Modified Tightening for Figure-of-Eight Sternal Wiring Closure

Bhagwat, Krishna A. MBBS, MCh (CTS)*; Stephens, Georgina C. MBBS*; Chakaramakkill, Mathew Jose MBBS, MCh (CTS); Ratinam, Ratheesraj MBBS

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: September/October 2015 - Volume 10 - Issue 5 - p 368–369
doi: 10.1097/IMI.0000000000000194
How-To-Do-It Articles

Abstract: This is a simple and quick method for the tightening of figure-of-eight wires routinely used for sternal closure. This technique gives a stable approximation, adequate reduction, and immobilization, providing higher strength and rigidity compared with conventional figure-of-eight closure. The advantage of this technique is that it tightens all the four wires equally, thus avoiding loose loops.

From the *Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Australia; †National Heart Centre, Singapore, Singapore; and ‡Department of Surgery, Monash Medical Centre, Melbourne, Australia.

Accepted for publication May 22, 2015.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Krishna A. Bhagwat, MBBS, MCh (CTS), Department of Cardiothoracic Surgery, Alfred Health, 55 Commercial Rd, Melbourne VIC 3181, Australia. E-mail:

Article Outline

Sternal wiring is an important aspect after median sternotomy for cardiac surgery. The incidence of wound complications has been reported to be from 0.5% to 5%, adding to morbidity and mortality in cases where mediastinitis develops. There have been many diverse techniques involved in the closure of sternum, but the optimum closure method remains controversial.1,21,2 We describe a simple modified figure-of-eight wiring closure.

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Four to five stainless steel wires of number 5 or 6 size are placed in a traditional figure-of-eight manner, extending from the manubrium to the xiphoid. The first wire is passed through the cortex of the manubrium as far as lateral as possible. The rest of the figure-of-eight wires are passed parasternally, minimizing the wire pull through in patients with diminished bone density, thus taking advantage of the strength of the lateral cortex. The second wire overlaps the sternomanubrium joint providing superior stability (Fig. 1A).

The main modification is in the tightening of the wires. The ends of the figure-of-eight are hand-twisted loosely when the sternum is still open. The twister hook is then used to hook both loops of the wire as they are pulled up vertically (Fig. 1B). This aids in sternum approximation and tensions all portions of the figure-of-eight wire equally. Care is taken to check that the loops of each figure-of-eight are of the same length. The hook is then used to tighten all the four wires together, making a four-stranded knot increasing the strength of the knot with equal distribution of tension throughout (Fig. 1C).

Cutting the two wires on one side of the four-stranded knot aids quick and easy removal of these wires.

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Multiple factors that affect sternal healing are reported in the literature.1,31,3 Preoperative parameters reported are male sex, hyperlipidemia, history of smoking, peripheral arterial disease, diabetes mellitus, chronic obstructive pulmonary disease, renal insufficiency, and regular intake of steroids. Among the intraoperative risk factors are the use of a thoracic artery as a bypass vessel and prolonged duration of operation. Postoperative factors include the requirement for rethoracotomy for bleeding, postoperative liver insufficiency, postoperative renal failure, postoperative respiratory failure, laparotomy for gastroenterological complications, prolonged ventilation, and prolonged intensive care unit stay.

There is no known wiring technique that provides excellent sternal stabilization and rigidity permitting secure bony union despite the previously mentioned risk factors for sternal healing.

The figure-of-eight wiring is one of the most popular techniques used and possesses advantages over interrupted simple cerclage wires. It is known that the figure-of-eight wire technique distributes sternal stress over an increased area and limits longitudinal displacement.2,42,4

This modified technique tensions all the components of wires behind and in front of the sternum. This technique has a theoretical advantage of evenly stabilizing the lateral and anteroposterior distraction, hence diminishing wire cut-through. Tightening of all four wires together resists untwisting and breaking of the wires. The only disadvantage to this technique is that the bulk of the large twisted knot can be more prominent in thin individuals.

When the figure-of-eight wiring is performed parallel to the sternotomy or in the longitudinal axis and tightened in the modified way, it gives the added advantage of more lateral reinforcement as described by the Robicsek closure.5 It was observed that there were less wound complications in routine midline sternotomy closures. Even the clamshell (bilateral transverse thoracosternotomy) incisions that are notoriously known for sternal wound complications had better stability with this technique.

The noninferiority of this technique needs to tested with biomechanical studies.

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1. Kamiya H, Al-maisary SS, Akhyari P, et al. The number of wires for sternal closure has a significant influence on sternal complications in high-risk patients. Interact Cardiovasc Thorac Surg. 2012; 15: 665–670.
2. Tekümit H, Cenal AR, Tataroğlu C, Uzun K, Akinci E. Comparison of figure-of-eight and simple wire sternal closure techniques in patients with non-microbial sternal dehiscence. Anadolu Kardiyol Derg. 2009; 9: 411–416.
3. Schimmer C, Sommer SP, Bensch M, Bohrer T, Aleksic I, Leyh R. Sternal closure techniques and postoperative sternal wound complications in elderly patients. Eur J Cardiothorac Surg. 2008; 34: 132–138.
4. Ramzisham AR, Raflis AR, Khairulasri MG, Ooi Su Min J, Fikri AM, Zamrin MD. Figure-of-eight vs. interrupted sternal wire closure of median sternotomy. Asian Cardiovasc Thorac Ann. 2009; 17: 587–591.
5. Robicsek F, Daugherty HK, Cook JW. The prevention and treatment of sternum separation following open-heart surgery. J Thorac Cardiovasc Surg. 1977; 73: 267–268.

Sternal complications; Sternal closure; Sternal Wires; Figure-of-eight

©2015 by the International Society for Minimally Invasive Cardiothoracic Surgery