mills S A, Hudspeth A S, Johnston F R, Cordell A R. A prospective study of sternal wound complications. Ann Thorac Surg. 1984;37:412–416.

  • Demmy T L, Park S B, Liebler G A, et al. Recent experience with major sternal wound complications. Ann Thorac Surg. 1990;49:458–462.

  • Loop F D, Lytle B W, Cosgrove D M, et al. J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: Early and late mortality, morbidity, and cost of care. Ann Thorac Surg. 1990;49:179–186. discussion 186–187.

  • Hendrickson S C, Koger K E, Morea C J, Aponte R L, Smith P K, Levin L S. Sternal plating for the treatment of sternal nonunion. Ann Thorac Surg. 1996;62:512–518.

  • Holderman H H. Fracture and dislocation of the sternum: Report of three cases in surgery. Ann Surg. 1928;88:252–259.

  • Losanoff J E, Jones J W, Richman B W. Primary closure of median sternotomy: Techniques and principles. Cardiovasc Surg. 2002;10:102–110.

  • Timmes J J, Wolvek S, Fernando M, Bas M, Rocko J. A new method of sternal approximation. Ann Thorac Surg. 1973;15:544–546.

  • Severson E P, Thompson C A, Resig S G, Swiontkowski M F. Transverse sternal nonunion, repair and revision: A case report and review of the literature. J Trauma. 2009;66:1485–1488.

  • Hills M W, Delprado A M, Deane S A. Sternal fractures: Associated injuries and management. J Trauma. 1993;35:55–60.

  • Wu L C, Renucci J, Song D H. Rigid-plate fixation for the treatment of sternal nonunion. J Thorac Cardiovasc Surg. 2004;128:623–624.

  • Kouchoukos N T, Wareing T H, Murphy S F, Pelate C, Marshall W G., Jr Risks of bilateral internal mammary artery bypass grafting. Ann Thorac Surg. 1990;49:210–217. discussion 217–219.

  • Zacharias A, Habib R H. Factors predisposing to median sternotomy complications. Deep vs superficial infection. Chest. 1996;110:1173–1178.

  • Hazelrigg S R, Wellons H A, Jr, Schneider J A, Kolm P. Wound complications after median sternotomy. Relationship to internal mammary grafting. J Thorac Cardiovasc Surg. 1989;98:1096–1099.

  • Shafir R, Weiss J, Herman O, Cohen N, Stern D, Igra Y. Faulty sternotomy and complications after median sternotomy. J Thorac Cardiovasc Surg. 1988;96:310–313.

  • Kalush S L, Bonchek L I. Peristernal closure of median sternotomy using stainless steel bands. Ann Thorac Surg. 1976;21:172–173.

  • Sirivella S, Zikria E A, Ford W B, Samadani S R, Miller W H, Sullivan M E. Improved technique for closure of median sternotomy incision. Mersilene tapes versus standard wire closure. J Thorac Cardiovasc Surg. 1987;94:591–595.

  • Culliford A T, Jr, Cunningham J N, Jr, Zeff R H, Isom O W, Teiko P, Spencer F C. Sternal and costochondral infections following open-heart surgery. A review of 2,594 cases. J Thorac Cardiovasc Surg. 1976;72:714–726.

  • Taber R E, Madaras J. Prevention of sternotomy wound disruptions by use of figure-of-eight pericostal sutures. Ann Thorac Surg. 1969;8:367–369.

  • Gorlitzer M, Wagner F, Pfeiffer S, et al. A prospective randomized multicenter trial shows improvement of sternum related complications in cardiac surgery with the Posthorax support vest. Interact Cardiovasc Thorac Surg. 2010;10:714–718.

  • Moore R, Follette D M, Berkoff H A. Poststernotomy fractures and pain management in open cardiac surgery. Chest. 1994;106:1339–1342.

  • Cabbabe E B, Cabbabe S W. Surgical management of the symptomatic unstable sternum with pectoralis major muscle flaps. Plast Reconstr Surg. 2009;123:1495–1498.

  • Mayba I I. Non-union of fractures of the sternum. J Bone Joint Surg Am. 1985;67:1091–1093.

  • Coons D A, Pitcher J D, Braxton M, Bickley B T. Sternal nonunion. Orthopedics. 2002;25:89–91.

  • Serry C, Bleck P C, Javid H, et al. Sternal wound complications. Management and results. J Thorac Cardiovasc Surg. 1980;80:861–867.

  • Ståhle E, Tammelin A, Bergström R, Hambreus A, Nyström S O, Hansson H E. Sternal wound complications—incidence, microbiology and risk factors. Eur J Cardiothorac Surg. 1997;11:1146–1153.

  • Wu L C, Renucci J D, Song D H. Sternal nonunion: A review of current treatments and a new method of rigid fixation. Ann Plast Surg. 2005;54:55–58.

  • Robicsek F, Daugherty H K, Cook J W. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg. 1977;73:267–268.

  • Pairolero P C, Arnold P G. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg. 1984;88:357–364.

  • Goodman G, Palatianos G M, Bolooki H. Technique of closure of median sternotomy with trans-sternal figure-of-eight wires. J Cardiovasc Surg (Torino) 1986;27:512–513.

  • Mariani M A, Vaccari G, Marullo A, et al. Combined use of single and double-cross steel wires for closure of midline sternotomy. J Cardiovasc Surg (Torino) 1998;39:833–837.

  • Casha A R, Yang L, Kay P H, Saleh M, Cooper G J. A biomechanical study of median sternotomy closure techniques. Eur J Cardiothorac Surg. 1999;15:365–369.

  • Cohen D J, Griffin L V. A biomechanical comparison of three sternotomy closure techniques. Ann Thorac Surg. 2002;73:563–568.

  • Smoot E C, Weiman D. Paramedian sternal bone plate reinforcement and wiring for difficult sternotomy wounds. Ann Plast Surg. 1998;41:464–467.

  • Actis Dato G M, Deorsola L, Ruffini E. Interlocking sternal closure. Ann Thorac Surg. 1998;66:1860–1861.

  • Murray K D, Pasque M K. Routine sternal closure using six overlapping figure-of-8 wires. Ann Thorac Surg. 1997;64:1852–1854.

  • Katz N M. Pericostal sutures to reinforce sternal closure after cardiac surgery. J Card Surg. 1997;12:277–281.

  • Jelić I, Anić D. Pericostal sutures to reinforce sternal closure after cardiac surgery. J Card Surg. 1998;13:494–495.

  • Soroff H S, Hartman A R, Pak E, Sasvary D H, Pollak S B. Improved sternal closure using steel bands: Early experience with three-year follow-up. Ann Thorac Surg. 1996;61:1172–1176.

  • Badellino M, Cavarocchi N C, Kolff J, Alpern J B, McClurken J B. Sternotomy closure with Parham bands. J Card Surg. 1988;3:235–236.

  • LeVeen H L, Piccone V A. Nylon-band chest closure. Arch Surg. 1968;96:36–39.

  • Al-Naaman Y D, Al-Ani M S. Sternal staple: Simple and rapid device for closure of median sternotomy. Ann Thorac Surg. 1976;21:170–171.

  • Osada T, Kawachi K, Fujikawa T, et al. [A new method for closure of median sternotomy: Application of a stapler system] Kyobu Geka. 1990;43:973–976.

  • Zurbrügg H R, Freestone T, Bauer M, Hetzer R. Reinforcing the conventional sternal closure. Ann Thorac Surg. 2000;69:1957–1958.

  • Eich B S, Heinz T R. Treatment of sternal nonunion with the Dall-Miles cable system. Plast Reconstr Surg. 2000;106:1075–1078.

  • Vincent J G. Update on sternal osteosynthesis. Ann Thorac Surg. 1986;41:216–218.

  • Ozaki W, Buchman S R, Iannettoni M D, Frankenburg E P. Biomechanical study of sternal closure using rigid fixation techniques in human cadavers. Ann Thorac Surg. 1998;65:1660–1665.

  • Bertin K C, Rice R S, Doty D B, Jones K W. Repair of transverse sternal nonunions using metal plates and autogenous bone graft. Ann Thorac Surg. 2002;73:1661–1662.

  • Sherman J E, Salzberg A, Raskin N M, Beattie E J. Chest wall stabilization using plate fixation. Ann Thorac Surg. 1988;46:467–469.

  • Gottlieb L J, Pielet R W, Karp R B, Krieger L M, Smith D J, Jr, Deeb G M. Rigid internal fixation of the sternum in postoperative mediastinitis. Arch Surg. 1994;129:489–493.

  • Cheng W, Cameron D E, Warden K E, Fonger J D, Gott V L. Biomechanical study of sternal closure techniques. Ann Thorac Surg. 1993;55:737–740.

  • Olbrecht V A, Barreiro C J, Bonde P N, et al. Clinical outcomes of noninfectious sternal dehiscence after median sternotomy. Ann Thorac Surg. 2006;82:902–907.

  • Sargent L A, Seyfer A E, Hollinger J, Hinson R M, Graeber G M. The healing sternum: A comparison of osseous healing with wire versus rigid fixation. Ann Thorac Surg. 1991;52:490–494.

  • Fawzy H, Alhodaib N, Mazer C D, et al. Sternal plating for primary and secondary sternal closure; can it improve sternal stability? J Cardiothorac Surg. 2009;4:19.

  • Mitra A, Elahi M M, Tariq G B, Mir H, Powell R, Spears J. Composite plate and wire fixation for complicated sternal closure. Ann Plast Surg. 2004;53:217–221.

  • Hallock G G, Szydlowski G W. Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system. Ann Plast Surg. 2007;58:640–644.

  • Cicilioni O J, Jr, Stieg F H, III, Papanicolaou G. Sternal wound reconstruction with transverse platefixation. Plast Reconstr Surg. 2005;115:1297–1303.

  • Huh J, Bakaeen F, Chu D, Wall M J., Jr Transverse sternal plating in secondary sternal reconstruction. J Thorac Cardiovasc Surg. 2008;136:1476–1480.

  • Morgan A. Treatment of chronic nonunion of a sternal fracture with bone morphogenetic protein. Ann Thorac Surg. 2008;85:e12–e13.